The concept that the outcomes of spinal manipulation therapy (SMT) – the hallmark intervention of chiropractors which they use on practically every patient – are optimized when the treatment is aimed at a clinically relevant joint is commonly assumed and central to teaching and clinical use of chiropractic. But is the assumption true?

This systematic review investigated whether clinical effects are superior when this is the case compared to SMT applied elsewhere. Eligible study designs were randomized controlled trials that investigated the effect of SMT applied to candidate versus non-candidate sites for spinal pain.

The authors obtained studies from four different databases. Risk of bias was assessed using an adjusted Cochrane risk of bias tool, adding four items for study quality. Between-group differences were extracted for any reported outcome or, when not reported, calculated from the within-group changes. Outcomes were compared for SMT applied at a ‘relevant’ site to SMT applied elsewhere. The authors prioritized methodologically robust studies when interpreting results.

Ten studies were included. They reported 33 between-group differences; five compared treatments within the same spinal region and five at different spinal regions.

None of the nine studies with low or moderate risk of bias reported statistically significant between-group differences for any outcome. The tenth study reported a small effect on pain (1.2/10, 95%CI – 1.9 to – 0.5) but had a high risk of bias. None of the nine articles of low or moderate risk of bias and acceptable quality reported that “clinically-relevant” SMT has a superior outcome on any outcome compared to “not clinically-relevant” SMT. This finding contrasts with ideas held in educational programs and clinical practice that emphasize the importance of joint-specific application of SMT.

The authors concluded that the current evidence does not support that SMT applied at a supposedly “clinically relevant” candidate site is superior to SMT applied at a supposedly “not clinically relevant” site for individuals with spinal pain.

I came across this study when I searched for the published work of Prof Stephen Perle, a chiropractor and professor at the School of Chiropractic, College of Health Sciences, University of Bridgeport, US, who recently started trolling me on this blog. Against my expectation, I find his study interesting and worthwhile.

His data quite clearly show that the effects of SMT are non-specific and mainly due to a placebo response. That in itself is not hugely remarkable and has been suspected to some time, e.g.:

What is remarkable, however, is the fact that Perle and his co-authors offer all sorts of other explanation for their findings without even seriously considering what is stareing in their faces:



This might be almost acceptable, if chiropractic would not also be burdened with significant risks (as we have discussed ad nauseam on this blog) – another fact of which chiros like Perle are in denial.

What does all that mean for patients?

The practical implication is fairly straight forward: the risk/benefit balance of chiropractic is negative. And this surely means the only responsible advice to patients is this:


19 Responses to Chiropractic has been shown to be a dangerous placebo therapy. My conclusion: do not consult chiropractors!

  • There is an established, valid, science-based profession for physical therapy, which is integrated within the health care team. Physiotherapy is widely available and has no need for magical thinking.

      • Prof. Ernst. I have asked Dr. Sue Ieraci to provide peer reviewed, science-based evidence that Physiotherapy has a science base in itself. This is especially in regard to the use of exercise therapy, which for low back pain is no better than a placebo. She has been unable or unwilling to provide this evidence. Perhaps you and your team can provide me with any evidence for the use of physiotherapy in the treatment of neuro-Musculo-skeletal conditions.

        • what a silly request
          1) I don’t have a team any more for the last decade;
          2) why should I do anyone’s homework
          3) what has this to do with the topic of this post?

          • Prof. Ernst.
            1) Your “team” would include people like David Nette and Richard Rawlings, who regularly contribute to your “anti-chiropractic: diatribe.
            2) The request was that Dr. Sue Ieraci provide evidence (peer reviewed and science based) that physiotherapy was science based, especially the method of treatment they use the most frequently. i.e. Prescriptive exercises. I presumed that if she was unable to provide it, then possible you could. Not my homework, but hers.
            3) Dr. Ieraci made a statement that I asked her to verify and substantiate. If you look at the very top of this page you will see the statement that you wrote, “Please remember: if you make a claim in a comment, support it with evidence.” That is all that I am asking her to do. I presume that she and you (by default) are unable to do this.
            Not a “silly” request, but a legitimate one to try to ascertain the extent of Dr. Ieraci’s knowledge and her ability to do research. Asking someone to legitimize their statement is not silly, she should have that information at her fingertips and be able to provide it.

