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

A new update of the current Cochrane review assessed the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain. The authors included all randomised controlled trials (RCTs) examining the effect of spinal manipulation or mobilisation in adults (≥18 years) with chronic low back pain with or without referred pain. Studies that exclusively examined sciatica were excluded.

The effect of SMT was compared with recommended therapies, non-recommended therapies, sham (placebo) SMT, and SMT as an adjuvant therapy. Main outcomes were pain and back specific functional status, examined as mean differences and standardised mean differences (SMD), respectively. Outcomes were examined at 1, 6, and 12 months.

Forty-seven RCTs including a total of 9211 participants were identified. Most trials compared SMT with recommended therapies. In 16 RCTs, the therapists were chiropractors, in 14 they were physiotherapists, and in 5 they were osteopaths. They used high velocity manipulations in 18 RCTs, low velocity manipulations in 12 studies and a combination of the two in 20 trials.

Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short term pain relief and a small, clinically better improvement in function. High quality evidence suggested that, compared with non-recommended therapies, SMT results in small, not clinically better effects for short term pain relief and small to moderate clinically better improvement in function.

In general, these results were similar for the intermediate and long term outcomes as were the effects of SMT as an adjuvant therapy.

Low quality evidence suggested that SMT does not result in a statistically better effect than sham SMT at one month. Additionally, very low quality evidence suggested that SMT does not result in a statistically better effect than sham SMT at six and 12 months. Low quality evidence suggested that SMT results in a moderate to strong statistically significant and clinically better effect than sham SMT at one month. Additionally, very low quality evidence suggested that SMT does not result in a statistically significant better effect than sham SMT at six and 12 months.

(Mean difference in reduction of pain at 1, 3, 6, and 12 months (0-100; 0=no pain, 100 maximum pain) for spinal manipulative therapy (SMT) versus recommended therapies in review of the effects of SMT for chronic low back pain. Pooled mean differences calculated by DerSimonian-Laird random effects model.)

About half of the studies examined adverse and serious adverse events, but in most of these it was unclear how and whether these events were registered systematically. Most of the observed adverse events were musculoskeletal related, transient in nature, and of mild to moderate severity. One study with a low risk of selection bias and powered to examine risk (n=183) found no increased risk of an adverse event or duration of the event compared with sham SMT. In one study, the Data Safety Monitoring Board judged one serious adverse event to be possibly related to SMT.

The authors concluded that SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.

This paper is currently being celebrated (mostly) by chiropractors who think that it vindicates their treatments as being both effective and safe. However, I am not sure that this is entirely true. Here are a few reasons for my scepticism:

  • SMT is as good as other recommended treatments for back problems – this may be so but, as no good treatment for back pain has yet been found, this really means is that SMT is as BAD as other recommended therapies.
  • If we have a handful of equally good/bad treatments, it stand to reason that we must use other criteria to identify the one that is best suited – criteria like safety and cost. If we do that, it becomes very clear that SMT cannot be named as the treatment of choice.
  • Less than half the RCTs reported adverse effects. This means that these studies were violating ethical standards of publication. I do not see how we can trust such deeply flawed trials.
  • Any adverse effects of SMT were minor, restricted to the short term and mainly centred on musculoskeletal effects such as soreness and stiffness – this is how some naïve chiro-promoters already comment on the findings of this review. In view of the fact that more than half the studies ‘forgot’ to report adverse events and that two serious adverse events did occur, this is a misleading and potentially dangerous statement and a good example how, in the world of chiropractic, research is often mistaken for marketing.
  • Less than half of the studies (45% (n=21/47)) used both an adequate sequence generation and an adequate allocation procedure.
  • Only 5 studies (10% (n=5/47)) attempted to blind patients to the assigned intervention by providing a sham treatment, while in one study it was unclear.
  • Only about half of the studies (57% (n=27/47)) provided an adequate overview of withdrawals or drop-outs and kept these to a minimum.
  • Crucially, this review produced no good evidence to show that SMT has effects beyond placebo. This means the modest effects emerging from some trials can be explained by being due to placebo.
  • The lead author of this review (SMR), a chiropractor, does not seem to be free of important conflicts of interest: SMR received personal grants from the European Chiropractors’ Union (ECU), the European Centre for Chiropractic Research Excellence (ECCRE), the Belgian Chiropractic Association (BVC) and the Netherlands Chiropractic Association (NCA) for his position at the Vrije Universiteit Amsterdam. He also received funding for a research project on chiropractic care for the elderly from the European Centre for Chiropractic Research and Excellence (ECCRE).
  • The second author (AdeZ) who also is a chiropractor received a grant from the European Chiropractors’ Union (ECU), for an independent study on the effects of SMT.

After carefully considering the new review, my conclusion is the same as stated often before: SMT is not supported by convincing evidence for back (or other) problems and does not qualify as the treatment of choice.

108 Responses to Update on spinal manipulation for back pain confirms: it is not the treatment of choice

  • Dear professor,
    I will of course take the time to study the chocrane review, especially the amazing difference between their conclusion and your conflicting headline.

    However I noticed more than half of the studies reviewed had nothing to do with chiropractic but all of your criticism involved chiropractors. Please notice the fact that I know you like to dismiss. SMT is part of the techniques chiropractors use but it is NOT chiropractic. Please try and stick to science and evidence. The debate is of spinal manipulation for chronic non specific low back pain and not chiropractic.

