The American Chiropractic Association (ACA) have just published new guidelines for chiropractors entitled ‘Guidelines for Disaster Service by Doctors of Chiropractic’. Let me show you a few short quotes from this remarkable document:

… Doctors of Chiropractic are uniquely qualified to serve in emergency situations in various capacities.

… their assessment and treatments can be performed in austere environments, on site or at staging areas providing rapid attention to the injury, accelerating healing and often decreasing or substituting the need for pharmaceutical intervention…

Through their education as primary care physicians, Doctors of Chiropractic have demonstrated competence in first aid and resuscitation skills and are able to assess, diagnose and triage so they may serve as first responders in the immediate care of victims at a disaster site…

During and after the disaster, the local Doctors of Chiropractic should interface with the state association and ACA to report on execution of action and outcome of the situation, make suggestions for response to future disasters and report any significant contacts made.


Please allow me to make just 10 corrections and clarifications:

  1. Chiropractors are not medical doctors; to use the title in any medical context is misleading, to use it in the context of medical emergencies is quite simply reckless.
  2. Chiropractors are certainly not qualified to serve in emergency situations. This would require a totally different training, experience and set of skills.
  3. I am not aware of any good evidence that chiropractic can accelerate healing of any medical condition.
  4. I am also not aware that chiropractic might decrease or substitute the need for pharmaceutical interventions in emergency situations.
  5. Chiropractors are not primary care physicians.
  6. Chiropractors have not demonstrated competence in first aid and resuscitation skills.
  7. Chiropractors are not trained to diagnose the complex and often life-threatening conditions that occur in disaster situations.
  8. Chiropractors are not trained as first responders in disaster situations.
  9. Chiropractors are not qualified or trained to report on execution of action and outcome of disaster situation.
  10. Chiropractors are not qualified or trained to make suggestions for response to future disasters.

The new ACA guidelines are but a thinly disguised attempt to boost chiropractic. They have the potential to endanger lives. And they are an insult to those professionals who have trained hard to acquire the skills to respond to emergencies and disaster situations.

In other words, they are guidelines not for dealing with disasters, but for creating them.

86 Responses to Disaster Service by Chiropractors – Yes, it’s quite a disaster!

  • Dear professor,
    As an Army paramedic with significant experience AND a trained Chiropractor I can agree with some of your points. However…
    1. Chiropractors are trained in basic first aid and ATLS when there are no other better trained personals than yes the Chiropractor is oblighed to assist according to his training skills.
    2. Chiropractors are according to training and federal regulations in USA and other countries primary contact physicians. When you decide to downgrade an entire profession and dismiss their training please add ” in my own personal opinion”.

    • PRIMARY CARE PHYSICIAN: A mainstream physician who provides care to a patient at the time of first (non-emergency) contact, which usually occurs on an outpatient basis. In the US, primary care providers include internists (formerly, general practitioners), family practitioners and paediatricians; in many regions of the US, gynaecologists provide primary care to women.
      PRIMARY CONTACT PHYSICIAN: A physician who can be contacted by patients directly without referral from another source.
      “Chiropractors are trained in basic first aid and ATLS when there are no other better trained personals than yes the Chiropractor is oblighed to assist according to his training skills.” this may be so, but it does not mean that they are ‘are uniquely qualified to serve in emergency situations’.

    • “AND a trained chiropractor…” Is that meant to impress us or make us question your ability to understand what “training” is? Stitching a wound on a field of battle is an honorable skill-set…pretending to understand the spine and find subluxations is a criminal venture.
      Clearly the army training was sufficient teach you to triage injured soldiers but not to recognize that chiropractic is a cultist quack-religion?

    • 2. Chiropractors are according to training and federal regulations in USA and other countries primary contact physicians.

      Big woop. This is what SBMers call Legislative Alchemy, having nothing to do with medical or scientific merit and everything to do with its proponents’ ability to cross their Representatives’ palms with gold.

    • I was a paramedic and a cop for many years and am well versed in emergency response to disaster situations. I have been a chiropractor for over 30 years and have been a member of a federal disaster team for over 15 years. While not officially recognized by the federal disaster response teams, chiropractic is integrated into many other federal programs including the VA and MTFs.
      Once the word gets out that a chiropractor is on-site of a disaster scene, the call for assistance is sometimes overwhelming. If you have never been deployed to a disaster, you are not aware of the extreme physical demands placed upon the responders as we are tasked with setting up medical treatment facilities in austere environments. Much like the Reserves, federal disaster teams are staffed with citizens who leave their everyday life as a nurse, medic, doctor, engineer etc, to respond to the needs of those impacted by the disaster. These are not trained athletes. They often end up with musculoskeletal ailments that are managed quite well with chiropractic hands-on care.
      There are some chiropractors who have no business and likely no desire to help during an extreme disaster event. But there are chiropractors who are willing and able to work side by side with their allopathic counterparts to help those in need.
      Howard Levinson, DC

  • “Chiropractors are according to training and federal regulations in USA and other countries primary contact physicians”
    I would understand this to mean that they accept self-referrals from patients, which is rather different from being a primary care physician, who (at least in the UK) is the person in overall charge of somebody’s health care.