          • “Not a “silly” request”, said the person who just declared that I have a team that not even I knew about.

          • Prof Ernst. My use of the word “team” is correct. The definition of the word “team” is ….In English, team is a noun that refers to a group of people or animals who work together to achieve a common goal.
            The group of people who contribute to your pages, in support of your goal, fit within the definition of the word “team”. It is just that you do not realize that you have inadvertently created one, albeit informally.

          • thank you for the English lesson!
            do the people you mentioned have a ‘common goal’?
            I don’t know their goal, do you?
            and what do you think is my goal?

    • I am a physiotherapist and have worked as an osteopath (very similar to chiropractic) for 20 years. It’s surreal for me to read that you should never see a chiropractor. It’s like a person who catalogs sexual abuse committed by priests and orders no one to talk to any priest.

      • so, in which situation should a patient consult a chiro?

        • He should consult a chiropractor when he feels limited movement of a joint nature. In my opinion, which can be confirmed by research, the problem with cervical spine manipulations lies in the fact that some therapists perform rotations by holding the head with both hands, instead of resting their fingers on the posterior surface of the transverse processes to manipulate the specific vertebra that has an osteopathic lesion in extension and rotation. As sometimes the patient has an injury like this, but also has a vertebra blocked in flexion and latero-flexion (which are corrected in latero-flexion), problems occur.

          They must also occur due to the fact that some therapists do not master other techniques, resorting only to joint manipulation, hence the phenomenon “if I only have a hammer, every problem is a nail” occurs. And as some sell many sessions on the first day, I suppose they end up manipulating unnecessarily. There are other reasons as well, already known.

          A mechanical injury can only be corrected by a mechanical correction. Unless they invent a pill with 2 arms, 2 hands, a brain, etc.

          It is common to see patients who waited for the injury to go away on its own or used anti-inflammatories without success for months, and with manipulation, they can move perfectly again. Soon after the manipulation, we noticed the patient breathing a sigh of relief, as he was freed from the burden, and left the office feeling grateful. I myself have suffered from 4 osteopathic injuries and have been cured by colleagues. I have also taught interns how to manipulate the cervical spine using my neck.

          What I disagree with is banning an activity because of a few professionals. Therefore, we would have to ban all professions, because who doesn’t make mistakes? What must be done is to find errors and establish new behaviors, so that there is progress.

          I know that joint manipulations have caused several injuries and deaths (I recently read the book chapter in your previous post, very good, congratulations), but not correcting the positioning of the vertebrae can cause descending scoliosis, loss of movement due to compression of the nerve exit and excruciating pain that prevents work, leading to depression and dangerous, unnecessary surgeries.

          • “not correcting the positioning of the vertebrae can cause descending scoliosis, loss of movement due to compression of the nerve exit and excruciating pain that prevents work, leading to depression and dangerous, unnecessary surgeries”
            do you have any evidence for these claims or are they merely opinion-based?

          • ‘Not correcting the positioning of the vertebrae can cause descending scoliosis’ What sort of scoliosis ? Structural or Functional ( I take it you know the difference?) But no it can’t- there is absolutely no evidence for this claim at all!

    • Sue, you may have seen at the top of the page this quote, “Please remember: if you make a claim in a comment, support it with evidence.”
      So, I await you supporting evidence that physiotherapy is a science-based profession. I can provide evidence at a commission of inquiry level, that chiropractic is. Can you do this for physiotherapy? If so, please provide it.

      In the meantime, you might like to comment on the main form of treatment that physiotherapists use, i.e. exercise, in regard to this latest review by Cochrane,

      Review Cochrane Database Syst Rev. 2023 Aug 30;8:CD009365. doi: 10.1002/14651858.CD009365.pub2.