  • A pity the review did not clarify what is meant by SMT — does it mean the Thrusts known as Spinal Manipulation for supposed sublaxions performed by chiropractors or the manual therapy performed by pyyhsiotherspists known as i understand as spinal mobilisation? It is an important distinction becsuse the manual therapy offered by physios is part of a short term approach combined with empowering the patient in the longterm with exercise and an understanding of pain. The SMT performed by chiropractors is part of a totally different approach – namely of diagnosing a skeletal ‘ defect ‘ sowing the seeds of permanence and then commiting the patient to a longterm therapy. I see nothing wrong with a short term therapy to relive pain , geting the patient in a good mental state so that he is equipped to start to self manage.- this being the aim of a good physiotherapist

    • yes; but they did specify that the primary investigators were trained as chiropractor in the studies with the following reference numbers:28 29 34 40 41 44 45 46 51 67 69 (and similarly for other professionals too). with that information one can try to sort out your question

      • the way it looks to me, after just glancing at this, is that SMT done by one profession is not significantly better than done by another. but that needs a more in-depth analysis to be sure.

  • Dear ‘professor’

    “SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term.”

    It appears SMT for chronic non specific LBP is as good but not better than other recommended treatments. It is therefore a legitimate technique as part of the entire clinical management. Again, the review discussed the use of manipulation NOT the practice of chiropractic. I am sorry it does not fit your political agenda.

    “Update on spinal manipulation for back pain confirms: it is not the treatment of choice”

    Cheap manipulation of the recommendations.
    Is there any “treatment of choice”?
    does the review even examine what is the treatment of choice in non-specific chronic LBP?
    Does the review discuss patient selection to even begin choosing a preferable technique?

    Why manipulate the science? Why can’t you openly discuss the issue with its complexities and limitations without coming out with bogus headlines that have NOTHING TO DO with the Cochran review.

    In case you are actually intrested in the science I offer you read:
    Clinical practice guidelines for the management of nonspecific low back pain in primary care: an updated overview” by Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CWC, Chenot JF, van Tulder M, Koes BW (2018) Eur Spine J

    • which political agenda?
      I am reporting the findings of a review and providing my comments based on many years of research experience on the subject.
      show me where I reported anything with an ‘agenda’ or stop stating nonsense.

  • Kuczynski, in IJOSPT 2012 published: Effectiveness of PT administered SMT for LBP: a systematic review and found SMT across professions yeilded equal outcomes.
    These chiroquackers are so partisan and up to their Atlas’s in financial-protectionism they make politicians look like philanthropists. Every time a “DC”, “Dr (of quackery) or a “different-kind o’chiropractor” posts a comment it’s like putting sand in sex lubricant. Shakespeare said “if you have not a virtue adopt one”….that’s the deal every time a chiroquacker starts a sentence with: “the science says…”.

  • I still have not received an answer to the questions I frequently pose:
    Why do not those with an interest in spinal malfunction/pain/disability, train as doctors (MDs) or physiotherapists and then, if they are still so minded, specialise in ‘chiropractic’ as post-grads?

    Presumably, because they want to join a ‘profession’ set up by its founder as an alternative to medicine, and placing reliance even today on out-moded concepts of vitalism and ‘subluxations.’

    Presumably such practitioners like to style themselves as ‘doctors’ because they wish to gull vulnerable patients.
    I cannot imagine any other reason.

    If they were proud of their ‘profession’ they would style themselves as ‘Chiropractor X’ (Cp X) – as a priest might be ‘Rev.’or a military officer, ‘Lt.’.

    SMT may well have beneficial effects, but what is it that ‘chiropractic’ does that could not be done by other practitioners trained in SMT?
    I.e.: “What is the point of chiropractic?”

    • one could almost come to the conclusion that DC stands for ‘Doctor of Charlatanry’.

      • ‘Doctor of Charlatanry’
        “chiroquacker”
        Are now winning arguments.
        @Richard Rawlins
        Are MDT, Maitland, Mulligan, PIM, MET, Neurodymanics, Traction etc all the same and would just one approach help everyone?

  • “In 16 RCTs, the therapists were chiropractors, in 14 they were physiotherapists, and in 5 they were osteopaths. They used high velocity manipulations in 18 RCTs, low velocity manipulations in 12 studies and a combination of the two in 20 trials.”
    But
    “Less than half the RCTs reported adverse effects. This means that these studies were violating ethical standards of publication. I do not see how we can trust such deeply flawed trials.”
    Chiropractic – 28 29 34 40 41 44 45 46 51 53 54 55 66 67 69 70.
    Physiotherapy – 27 30 33 36 39 43 47 48 50 57 58 59 63 64.
    medical manipulator or orthomanual therapist – 31 35 52 56 60 68.
    osteopath – 32 38 49 65 72.
    Trials that reported Adverse Events – 27 28 29 30 31 33 34 35 36 40 41 43 44 45 51 56 60 61 62 67 70 71 72.
    Chiro = 7/16
    Physio = 5/14
    Medical Manipulator = 4/6
    According to the regulars here chiro’s bury their heads in the sand when it comes to adverse events.
    The “deeply flawed trials” must be the chiro trials.
    Forget the rest and just make it a “cheap shot” on chiropractic and while we’re at it lets attack the lead author while ignoring the co-authors. Have you bothered to check then as well Edzard? Here you go I’ll make it easy for you:
    https://www.researchgate.net/profile/Marienke_Middelkoop
    https://www.researchgate.net/scientific-contributions/2120214420_Willem_J_J_Assendelft
    https://www.researchgate.net/profile/Michiel_Boer
    https://www.researchgate.net/profile/Maurits_Tulder
    But hay why pass up the opportunity to just make it a “cheap shot” on chiropractic to quote highly regarded physio researcher Steve Kamper.