    Would a primary contact chiropractor be responsible for ensuring that childhood vaccinations are up-to-date, monitoring diabetes, supervising pregnancy, liasing with Social Services over the care and housing of vulnerable persons… ?

    • precisely!

    • Of course not they will have the responsibility to refer to the health practitioner that does. But they are trained and capable to accept people “off the street” and conduct a health assessment, recognize health risks, refer for further testing and consultations and make a working diagnosis and decision whether or not the patient is suitable for conservative rehabilitative care.

  • Dr Guy Almog wrote: “the Chiropractor is obliged to assist according to his training skills”

    Therein lies the problem.

    Notwithstanding the blatant lack of evidence for administering the chiropractic interventions in the scenarios below, I wonder how many thorough patient histories were taken and if any complications from treatment were recorded…


    “On 9-11-01, when America was wounded and needed healing, doctors of chiropractic were among the first health care providers at the disaster sites. The New York Chiropractic leadership coordinated with the American Red Cross to credential some 1,500 doctors from state, national, and international associations. Chiropractors worked at five relief sites, including one just yards from the rubble of the Twin Towers, and gave adjustments around the clock.”


    “The chiropractic care that takes place in the field on an emergency site has a different rhythm than what occurs in many chiropractic offices. The assessment is thorough but shorter, and each worker who came was fully assessed for vertebral subluxation every time because there might be a different doctor adjusting each time.”



    “Our first order of business was to go to the refugee tent areas and deliver food (rice) and water…we then started to treat the people on the portable tables we had brought with us…next thing we knew, we were adjusting and treating person after person for a couple of hours straight. The eight of us took turns evaluating injuries and administering and administering adjustments for whole-body injuries”


    “With trust established, a brave Haitian would lie down on the adjusting table. A doctor would quickly evaluate him and then adjust his spine.”



    “It’s important that those people who were under so much stress who live in Puerto Rico that they are treated chiropractically to make sure that there subluxations are adjusted due to the hard work and stress they are enduring.”


  • In the UK, there is only one standard of medical practitioner who can be registered with the regulatory body (General Medical Council). Any one can style themselves ‘doctor’, but not claim to be a registered medical practitioner, unless they are.

    Some UK chiropractors do like to style themselves ‘doctor’ – but they know perfectly well that misleads patients as to their professional status.
    Indeed, many might think that is their intention.

    If chiropractors are as proud of their profession as they claim to be, why do they not style themselves as ‘Chiropractor’?
    Thus: “Ch Smith” – not “Dr Smith”.
    Many other professions use nominal titles: ‘Lieutenant’; ‘Admiral’; ‘Reverend; Senator…’; (Lt; Adml; Rev.; Sen. …).
    It was Palmer who stated “chiropractic is a different system of medicine…”.

    Answer: They want to mislead the public and patients. Whatever other reason can there be?

    And, just to be clear, would those who advance the policy of chiropractors being involved in disaster management, be content to have chiropractors attend them in the event of a RTA or other serious incident?
    Are their diaries or personal information on smart phones annotated: “In case of emergency, call Chiropractor (Smith)…”?

    If not, why not?

    Chiropractors who want to drive a car should train and get a licence as a driver.
    Chiropractors who want to be a pilot should train to be a pilot.
    Chiropractors who want to be doctors should train as doctors.


    If not, why not?

    • RR, you are still confused over the use of the title “doctor”. Which is a shame, because you appear to be really well trained in other areas, such as magic.
      Medical Practitioners in the U.K., Australia and New Zealand come out of Medical School (not doctor school) with a double Bachelors degree. (not a degree in doctoring). They are the registered as a “medical practitioner” not a “doctor”. The use of the title “doctor” is purely a courtesy title used by medical practitioners, dentists, vetinarians, chiropractors and soon physiotherapists as they graduate from a U.S. educational facility with a “Doctor of Physical Therapy” degree. How are you going to cope with that?
      The true use of the title “doctor” should be reserved for those people having done post graduate studies and have PhD’s, are Doctors of Divinity, Doctors of Law or Doctors of Medicine, not medical practitioners, dentists, vets, chiropractors and physiotherapists, who use it as a courtesy title.
      But you knew that anyway, didn’t you?

      • “The true use of the title “doctor” should be reserved for those people having done post graduate studies and have PhD’s, are Doctors of Divinity, Doctors of Law or Doctors of Medicine, not medical practitioners, dentists, vets, chiropractors and physiotherapists, who use it as a courtesy title.”

        Agreed 100%. But I have many American friends who say that ‘PhD’ stands for ‘phoney doctor’. The title has become completely bastardized by popular usage.

  • Do you know what “skill acquisition” means?

    “It is advisable that team interaction and skill acquisition be achieved before an event requiring engagement and response.”