    • and where exactly did I make this ‘cheap shot’?it was a chiro-promoter who made the ‘cheap shot’:
      Any adverse effects of SMT were minor, restricted to the short term and mainly centred on musculoskeletal effects such as soreness and stiffness – this is how some naïve chiro-promoters already comment on the findings of this review. In view of the fact that more than half the studies ‘forgot’ to report adverse events and that two serious adverse events did occur, this is a misleading and potentially dangerous statement and a good example how, in the world of chiropractic, research is often mistaken for marketing.

      SO PERHAPS YOU WANT TO DIRECT YOUR CRITICISM IN ANOTHER DIRECTION?

    • I know these chaps personally, have shared platforms with them, and have co-authored articles with some of them.

    • The chiroquacker commentaries are so rife with financial & egoistic-protectionism bias they are painful to read. Interesting how they accuse Dr Ernst of being biased…his being towards truth. A concept quacks find impossible to accept.

      • Edzard.
        Sidney Rubinstein, Annemarie de Zoete, Marienke van Middelkoop, Willem J J Assendelft, Michiel R de Boer and Maurits W van Tulder have written a balanced review:
        “Implications for clinicians
        SMT can be delivered as a standalone therapy, although it is typically offered within the constructs of a broader treatment package, together with exercise therapy or combined with usual care, as is recommended in recent national guidelines for low back pain.582 This is important because SMT is by nature a passive treatment. Therefore, to prevent inappropriate behaviour and to empower patients to take control of their condition it is vital that practitioners impart the proper message to their patients.

        The incidence of adverse events and serious adverse events based on the studies included here are difficult to assess because less than half of the randomised controlled trials examined these, and in most of the studies the methodology was unclear. Importantly, given the low incidence of serious adverse events, randomised controlled trials are not the design of choice. Based on a recent systematic review, serious adverse events after SMT for low back pain are thought to be rare and include case reports of cauda equina syndrome, fractures, and neurological or vascular compromise.83 A recent comprehensive scoping review, which examined the risks of manual treatments to the spine, identified 250 articles in which serious adverse events were reported. Most of these focused on adverse events after treatment to the neck.84 The body of evidence, which includes data from large, prospective observational studies of SMT, suggests that benign adverse events are common and serious adverse events are rare. The incidence and causal relations with serious adverse events are difficult to establish, in part due to inherent methodological limitations of the included studies. Importantly, predictors of these events are unclear. Given this, clinicians should ensure that patients are fully informed of potential risks before treatment.”

        Their discussion of the implications and limitations as well are balanced and unbiased.

        “All authors critically revised the article for important intellectual content and gave final approval for the article”.

        “All authors” yet you single out the chiropractors?

        • I mentioned the conflicts of interest where they were provided. how is that ‘singling out’?

          • You take a balances well written review, pick out a couple of points and turn it into a negative.
            Do you agree or disagree with what the authors wrote above and the discussion?

    • Crackpot_Chiro,
      Are you still peddling the same nonsense? At least you provide some humour here.

  • @“Dr Guy”: “It appears SMT for chronic non specific LBP is as good but not better than other recommended treatments. It is therefore a legitimate technique as part of the entire clinical management. Again, the review discussed the use of manipulation NOT the practice of chiropractic”.
    So chiroquacker management also includes AK, leg length assessment, allergy testing, thermography, energy-balancing, cranial-manipulation etc etc…and MANY chiroquackers have abandoned SMT for Activator, Impulse, Pro-Adjustor and other arcane scams. WHY, if the “science” and effectiveness of SMT is so obvious would those dolling it out daily switch to total BS scams? Perhaps because “it” (manual therapy) is ALL based on temporary placebo and non-specific effects? It matters not WHAT you dispense…it matters entirely what rhetoric accompanies it to ensnare the gullible and non-science minded.
    And if you are proposing that an education and a license as a “doctor of subluxations” somehow also gives you inclusion rights into exercise-physiology, biomechanics and physical therapy I’d suggest you thoroughly investigate then pursue one of those real degrees instead and understand your woeful inadequacy.

  • Sorry Sir you DID NOT report the outcome of the chocrane review you stated a headline that has nothing to do with the review published.
    Again I ask you

    Where was there any statement regarding the “treatment of choice” in the published review?

    • “you DID NOT report the outcome of the chocrane review”
      WRONG!
      “you stated a headline that has nothing to do with the review published”
      THE HEADLINE REFERS TO MY COMMENTS AND INTERPRETATION OF THE REVIEW
      “Where was there any statement regarding the “treatment of choice” in the published review?”
      MY BLOG OFFERS COMMENTS AND INTERPRETATIONS OF THE EVIDENCE.

      GOT IT?

      SORRY THAT YOU TAKE A WHILE TO COMPREHEND SIMPLE THINGS.

      • You know well that if a chiropractor was “interpreting” a paper conclusion in such an inaccurate way you would have had a field day.

        No one claimed SMT to be the treatment of choice and the review did not discuss that question at all.

        • are you deaf?
          my comment is partly about this – are you saying I am not allowed to put such an important point in a comment?
          get real!

  • As for the review published I myself find it quit useless.

    I don’t know what is ” non specific low back pain”, I know what is facet sprain strain or internal disc derangement or facet cyst or myofacial pain etc… And the protocols I am using are diagnosis based and so such a broad conclusion does not help me improve my practice.

    • bearing in mind that the methods to arrive at ‘diagnoses’ are not validated, this is a fairly daft statement.

    • if that were so then the chirpractic you offer would be targeted precise and short term – as opposed to what is offered which is defect based , long term and not evidence based. You confuse treatment for acute with chronic but offer the same treatment for both

    • “Nonspecific low back pain is pain not attributed to a recognizable pathology (e.g., infection, tumor, osteoporosis, rheumatoid arthritis, fracture, inflammation).” https://www.aafp.org/afp/2011/0815/p437.html

    • @ faux-doctor-guy: Interestingly having recently seen information about the “facet pain” to which you are so adept at recognizing:
      J Anesthesiol. Nov 27, 2015; 4(3): 49-57
      doi: 10.5313/wja.v4.i3.49
      Zygapophysial joint pain in selected patients
      Stephan Klessinger: Department of Neurosurgery, Nova Clinic Biberach, 88400 Biberach, Germany
      Abstract:
      “…The importance of the z-joints as a pain generator is often underestimated because the prevalence of z-joint pain (10%-80%) is difficult to specify. Z-joint pain is a somatic referred pain. Morning stiffness and pain when moving from a sitting to a standing position are typical. No historic or physical examination variables exist to identify z-joint pain. Also, radiologic findings do not have a diagnostic value for pain from z-joints. The method with the best acceptance for diagnosing z-joint pain is controlled medial branch blocks (MBBs). They are the most validated of all spinal interventions, although false-positive and false-negative results exist and the degree of pain relief after MBBs remains contentious. The prevalence of z-joint pain increases with age, and it often comes along with other pain sources. Degenerative changes are commonly found. Z-joints are often affected by osteoarthritis and inflammatory processes. Often additional factors including synovial cysts, spondylolisthesis, spinal canal stenosis, and injuries are present. The only truly validated treatment is medial branch neurotomy. The available technique vindicates the use of radiofrequency neurotomy provided that the correct technique is used and patients are selected rigorously using controlled blocks”.

      And by Bogduk; 2010 On lumbar blocks:
      “This is not a problem for cervical medial branch blocks because the prevalence of cervical zygapophysial joint pain is 60% [14], and the diagnostic confidence is 81%. Lumbar zygapophysial joint pain is not that common. The more favourable estimates place its prevalence at about 40%; more critical estimates place it as low as 5% [1,10]. In the case of the former, one in three diagnoses will be wrong; in the case of the latter, seven in eight will be wrong.
      For these reasons, comparative local anaesthetic blocks are not valid for the diagnosis of lumbar zygapophysial joint pain. The only means by which a practitioner can become confident that their patient actually does have lumbar zygapophysial joint pain is to perform placebo-controlled, diagnostic blocks. Without this measure, practitioners will overestimate the prevalence of lumbar zygapophysial joint pain; an inordinate number of patients will be accorded an incorrect diagnosis and be directed to inappropriate treatment”.
      I’m anxious to see what technological-advances you DCs are using in your clinical findings of “facet” sprains and pain?
      Aside from AK, motion-palpation and short-leg analysis…

  • oops – my reply was to ‘Dr Guy ‘

  • The section that contains the most applicable insight since very few appear to use SMT as a sole modality in clinical settings.

    SMT as adjuvant therapy

    Seven studies examined the adjuvant effects of SMT when combined with other therapies.35454956646573

    Pain—Moderate quality evidence suggested that SMT results in a small, statistically significant but not clinically better effect at one month and 12 months, and low quality evidence that SMT does not result in a statistically better effect as an adjuvant therapy at six months (fig E in appendix 5).

    Back specific functional status—Moderate quality evidence suggested that SMT results in a small, statistically significant and clinically better effect at one month, and low quality evidence that SMT results in a small, statistically significant and clinically better effect at 12 months, but not statistically significant effect at six months (fig F in appendix 5).

  • The problem boils down to the title:
    “Update on spinal manipulation for back pain confirms: it is not THE treatment of choice”.
    Spinal manipulation is not THE only treatment provided by chiro’s unless you are a subluxation buster.
    Chiropractic is not a technique.

    • we have discussed the reasons why chiros want to re-invent themselves and prefer your definition often enough.
      here you find many attempts to define chiropractic, and by no means all agree with the self-serving one you and many chiros now prefer:
      https://www.jpsmjournal.com/article/S0885-3924(07)00783-X/fulltext
      WIKI is also interesting: “Chiropractic is a form of alternative medicine mostly concerned with the diagnosis and treatment of mechanical disorders of the musculoskeletal system, especially the spine. ”
      DD Palmer himself reasoned that “chiropractic was a cure for many diseases because it went directly to the cause.”

      A PROFESSION CANNOT BE A CURE!
      right?
      got it?
      chiros may re-define themselves, but that does not mean that I or other critical analysts have to go along with their game of smoke and mirrors.

    • The “treatment of choice” for most chiropractors is a multimodal approach.

      According to the latest Job Analysis:

      In 2014, 98.8% of chiropractors gave ergonomic/postural advice and 98.5% promoted physical fitness/exercise on a daily basis.

      In 2009, 96.8% utilized corrective or therapeutic exercise and 92.3% performed rehabilitation/stabilization exercises of the spine.

      Thus, very few (less than 1%?) would only use spinal manipulation for all their chronic low back pain patients.