  • And so innocent victims of a disaster are then infiltrated by quacks, to solicit business and “enhance” the injured into changing their paradigm to include “chiroquacker assessment and “care””? There are millions of RNs worldwide….IF victims need triage that’s what they learned throughout their entire education. RNs don’t palpate injured peoples spines, find sore spots then “manipulate” them with 1000 year old gypsy trickery pretending to be actual-healthcare.
    Missionaries infiltrate a culture under the premise of giving aid and care but their real purpose is to find gullible marks to increase their ranks. Chiroquackery learned well.

  • “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” – Abraham Maslow, 1966

    One of my favourite quotes, and apposite in this context.

  • Yah, one has to differentiate between those who are addressing the MSK issues of first responders and the nut jobs going into 3rd world countries.

  • I would like to tell you about a study we conducted at the EMERGENCY DEPARTMENT in Asaf HaRofe General Hospital in Israel. Where we examined in a double blinded randomized “add on therapy” study the effect of adding chiropractic treatment in compared with accepted sham treatment.
    The results were analysis by Tel Aviv Mathematics department and the entire study supervised by the Helsinki committee.
    The outcome were 30% less pain leaving the A&E, improved ROM, less drug usage in the days following. If you are interested I can send the summery as it was presented in several conferences one of them was the Israeli Spine Surgeon Society.
    My point is that Chiro and Ortho surgeons can and do work together in a complimenting manner. We put our ego aside and work together for the benefit of the PATIENT. This I have been doing within the hospital setting for the past 15 years.
    This struggle that happens on this site just does not happen when you work together. Eventually in practice you learn how limited we are in our abilities to help and how much we depend on our entire team to succeed. In my unit we don’t spend time on proving and arguing chiropractic we place our efforts in improving techniques and protocols.

    • please post a link to the published paper

    • @Guy: So, again your point is? You are proposing a 4 year, $200,000.00 “education” leading to a doctorate in an arcane, cultish pseudoscience…a doctorate which is non-transferable to any real-university or to enhance any other professional degree (a doctorate NEVER pursued post a PhD or MD), leading only to defrauding the general public with hyperbolic nonsensical rhetoric regarding the “big idea”….is worth maintaining as a separate and distinct “profession”? And if the Palmarian BS isn’t the focus then you’re simply pretending to be a PT without the proper license? Which of the 100 inane “techniques” pretending to represent “chiropractic” was chosen for the profound intervention? And what adjudication processes? Leg checks, AK, motion-palpation, Toftness, spiritual-intercession????
      All this for a temporary quiescence in 30% in non-descript MSK “pain”. An outcome overwhelmingly due to non-specific effects. A “treatment” which never leads to actual alterations in anatomy or physiology….but may well lead an uncritical “patient” adopting the utterly specious notion their spinal alignment has some meaning and only a DC (and not just ANY DC but the ones who “practice” like “me”) can create these “profound outcomes”.
      It is indefensible to anyone except those getting a pecuniary reward….it is a profession of connivers.

  • @Blue

    I thought I had seen the most extreme examples of health related make-believe. Your links prove I had still not seen the bottom of the barrel.

  • “..with hyperbolic nonsensical rhetoric regarding the “big idea””

    What percentage of chiropractors today actually hold onto the “big idea”?

    A slip on the snowy sidewalk in winter is a small thing. It happens to millions. A fall from the ladder in the summer is a small thing. It also happens to millions. The slip or fall produces a subluxation. The subluxation is a small thing. The subluxation produces pressure on a nerve. That pressure is a small thing. That decreased flowing produces a dis-eased body and brain. That is a big thing to that man. Multiply that sick man by a thousand, and you control the physical and mental welfare of a city. Multiply that man by one hundred thirty million, and you forecast and can prophesy the physical and mental status of a nation. So the slip or fall, the subluxation, pressure, flow of mental images, and dis-ease are big enough to control thoughts and actions of a nation. Now comes a man. And one man is a small thing. This man gives an adjustment. The adjustment is a small thing. The adjustment replaces the subluxation. That is a small thing. The adjusted subluxation releases pressure upon nerves. That is a small thing. The released pressure restores health to a man. This is a big thing to that man. Multiply that well man by a thousand, and you step up the physical and mental welfare of a city. Multiply that well man by a hundred thirty million, and you have produced a healthy, wealthy, and better race for posterity. So, the adjustment of the subluxation to release pressure upon nerves, to restore mental impulse flow, to restore health, is big enough to rebuild the thoughts and actions of the World. The idea that knows the cause, that can correct the cause of dis-ease, is one of the biggest ideas known. Without it, nations fall; with it, nations rise. The idea is the biggest I know of.

    • @DC

      The slip or fall produces a subluxation. The subluxation is a small thing. The subluxation produces pressure on a nerve. That pressure is a small thing. That decreased flowing produces a dis-eased body and brain.

      So put your money where you mouth is and provide robust evidence for the inevitable ‘subluxation’ in every case of a slip on a snowy sidewalk or a fall from a ladder. Last time I knew anyone who fell from a ladder he died as a result. His ‘subluxation’ was a subdural haematoma. Last time I knew someone who slipped heavily on a snowy path her ‘subluxation’ was a fracture of the neck of her femur.

      What self-serving poppycock you post in your comment! It could have come straight from Palmer himself. Surely common sense is more than enough for anyone to recognize that your claim slips and falls result every time in a ‘subluxation’ is pure nonsense.

    • @DC: next to quotes from L Ron Hubbard Ol’ DD Palmer is the tops!
      How many DCs ascribe to the “big (wrong) idea”? I’d hope all-of-them is the accurate answer. Since a doctorate OF or IN Chiropractic can be NOTHING ELSE but the big idea. That’s what the $200,000 education is all about.
      Otherwise it’s just public-deception. The public pays chiroquackers to dispense “the big idea”.

      • Actually, I didn’t hear about The Big Idea until after I graduated from college. You seem to be working off of unreliable information.

  • Why not contact the PI and ask him the status?

    Principal Investigator: Shmuel Bar-Haim, MD

    • @DC

      From your link: “Actual Study Completion Date: September 2011” “Last Update Posted: January 31, 2012”. “No Study Results Posted on for this Study”.

      So in seven years, the authors have not been motivated to write a paper detailing the study, or even to upload the study results to the official website for registering clinical trials. I’ll draw my own conclusions from that, thank you.

  • @DC

    From the link: “Actual Study Completion Date: September 2011” “Last Update Posted: January 31, 2012”. “No Study Results Posted on for this Study”.

    So in seven years, the authors have not been motivated to write a paper detailing the study, or even to upload the study results to the official website for registering clinical trials. I’ll draw my own conclusions from that, thank you.

  • Regardless, my question to Mr. Kenny was, what percentage of chiropractors hold onto the Big Idea?

    “leading only to defrauding the general public with hyperbolic nonsensical rhetoric regarding the “big idea””

    • wasn’t BJ Palmer’s big idea to defraud to public?

    • DC: My answer, based on an afternoon of pursuing DC websites (at last count 224), I must draw the conclusion: virtually ALL. Albeit if there are 60,000 in the US 224 is a tiny %. BUT it is extremely telling that of those 224 random viewings ALL directly stated OR alluded to “misalignment”, subluxation, impinged-nerves, assessment acumen & palpation-skills (leading to supra-mundane diagnostic deductions regarding the location-of-mal-alignment/motion impairment). Those using Activator, Impulse and Pro-adjusting “guns” (more than 50%) were utterly immersed in subluxation-rhetoric. ALL made overt claims for more than a dozen conditions positively treated by their “advanced methods” of detection and correction. ALL directly or indirectly claimed “health” was at risk by leaving chiropractic-adjustments out of your lifestyle.
      Here are 2 very typical examples: “chiropractic isn’t just about pain….! DCs are the ONLY health professional that specializes in removing misalignments in the spine that affects your child’s nervous system function”.
      OR: “Dr H uses the most advanced adjusting tool on the market: the Impulse IQ. The correction of these subluxations helps improve function of the nerves and muscles so the body can heal itself. It takes a series of adjustments to allow enough time for this to happen”. And on and on and on and on it comes.
      And I didn’t even include those entrepreneur-extraordinaires defrauding the public with “functional medicine”, stem-cells, Foot Leveler orthotics, functional-movement-screen or AK based nutritional and allergy analysis.
      You DCs should be proud. But deluding yourself that your 8000 close friends doing evidence-based “treatments” constitute the majority of chiroquackers is just that, a delusion.

      • I did something similar and got a similar result:

        • I’m really not surprised. What else is chiropractic?!

          But I freely admit I had not previously heard of BJ Palmer’s ‘big idea’. I have great difficulty imagining that any reasonable person reading DC’s post above [Saturday 02 March 2019 at 14:15] and realizing the words come from BJ Palmer, the person who dreamt up chiropractic, could ever (a) want to become a chiropractor or (b) want to visit one.

      • Ignoring the issues with using Google (or whatever) as a “research method” my question was regarding The Big Idea…which goes way beyond “misalignment” or “subluxation”.

        I will take it that you don’t know the answer to my question.

  • The study was published in several conferences if you send me an email I will send you the proceedings. Because it was extensively published in conferences of chiro, Emergency medicine and Ortho we did not pursue journal publication. What is wrong with you people???

    • ” What is wrong with you people???”
      nothing – some of us merely like peer-review

    • I sent an email to you Dr. Guy Almog requesting the paper. I, unlike some, feel confident to evaluate the paper outside journal peer review. Thank you.

    • just googled you and found this:
      “Guy Almog is a Head of chiropractors in the hospital, “Assaf Harofeh”. He was educated at the University of British Chiropractic AECC in Portsmouth. He is certified specialist in this field. Specialist in sports injuries and limb injuries in Sollihul hospital, England.”
      The last time I was there, the AECC was in Bournemouth!