      • I know you have difficulties understanding this – so, let me put it simply:
        The “treatment of choice” for most surgeons is a multimodal approach.
        practically all use medications, counselling, wound care, etc.
        all use surgery and every assessment of surgeons would focus on their surgery.

        ALL CHIROS USE MANIPULATIONS AND EVERY ASSESSMENT OF CHIROS MUST FOCUS ON MANIPULATION

        got it?

        • Duh. Of course chiropractors assess for the appropriate use of spinal manipulation. They also assess to see if ergonomic changes are needed, if rehab is needed, if referral is needed, if co-management is needed, if lifestyle changes are needed, etc, etc.

          Let me put it simple for you since you seem to have problem understanding this…

          You can’t reduce a profession to a single modality when they use a multimodal approach.

          • “Of course chiropractors assess for the appropriate use of spinal manipulation.”
            yes, I know.
            but that’s hardly enough.
            what needs assessing is the efficacy and the risks of SMT
            and that needs to be done by experts who have no axe to grind: non-chiros.
            “You can’t reduce a profession to a single modality when they use a multimodal approach.”
            so, if surgeons prescribe efficacious pain-killers, they are ok, even if they do useless and dangerous operations?
            ONE HAS TO ASSESS CLINICIANS ON THE BASIS OF THEIR HALLMARK TREATMENT!

          • Their “hallmark treatment” is a multimodal and wholistic approach. Heck, even DD Palmer mentioned the health benefits of exercise…I believe around 1908.

          • Heck no!
            advice to exercise is what all do, even my gran did it.
            a HALLMARK treatment describes a therapy that is common and characteristic to a profession.

          • The hallmark of the chiropractic profession is a conservative approach to nonspecific spinal conditions.

            Within that conservative approach is to incorporate spinal manipulation, exercise, rehab, ergonomics, lifestyle advice, etc as deemed appropriate for that case.

            You seem to be stuck in 1895.

          • “Let me put it simple for you since you seem to have problem understanding this…”

            Another dopey chiro pretending to be clever and failing badly.

          • @DC
            How dare you challenge one of the tenets of the faith of the cynics on this blog.
            Tennet #1. ALL chiropractors believe in mythical subluxations.
            Tennet #2. ALL chiropractors just crack backs.
            To question these beliefs would be painful just like the evangelical subluxation chiropractors.
            The irony is that they both use the same arguments

          • Critical_Chiro….yes, I’ve seen it often with so called skeptics, they become what they hate…they turn into pseudoskeptics (or reveal that they always were such)

            But I do understand their desire to reduce chiropractic to a single modality and base it off a 120 year old philosophy…that’s an easy target.

    • It seems to me real science-based endeavors and many millions of educated people in real, substantial industries make up the “medical” world. Surgeons, medical doctors, lab techs, pharmacists, PhD chemists, physiologists, hematologists etc etc etc. all try to contribute REAL insights.
      I don’t see this “industry” always making up excuses as to why they, or the general populace need to be involved in “medicine”….or strive to add to this body of knowledge, or seek its experts when sick.
      Chiropractic on the other hand MUST solicit and self-aggrandize….it distances itself, overtly or covertly, with “medicine”. It foists suggestions of “natural”, god-given, wholistic-insightful, super-mundane treatment options as an alternative to real-science….and makes up its own body of proof.
      They circle their wagons and play protectionism better than any other religion save Scientology. They make sure their well-heeled marketing arm has a retort to every nay sayer. WHY? Could it be that the foundation on which it is build is at best faulty, at worse non-existent? And any investigative wind that blows along could upset the apple cart? Since it is rhetoric, not results or substance that drives the gullible to a DC I can fully understand why trying to shout down every critic with banal, arcane and pseudo logic is co compelling to these cultists.

  • As a chiropractor as opposed to a physiotherapist, I can be licensed to take my own x-rays as imaging is essential to provide modern day chiropractic spinal rehabilitation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024283/
    That is one of a number of reasons why I prefer to be a chiropractor.

  • taking xrays is completely against the guidelines for treating back pain skeletal issues. images show show up natural progression of skeleton but chiros use what they find as the reason why their treatment is needed. they make the false assumption that there is a ‘ perfect’ skeleton and then diagnose any thing that differs as needing their treatment. It is absolutely flawed thinking.

    • HEAR, HEAR

      • X-ray guidelines do exist that dictate the use of x-ray for chiropractic management, especially structural rehabilitation. https://www.chiropractic.org/radiology-guidelines/

        • An interesting document.

          Title: “Practicing Chiropractors’ Committee on Radiology Protocols (PCCRP) For Biomechanical Assessment Of Spinal Subluxation In Chiropractic Clinical Practice”.

          Section V: “Vertebral subluxation should be maintained as the primary health disorder that comprises the Chiropractic professions identity”. The section goes on to define 6 structural categories of subluxation and that radiography is indicated for the qualitative and/or quantitative assessment of the biomechanical components of these six categories. Perhaps I’m naive, but this strongly suggests to me that radiology must indeed be the norm for chiropractors.

          The document is 10 years old. We have chiros repeatedly assuring us on this blog that the ‘profession’ is undergoing reform and that ‘subluxations’ are a thing of the past. So either the document is out of date and should be entirely disregarded, or it tells a truth that many comments on this block seek to obfuscate.

          Should ‘Critical_Chiro’ be reading this: ‘carpet bombing’ is saturation bombing that uses multiple explosives to cover every part of a target. I (and others) in fact drop only a single bomb: that chiropractic is firmly grounded in the discredited concept of the ‘subluxation’ as introduced without evidence by its founder. As such it is pseudo-medicine and the tricks it uses are merely theatrics. Thank you to Mr Epstein for drawing our attention to a formal document that confirms the point.