  • if you googled me you will know that i have no website and my facebook page is only for informative articles. i do not publish myself or my services in any way shape or form and i avoid publicity in anyway i can. my clinic is very buisy and i work together with many GP’s and Ortho surgeons who i consider friends and collegues.
    the AECC at the time was affilliated with portsmouth uni and my BSc. and MSc. are from portsmouth uni. i don’t know where you got your info from. if you are intrested you can just ask me you will always get straight answers.

  • If its ok with you Prof. I will try and post it some how and give you guys the link.
    I don’t know the “heart 4U” company or website. As I told you maybe I am a bit old fashion but I have no website and I believe medical personnel should avoid PR. Now don’t jump at me… This is just my belief.

  • ” (b) want to visit one”

    And yet…

    “WASHINGTON, D.C. — Neck and back pain sufferers in the U.S. who saw healthcare professionals in the past 12 months for this type of pain were most likely to seek care from a medical doctor (62%) or a chiropractor (53%). About a third visited a massage therapist or a physical therapist for their neck or back pain (34% for each).”

    • @DC

      Duh! How many of these people have read the ‘big idea’? Chiros have been doing a great job of flim-flamming gullible marks for many years, and creating a false sense of trust. The ‘big idea’ should put that right.

      Hand them leaflets with the ‘big idea’ printed so they can give proper informed consent.

      • Again, what percentage of chiropractors hold to the Big Idea?

        • The Big Idea (as you presented it) is a hilariously transparent piece of nonsense. It clearly exposes the concept of chiropractic subluxations as a ridiculous fiction, for the sort of reason I already gave.

          How many practising chiros hold to the Big Idea I don’t know. But the proportion who subscribe to the fundamental chiropractic concept of spinal “subluxations” has been repeatedly surveyed. On this blog the most recent post to discuss this topic can be found here. Edzard’s conclusion in this post is trenchant and can be extrapolated to those who hold specifically to the Big Idea.

          “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!”

        • @DC; you need to get out and mingle with some real chiroquackers….not just those 8000 you have an intimate relationship with. My confusion however persists;
          Is it you and your alleged EB DCs who are practicing “real” chiropractic…OR the capacious number of DCs practicing subluxation correction?? And WHO-T-F are YOU to decide what “real”;chiropractic is??
          If you simply research “chiroquacker-colleges and the “big idea” you’ll be pleasantly surprised Few of them separate themselves from this core quackery principle. The largest and 2nd largest schools (Palmer and Life) have bigger than life size busts of the founding quacks AND plaques heralding the “idea” (and the profound value it has been to the human race) right there at their entrances.

          • I have had many contacts/discussions/debates with “chiroquackers”. Some of my social media groups have around 10,000 such members.

            It’s very unlikely you can provide any additional insight of this group.

    • @Guy Almog

      Thank you for providing a link to the details of the study you described in your comment of March 2nd.

      On a brief look through the study it seems to me the numbers of analysable patients in the three groups (16, 20 and 16) are far too small to draw any safe conclusions whatsoever.

      Some other points I’d regard as weaknesses… The end-points were first measured 30 minutes after drug treament then again after chiropractic or placebo Rx conducted straight after drug trteatment. Why was there no attempt to measure whether the apparently positive effects of chiropractic persisted at a later time point? Even a phone call to the patients 24 hours after ER admission would have provided some information on whether the positive effects of chiropractic were merely temporary.

      The weakest point I noticed was that in Fig. 2 there’s a large (positive) difference in the pain score for the group that received chiropractic treatment after drug Rx but before the manipulation happened! The text doesn’t mention this surely significant difference, but both the text and the figure are confusingly presented.

      The methods section mentions a questionnaire designed to reveal the success of the blinding process, but no results are presented.

      I appreciate the paper has not been peer-reviewed (any halfway decent referee would have a lot of points to raise). In a comment on March 3rd, in a moment of aggression, you wrote: “Because it was extensively published in conferences of chiro, Emergency medicine and Ortho we did not pursue journal publication. What is wrong with you people???” Edzard Ernst responded amiably “some of us merely like peer-review”. I’d go further: until a study has been published in a formal, archived, professional publication (which implies it would have undergone some level of peer review anyway) the study cannot be considered as seriously valid evidence. If you think that conference presentations, in which anyone can say or omit whatever they please, are a means of presenting your science to the world, you’re badly mistaken.

      I’m not in the least surprised that your study, in the version you have kindly linked to, is an inadequately powered, flawed attempt to prove a point. As such it has a lot in common with many other unconvincing clinical studies of chiropractic.

  • In this study, Efficacy of an Integrative approach Utilizing Chiropractic as an Add On Therapy for the treatment Back and Neck Pain in an Emergency Department Setting – A Comparative Randomized Controlled Trial (to which Guy Almog links above), references 4 and 5 are used to support the claim that “chiropractic has been found to be a safe and effective treatment for musculo-skeletal pain”.

    It’s worth noting that reference 4 is Thiel HW, Bolton JE, Docherty S, Portlock JC – Safety of chiropractic manipulation of the cervical spine: a prospective national survey. Spine 2007 Oct; 32(21): 2375-8 In it, over 50,000 neck manipulations were followed up and, apparently, none were found to have caused any serious side effects. However, Prof. Ernst questioned the study’s methodology:

    “The sample of this survey was sizeable but not large enough to exclude rare events. Thus the authors can only state that, at worst, the risk of serious adverse events within 7 days after manipulation is 2 per 10 000 treatment consultations. If the average patient has a series of 10 treatments, this risk could therefore be as high as 1 in 500 per patient. Given the nature of the risk, i.e. stroke or death, this is by no means negligible.
    The picture gets more complicated when considering the 698 treatment consultations of patients who failed to return for their next treatment. Theoretically some or most or all of these patients could have died of a stroke. Overlooking even one single serious adverse event would change the estimated incidence rates from this study quite dramatically. In my view, the most confusing aspect about the results of this survey is the fact that the incidence of minor adverse events is so low. Previous studies have repeatedly shown it to be around 50%. The discrepancy requires an explanation. There could be several but mine goes as follows: the participating chiropractors were highly self-selected. Thus they were sufficiently experienced to select low-risk patients (in violation of the protocol). This explains the low rate of minor adverse events and begs the question whether the incidence of serious adverse events is reliable.
    Studies of this nature are very difficult to conduct such that we can trust the results. One of the problems is that one has to rely on the honesty of the participating therapists who could have a very strong interest in generating a reassuring yet unreliable picture about the safety of their intervention.”
    Ref. Ernst, E. Focus Altern Complement Ther 2008; 13: 41–2

    Interestingly, in their response, two of the survey’s authors, HW Thiel and JE Bolton (both of the Anglo European College of Chiropractic), claimed that in the UK alone there were an estimated *four* million manipulations of the neck carried out by chiropractors each year. Yet, six months earlier, in October 2007, in a letter to the Journal of the Royal Society of Medicine, they claimed that the figure was estimated to be well over *two* million cervical spine manipulations. See:

    How that estimate could double in under six months is anyone’s guess, but it leaves them open to accusations that they may have been trying to play down the risks.

    With regard to reference 5, the United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ. 2004 Dec 11;329(7479):1377. Epub 2004 Nov 19, it was also criticised by Prof Ernst:

    “My reading of the results is that the data are compatible with a non-specific effect caused by touch: exercise has a significantly positive effect on back pain which can be enhanced by touch. If this ‘devil’s advocate’ view is correct, the effects have little to do with spinal manipulation per se. It would be relevant to know which of the three professional groups (chiropractors, osteopaths, physiotherapists) generated the largest effect size. This might significantly influence the referral pattern. A post-hoc analysis might answer this question. It is regrettable that the study only monitored serious adverse effects. There is compelling data to demonstrate that minor adverse effects occur in about 50% of patients after spinal manipulation. If that is the case, such adverse events might also influence GP’s referrals.”


    • Oh, I think one needs to question Ernst ability to comprehend and accurately report on the topic of serious AE from spinal manipulation done by chiropractors. Example….

      “RESULTS The review of the 32 papers discussed by Ernst found numerous errors or inconsistencies from the original case reports and case series. These errors included alteration of the age or sex of the patient, and omission or misrepresentation of the long term response of the patient to the adverse event. Other errors included incorrectly assigning spinal manipulation therapy (SMT) as chiropractic treatment when it had been reported in the original paper as delivered by a non-chiropractic provider (e.g. Physician).The original case reports often omitted to record the time lapse between treatment and the adverse event, and other significant clinical or risk factors. The country of origin of the original paper was also overlooked, which is significant as chiropractic is not legislated in many countries. In 21 of the cases reported by Ernst to be chiropractic treatment, 11 were from countries where chiropractic is not legislated.”‘Adverse-effects-of-a-Tuchin/54539726e80e6574ecb1bb230fd0e00763ecfc85Y

      (I’ve consistently been dealing with this “reCAPTCHA v3 test failed” on this sight. Too much time spent simply trying to post. Toodles).

  • Thiel study was well designed and carried out. The claim of safety does NOT exclude the chance for serious side effects. Safety is a matter of numbers, we can argue the safety of cervical manipulation in comparison to NSAID’s the numbers will surprise you and I personally am in favor of carful use of both.

    Last point regarding safety… I believe the best people to establish professional safety are the insurance companies. The fact that chiropractors insurance premium is comparable with physios and other Rehabilitative professionals says it all.

    • someone points out several serious flaws of a study —> you ignore them and respond stating the study was well designed and carried out.
      did they not teach you to think at the chiro-school?

  • 1. No comment was made regarding the summery I sent.
    2. You can critique every paper but Thiel study stands firm and his conclusions are carefully worded and precise.
    3. I was tought in chiro school to argue the science and respect all professionals.
    4. Can you answer the 2 points I made earlier without personal insults?