          • That document was put together mainly by those who practice a Technique that usually requires x rays…a Technique which very few chiropractors utilize.

            Interesting is that that group has a product designed to try and reduce cervical curvature…a product that Ernst seemed to be promoting in a prior blog….even though the research on it has some major concerns.

          • I have been promoting a product??????
            what have you been smoking, my dear friend?

          • Ah, DC. The ‘no true chiropractor’ fallacy rears its head once again.

          • Look at your blog where you discuss the Dennerol (TM).

          • no you look and cite back to me where I promote this product – if not, you would be a liar, wouldn’t you?

          • Promote: to encourage or support something (Cambridge dictionary)

            Comments by Ernst:

            “Thus, any inexpensive, effective and safe alternative would be welcome.”

            “But the device (Dennerol) has one huge advantage over chiropractic: it cannot cause much harm. The harm to the wallet is less than that of endless sessions chiropractors or other manual therapists (conceivably, a self-made cushion will have similar effects without any expense); and the chances that patients suffer a stroke are close to zero.”

          • so?
            are you disclosing yourself as a liar?

          • Nope.

            But if you wish to clarify your view, feel free to do so.

          • @FO
            Carpet bombing is defined as “Indiscriminate bombing of an area”
            Rather apt as you are happy to take out researchers and reformers.
            “chiropractic is firmly grounded in the discredited concept of the ‘subluxation’ as introduced without evidence by its founder.”
            Do you not find it ironic that you employ the same arguments as the vitalistic subluxation based chiropractors?
            Now the ICA???
            Michael Epstein they are a small group of chiropractors clinging to the past. Recently many of their executives resigned and comments from those leaving indicate that their membership is dwindling, around 200.
            The organization is a joke.

    • @burdle…”images show show up natural progression of skeleton but chiros use what they find as the reason why their treatment is needed. they make the false assumption that there is a ‘ perfect’ skeleton and then diagnose any thing that differs as needing their treatment.”

      Give us a percentage of chiropractors that use imaging for that purpose, with credible references.

      • Maybe you would like to advise me as to why a chiropractor does images and what he is looking for when he does them. How does a chiro use an image to decide treatment ?
        Bearing on mind it was you who said to use image to arrive at a diagnosis.

        Maybe you would like to explain why a physio does not require images to treat. ? And dont just say different modalities because that is not an answer ? The question is where is the need to ? I would maintain that every chiro meeting a new patient will do xrays if he is intending to treat them and patients are not yet informed enough and too vulnerable to realise that a chiro taking an xray does not validate the patient condition. i can only rely on my experience and what the chiro tells me namely that he needs to see ‘what is going on ‘

        • at some stage chiros bought their own X-ray machines; that’s when it became their ‘business’ to do as many X-rays as possible. and that’s the main reason, whatever they now claim.

        • Bundle…”Bearing on mind it was you who said to use image to arrive at a diagnosis.”

          Oh, show me where I wrote that.

          As far as the utilization of x rays, I shared a complication of papers on that subject awhile back. They do not support your claim that “ I would maintain that every chiro meeting a new patient will do xrays if he is intending to treat them…”

          In fact, it was the medical profession which is/was over utilizing x rays that prompted recent guidelines.

          • It’s interesting here in Australia.
            Years ago medical radiologists realized that chiro’s take xrays.
            Medicare (public health) here pays for the report not the actual taking of the xrays.
            So the radiologists tell the chiro’s send us your xrays and we will reimburse you $100 to cover the cost of taking the xrays and we will keep $60 for the report. Bonus you now get a medical report.
            Medicare cottons onto this so it stops paying the medical radiologists for the reports if the radiographers provider number is a chiropractic one.
            So what do the medical radiogists do, they “rent” the xray facilities within the chiropractic clinics and send in their radiographers to take the full spine three region films and the good times continue to roll.
            Medicare cottons onto this, warns chiropractors that they are over utilizing full spine xrays and subsequently takes the ability to order three region spinal xrays off chiropractors.
            This is not a problem for me as I rarely refer for xrays unless guideline compliant and then only the region clinically indicated.
            So now what do the medical radiologists who have now spent a lot on new EOS machines that take AP and lateral standing full spine films in one go.
            Here are the new xray referral pads just tick the “Chirpractic spine” box and we will take your full spinal films and only bill two regions to medicare.
            Who is the problem here?
            The vitalistic chiro’s addicted to full spine xrays or the medical radiologists addicted to the bu$$inesss?
            Food for thought.

          • This comment below is from a chiropractor on this very blog

            “As a chiropractor as opposed to a physiotherapist, I can be licensed to take my own x-rays as imaging is essential to provide modern day chiropractic spinal rehabilitation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024283/
            That is one of a number of reasons why I prefer to be a chiropractor.”

            That’s my point chiros say it is essential- guidelines – NICE guidelines say it isn’t!

          • He didn’t say x rays were essential.

          • Bundle…this is the group that would say x rays are essential. They are a small group.

            “The 2000-2001 Chiropractic Biophysics Practitioners Referral List booklet listed about 1,300 chiropractors worldwide who had attended a CBP seminar within the previous three years. The February 2009 CBP Online Referral Manual listed 953 who had attended during the previous two years. A pilot survey of chiropractors who graduated from Canadian Memorial College after 1980 found that 4 out of 83 respondents said they had attended CBP seminars and 2 out of 83 said they practiced it [18].” (Chirobase).