    You know if you claim to pursue EBM you might have to change your mind from time to time… This is also tought at chiro school at day 1.

    • @Guy: LOL, taught to “argue the science”. I think you meant to say “argue against science”….”and disparage every profession that dares use real science and decry quackery.

  • Please let’s keep to the point… If you read any unscientific claim I have made or any disrespectful remarks please let me know.

    • @Guy Almog

      Please see my critique of your study above. Your claims about the study appear to be unscientific.

    • @Guy: your inexplicable decision to pursue a profession of quackery is on you and your ilk. However the problem persists regarding science vs. religion. Science changes, religions (core beliefs; dogma) do not.
      A profession which “morphs” into or simply tries to usurps another’s identity isn’t interested in science per se but is simply refusing to die-off (as it rightly should)…it’s trying to reinvent itself to maintain financial relevance. That is a tiny minority of DCs (those pretending to be PTs or exercise physiologists without the proper license) the vast majority continue to chase the snipe they were taught by DD and BJ: “the magical big idea”. Again, visit websites, read what the college websites say about “health and chiropractic adjusting”. It ain’t changed in 120 years.
      Could a $200,000 “education” with a (fake) doctorate really be defensible without “it”? If all you DCs ever did was give transient relief to 40% (60% being irritated) for some MSK condition (typically the self-limiting ones only) how do you defend the “education” AND the $500 million US Medicare paid to DCs in 2017? And the billions private insurers paid (only 12% of DCs have cash-only businesses).
      Laying people on a table, palpating their spine (or extremities), checking their leg-length, pretending to deduce important information regarding pain, health and wellness via this religion…then whacking the “misaligned-ones back in” to “free innate” simply doesn’t warrant respectful interchange. Sorry but I feel the same way about bowing to Mecca 5 times a day or transubstantiation of the host. It’s nuttz and promulgated by people uninterested in truth or science or justice.

  • @ DC

    Re the study by Peter Tuchin which you reference above

    It appears that Tuchin is not a good example of a researcher who is capable of profound critical thinking. For example, in the following letter to an editor he references the dubious chiropractic researchers Cassidy, Goertz, and Hartvigsen in support of his arguments:

    You can read the background to some of Cassidy’s research here:

    And here’s some criticism of Christine Goertz, DC:

    “This trial follows the infamous ‘A+B versus B’ design. It will almost always generate a positive result – so much so that it is a waste of time to run the study because we know its findings before it has started. And if this is so, the trial is arguably even unethical.” Ref:
    Unfortunately for science, Goertz is Vice Chair-person of the Patient-Centered Outcomes Research Institute (PCORI), an independent non-profit organisation, which has allocated $5.7 million to fund “a study of access to holistic therapies for treating low back pain, including massage, acupuncture, osteopathy, chiropractic…”

    As for Jan Hartvigsen, DC, he had a major research role in the recent Lancet Back Pain series of papers which were met with severe criticism:


    And yet, in March 2019, Hartvigsen is giving an address entitled ‘Lessons from The Lancet: Our Great Global Opportunity’ at a large chiropractic convention:
    Ref: (p. 5)

    • Was Peter wrong regarding any of his critique of Ernst paper?

      • @ DC

        Yes, IMO Peter Tuchin (GradDipChiro) was wrong in his critique of the Ernst paper.
        [Ref. ]

        For a start, he claimed “Spinal manipulation therapy has strong evidence for treatment of low back pain, neck pain, headache and migraine [2-6]. This is supported by numerous systematic reviews of a large number of randomized controlled trials [7-10].”

        In reality, the evidence is not strong. It’s almost akin to a placebo response. Most notably, in support of his argument, he cites the UK BEAM Trial, The Meade Report, and two Bronfort papers. These have all been shown to be seriously flawed. He also cites the European Guidelines for the Management of Chronic Nonspecific Low Back Pain in which Alan Breen, DC, Professor of Musculoskeletal Health Care at the Anglo European College of Chiropractic, was a collaborator. With the regard to the development of the guidelines, it’s worth noting some of Prof. Edzard Ernst’s comments on official guidelines for the treatment of back pain:

        “Chiropractors argue that their approach must be safe and effective, not least because the official guidelines on the treatment of back pain recommend using chiropractic. However, this is true only for some, but by no means all, countries. Secondly, guidelines are well known to be influenced by the people who serve on the panel that develops them.”


        You can learn more about Breen here:

        Tuchin then goes on to say “Adverse events following SMT are common but usually result in minor, short term problems [11-14].” In support of this, one of his citations is the dubious Thiel and Bolton study, although I have to say that, overall, it’s curious that given that catastrophic complications are on record Tuchin fails to factor in responsible risk/benefit assessments. He also fails to highlight that there are no *reliable* screening methods available to determine which patients might be predisposed to complications and that strokes following neck manipulation can be delayed.