            Here is their view…

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024283/

            I do not support their position.

      • If chiros were honest enough to publish these figures I would.

    • @burdle…”taking xrays is completely against the guidelines for treating back pain skeletal issues.”

      Perhaps you should review the clinical guidelines for taking x rays. See table 4.

      https://annals.org/aim/fullarticle/746774/diagnostic-imaging-low-back-pain-advice-high-value-health-care

      • take a look at NICE guidelines for LBP under Imaging section 1.1.4 ‘ Do not routinely offer imaging ‘ – evidence based and upto date

      • I have just read your link and it says what I am saying. Read the abstract – it actually says only do them in specific circumstances and lists the specific circumstances and says do not do them unless there is evidence of a serious undelying condition or neurological defect. you ask your colleagues and record how many times they do NOT xray ? And basically if there is a suspicion of a serious underlying condition a chiro should be sending them to a doctor. anyway ( last sentence my words). There is masses of research on this topic- all concluding dont image. Chiros are not qualified to diagnose a serious condition any more than any lay person could.

        • I was just going to point this out to him too; thanks for saving me the time.
          as DC also argues the definition of chiropractic with me, how about a novel approach to this?
          A CHIRO IS A CLINICIAN WHO HAS LEARNT IN CHIRO-SCHOOL THAT HE/SHE CANNOT POSSIBLY EVER BE WRONG.

        • No, it does not say what you said…

          “”taking xrays is completely against the guidelines for treating back pain skeletal issues.”

          As far as the rest of your comments, you appear to be basing them more on opinions rather than facts.

          • yes it does – read it- no imaging unless signs or symptoms of a serious underlying condition or neurological defect suspected. chiros cannot possibly suspect either. So unless mysteriously all chiro patients fall into those two categories we are left with the fact that chiros xray most patients unnecessarily. You see it would be easy to track if physios xray because they would have to request one and it would appear on patients ‘ medical records. Chiros buy xray machines so we can only track by anecdote and personal experience when they are used. My 17 year old son went to a chiro with back pain. The chiro xrayed him at the first appt. and told him his pain was because he had an xtra vertebra in. umbar spine.

            Complete nonsense of course – the claim about source and readon for pain – not the xtra vertebra which is common but asymptomatic. Weekly treatment was suggested. Son did not follow through- pain went after a week. Now what bit of symptom of serious underlying condition or suspected neurological disorder was suspected here to warrant an xray. ?

            Mind you – I suppose if ill – trained people set themselves up as experts to treat skeletal. issues then I can see why they would not be competent enough to.make the distinction when interpreting the guidelines anyway !

          • I don’t know where you are getting your information from but the studies that have been done which compared chiropractors with their medical counterpart found that they are comparable in their ability to read x rays.

            Not only can chiropractors (in the USA) diagnosis many medical conditions we are bound by regulatory agencies to do so (not to do so risk of legal consequences).

            Finally, although an extra vertebrae is an incomplete report, they are often malformed and are often correlated to increase risk of back pain and may alter a clinical course of action.

            When you have some facts to share let me know. Until then, this is a pointless exchange.

  • You have no idea of my work and my clinical examination. All the chiropractic tests you like to dismiss comes IN ADDITION to standard acceptable orthopedic and neurological tests. You find it hard to believe you can check with my boss the head of orthopedic or the JCI that examined my unit twice already. You decided to call all chiropractors sharletans… That’s ok but reality says otherwise.

    • “All the chiropractic tests…” HAVE NOT BEEN VALIDATED AND ARE UNRELIABLE.
      if you disagree, don’t rant but show me the evidence, PLEASE.

    • This is what crackpot Almog does;

      Back Pain
      Treatment of neck pain
      herniated disk
      headache
      dizziness
      Sports injuries
      Rehabilitation after at work and road traffic accidents accident victims
      The pain in my knees and shoulders
      Pain or tingling, numbness radiated limbs
      herniated disk
      Prefabricated degenerative problems such as joint pains
      Prevention for all the above problems

      • @Frank Collins
        “Crackpot”??
        Another winning ad hom argument.
        So you got the above list from Guy Almog’s website. You conveniently skip over that he works in a multidisciplinary hospital.
        Then you copy and paste a list which most chiropractors, physiotherapists, orthopods, neurosurgeons, pain medicine etc treat and vainly attempt to turn it into a negative. So are the physio’s, neuro’s, ortho’s etc who treat those conditions also crackpots?

        To all the people reading Frank Collins post above it is emblematic of the problems on this site.

        I am all for critical appraisal of the science, constantly reevaluating what we do, looking for best practice and changing how we practice. That’s progress.
        Critics are a valuable resource who aid reform and progress.
        Unfortunately there is a difference between a critic and a cynic.
        The cynics on this site respond in a predictable way when the chiropractic bell is rung and look on the educators, researchers and reformers within chiropractic as acceptable collateral damage. They demand reform then carpet bomb the profession and don’t care who they hit.
        They are as much of a problem for reform as the vitalistic chiropractors who resist it.

  • @cc: why do u think that critics or cynics are interested in “reforming” that which is a malarkey profession, promulgated by the gullible and the financially entrenched? Why don’t you re-form YOUR alledged profession and then come back and show us the research proving your reformation? And if such is so obvious and your enlightenment so well-researched WHY-T-F do only a minority over the last 50 years wish to allow the reform you propose (whatever THAT happens to be…you never told us specifically)? And how do you know subluxation-theory is untrue, but what you do (??) isn’t equally balderdash?
    The newest grad and thus most “modern” DC opening in my neighborhood this year has the advertisement: “chiropractic adjustments to remove subluxation and restore health….from pediatric to geriatric”. “Chiropractic; health is wealth”.
    Sure sounds like her school ain’t been listening to your reformation nonsense.
    And I find it impossible to believe you can make a living as a Chiroquacker NEVER suggesting to ANY patient their spine is “out of align” or through some arcane test and a trust on a vertebra you don’t intend to address their problem. I happen to know you absolutely DO.

    • @MK
      “out of align” LOL
      “Arcane test” have to agree with you there.
      Recent research shows that only about 5% the standard orthopedic tests used by most chiro’s, physio’s, ortho’s have decent sensitivity or are stand alone. So that is why we do a battery of tests followed by a THOROUGH history. One of the most accurate and reliable tests? The practitioners clinical judgement that something is just not right.
      We are reforming and I have been harping on about it on this blog for years.
      Pity you are so blinkered and not listening.
      I am well aware that you and many of the regulars here are deeply entrenched in the belief that all chiropractors live, breath and worship at the high altar of the mighty subluxation and you will not change. You have invested too much of your time in one perspective/belief and are therefore incapable of change.
      Same with the subbie chiropractors.
      The only reason I persist is for all the lurkers who read this blog and do not post.
      Will we ever be rid of them? Probably not. But we are working hard to reduce their numbers to the absolute minimum.
      Both sides of the argument need to be put into the public record.

      • “The teaching of vertebral subluxation complex as a vitalistic construct that claims that it is the cause of
        disease is unsupported by evidence. Its inclusion in a modern chiropractic curriculum in anything other
        than an historical context is therefore inappropriate and unnecessary.”

        The International Chiropractic Education Collaboration

        Clinical and Professional Chiropractic Education: a Position Statement

  • @cc: I am neither entrenched nor committed to any particular “belief”. I am however a decade long surviver, having been married to a DC and neck-deep in every facet of chiroquackery including operating an office, staff, marketing, attending “educational” seminars and innumerable business-consulting seminars. I know what I speak IS far more true than false. And way more in line with DC practices than the tripe and sanguine rhetoric you robotically recite. Chiropractic was developed as fraud and perpetuates as fraud…it’s a healthcare farce with a tiny, tiny minority who got suckered in and now are trying to redeem themselves by usurping whatever they can to continue their money laundering with a modicum of pride. You are NOT PTs, biomechanists, exercise physiologists or psychologists…yet you somehow think your woeful education allows you facile entrance into all those arenas…and to project expertise in their regard. How many DCs regularly advertise themselves as “spinal experts”? I’d say virtually ALL.
    Even IF you were to uncover something with your arcane and/or unreliable and invalid tests….why should a patient assume a DC is then qualified to “treat” whatever condition you allegedly find?
    Most of the commenters and sensible people here are well aware DCs find (make-up) “alignment or fixation” issues and then sell “adjustments”. Pretending it isn’t the case and your constant reiteration of your false-premise leads me to think you are also a Scientologist.

  • Google: “Do You Need a Chiropractor? The Top 3 Reasons People Get to the chiropractor.
    The Joint (chiroquacker franchise, with over 400 locations and growing)
    What do people go to chiropractors for?”
    “When neck pain is caused by any sort of MISALIGNMENTS in the spine, chiropractic care may be able to straighten it out and alleviate the pain…”.
    The Joint Chiropractic ›
    I am still mystified that the chiroquacker commenters on this site are so compelled by their confirmation bias they refuse to see the google written all over the subway walls; chiroquackery IS finding and “fixing” (non-existent) intervertebral misalignment…better known as subluxation. Untrapping Innate-flow is just one extra bit of mucus to ensnare the gullible into thinking health and spinal-alignment are related. As we all know (proper) spinal-alignment (as proselytized by the religion of chiropractic) is unknowable even IF some arcane test says otherwise…and even if it could be deduced with valid tests it has zero bearing on pain or health as has been proven over these last 120 years.

  • As I read this Rubinstein review – the mean pain reduction is only 3.2 mm on a 100 mm VAS.
    If correct? – it´is weird that this study is used to support the use of SMT in clinical practice!

    • Spinal manipulation as a sole modality is not recommended in the treatment of nonspecific chronic low back pain. Fortunately, it appears very few chiropractors use spinal manipulation as such.

      • why use it at all?

        • Probably for the same reasons PTs use it…

          “The results of this systematic review indicate that physical therapy spinal manipulation of the lumbar spine is an effective form of intervention for a variety of patients with low back pain, although the degree of effectiveness is variable between studies.”

          https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3537457/#__sec6title

          • Probably for the same reasons DOs use it…

            “Stratified meta-analyses to control for moderator variables demonstrated that OMT significantly reduced low back pain vs active treatment or placebo control and vs no treatment control.”

            ttps://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-6-43

      • can you backup what you say with evidence ? I would maintain that there isn’t a single chiro who would not perform SMT on a patient who.presented with back pain. What else would he offer ? your are correct that it is not recommended ? but incorrect aboug your colleagues.

  • Authors’ response to criticism of their Systematic Review in the comments section of the BMJ:
    https://www.bmj.com/content/364/bmj.l689/rapid-responses

    • @BW
      Good critique from Mary and Neil.
      Good response from Sidney.
      Nice to see you citing research and not blogs Blue. There is hope for you. 🙂

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