        Tuchin concludes thus: “The general quality of the original case information used by Ernst was poor, which should have called into question the conclusions published in the 2007 Ernst paper. The lack of clinical detail in the original cases does not allow adequate conclusions to be drawn from these cases. For example, the vast majority of the original cases did not contain information about well-established confounding variables for these types of cases. Subsequently, no conclusions can be correctly derived about the impact of SMT on the development of VAD. The author of the 2007 paper should have concluded previous cases material was inadequate for any relationship between SMT and VAD to be assessed. The terms chiropractic treatment, chiropractic manipulation, chirotherapy and/or chiropractic procedure were used repeatedly, without identification of the practitioners’ qualifications. A study by Terrett found that ‘the words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organisations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a non-chiropractor’.”

        Rather than critique Tuchin’s conclusion, I think it’s more useful to post, in full, Prof. Ernst’s response to the criticism of his original paper:

        “I am impressed by the flurry of interest in my systematic review (JRSM 2007:100:330–338). The commentators make several general and some specific points which deserve an answer. Generally, the letter writers seem to think I should ‘take a more positive attitude’. Reviewing the risks of therapeutic interventions may look negative to those who make a living out of using them. However, in truth it is motivated by our desire to render our future health care safer. The commentators, I think, confuse ‘negative’ with ‘critical’, and I should point out that an uncritical scientist is a contradiction in terms. Another general theme of these letters is the claim that I ‘indiscriminately’ used ‘low-level evidence’. Systematic reviews on safety issues always have to rely heavily on case reports, many of which lack sufficient detail and thus conclusiveness. Yet when case-reports accumulate (in the case of chiropractic about 700 incidents have been published), they can send an important signal. To ignore it because of the low-level argument would quite simply be irresponsible. Moreover, I did, of course, report high-level evidence where this was available; the problem here is that such evidence is scarce and fails to confirm the view that spinal manipulations are low-risk. Several commentators criticize me for not discussing the frequency of serious adverse events and some even provide data of their own. They must have missed a whole section of my paper where I do discuss these issues. But let’s look at their figures: Bolton and Thiel state that there are over 2,000,000 cervical spine manipulations each year. Our UK survey disclosed 35 serious adverse effects within one year (JRSM 2001;94:107–110).2 Under-reporting was 100% in our series; this renders the calculation of any incidence impossible, so let’s be optimistic and assume it is only 90%. One severe adverse effect would thus occur in about 5,700 spinal manipulations. Assuming that, on average, patients receive about 30 spinal manipulations during the course of a treatment (three per session, 10 sessions per course), the figure would indicate that one in about 1,900 patients could experience a severe adverse effect. Of course, this is back of the envelope stuff, but it nevertheless might indicate that the true incidence of adverse events is quite different from what chiropractors believe. There seems to be a general consensus amongst the letter writers that my conclusions were ‘unjustified’. So let me re-state them: ‘Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissections followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.’ To reconsider policy is not to ban! But to ignore such data would be to fail the public’s interest. Several commentators make specific comments that cannot be left unchallenged. The Chairman of the GCC states that his institution ‘requires all chiropractors to explain to patients the risks and benefits’ of chiropractic. Langworthy et al. recently showed that ‘only 23% [of UK chiropractors] report always discussing serious risk’.3 Is Dixon implying that 77% of all UK chiropractors are being summoned before the GCC’s disciplinary panel? The President of the BCA accuses me of ‘misquotes and errors’ and of puffing up evidence ‘out of all proportion’. Should he not provide evidence for his allegation? He also asks whether we would ban injections because they cause inflammation and hurt—to which the answer must be yes, definitely, if these injections are not demonstrably effective! Mr Johnson states that ‘systems are in place for adverse event reporting of spinal manipulation’. Yet the Chair of the NCOR confirms that ‘spinal manipulation is not currently subject to post-marketing surveillance’. Professor Grunnet-Nilsson states that ‘at least 20 other papers’ have already addressed my topic. Does he mean to say that we therefore do not need to update our knowledge— which, of course, was the stated aim of my systematic review? In conclusion, it is an important and positive move to keep potential risks of therapeutic interventions under close scrutiny. It is also good to discuss discrepancies of opinion openly. In doing so we should, however, abstain from ad hominem attacks and insults (e.g. ‘Professor Ernst . . . has a problem with chiropractic’ [Lewis], ‘Professor Ernst has published a so-called ‘‘systematic review’’ . . . unsubstantiated claims masquerading as a systematic review’ [Bolton and Thiel], ‘this . . . paper is embarrassing’ . . . [Grunnet-Nilsson]). Scientific disputes are productive: mud battles are not.”


        • BW. Thank you for your response.

          If Ernst is correct that “One severe adverse effect would thus occur in about 5,700 spinal manipulations…” and if that applies to US chiropractors, that would equate to around 175 serious adverse events occurring every business day (around 1 million spinal adjustments are performed per business day by chiropractors) or around 45,000 serious AE per year. Yet in the course of history, according to Ernst, only 700 have been reported in the literature (in the past 120 years or so?) and mainly in the form of case reports, in which causality cannot be determined. It does seem the 1/5,700 is questionable.

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