      Authors’ conclusions: Exercise therapy compared to sham/placebo treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. Exercise therapy compared to no treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. We downgraded the certainty of the evidence to very low for inconsistency, risk of bias concerns, and imprecision (few participants).

      While the evidence is uncertain, it is damming of the physiotherapy profession that bases a significant amount of their treatment on a form of therapy that is no better than a placebo.

      • Sue, as you have yet to provide any evidence that exercise is a proven and scientifically evidence-based treatment for low back problems and that is all that physiotherapists have to offer patients with these conditions, we can now expect that you will be lobbying for the closure of all physiotherapy schools in Australia. Afterall, the mechanism for most neuromusculoskeletal problems is biomechanical. If an exercise does not help low back pain, it is not going to help carpel tunnel syndrome, torticollis, rib pain, sciatica etc.
        While you are on the crusade to shut down physiotherapy schools, you might like to look at the use of Paracetamol in the treatment of low back pain, or any pain.
        Time for you to be consistent with your statements, Sue. Don’t be lazy..

  • Edzard and burdle,

    I chose to heal people in my life, and through college professors, courses (34 in 22 years) and reading books, I was taught the claims I made. I know I should check what I was taught orally or read in books, through bibliographical references, but I did so few times, perhaps due to the knowledge we obtain by studying physiology, kinesiology and other basic subjects. I believe that the combination of professional practice and research is ideal, which is why I visit this blog.

    Professional practice is important to understand the day-to-day reality of the professions involved in healing people. Those who do not have this experience may be held hostage by studies that are soon contradicted by other studies.

    Just as I made assumptions about why chiropractors and osteopaths might be causing injuries and deaths, I also made assumptions about unnecessary spinal surgeries. In day-to-day practice, here in Brazil, doctors are not interested in physically evaluating the patient, due to the fact that the anti-inflammatory drugs they prescribe will deinflame the spine as well as the sacroiliac spine, and the problem is often in this joint. Very few doctors practice osteopathy in my region, so not knowing how to evaluate osteopathic lesions clinically and the fact that osteopathic lesions are not commonly identified in imaging tests exacerbates the problem.

    I will tell you 2 cases, I work on the second floor of a public hospital with patients with different health conditions, on the fourth floor are patients who are about to undergo spinal surgery. A colleague called me to see a patient there and I discovered that she had no reason to undergo surgery (small disc protrusions, no loss of movement…) And her main complaint was precisely the left sacroiliac joint, a joint that is affected by those who increases weight suddenly, among other causes. I explained to her that her problem wasn’t with her spine, that she didn’t need surgery, that I had already had the same injury and that I had gotten better with osteopathic manipulation, as had many of my other patients, but she didn’t listen to me. , arguing that she had come from the interior of the state, that it had been difficult to get that opportunity and that she had been hospitalized for 45 days waiting for surgery. Result, when I went to see her on my next day of work (2 days later), she had already had surgery.

    The other case: a 16-year-old boy with suspected heart disease, upon assessment I saw that it was an osteopathic lesion on the ribs, I mentioned it to him and carried out the maneuvers, the result, after several tests, he was discharged yesterday, without pain and without heart disease. The cause was postural and ergonomic.

    Want one more? Patient supposedly with low back pain in the medical record, in clinical evaluation, osteopathic lesion in the sacroiliac joint. Correct. After 2 days she said the pain was gone. The next day she underwent bowel surgery and woke up with very intense pain in her lumbar spine. She reassured me that she had never felt lower back pain. That it was a new pain, which appeared during the surgery. However, they wrote in the medical record that she had low back pain, just as she had before.

    • perhaps you should find a course that teaches you what evidence is and what it is not?

      • I studied physiotherapy for 5 years at the best college in my state, and it continues to this day (the Ministry of Education announced this week that the course at the Escola Bahiana de Medicina e Saúde Pública is the best in the state and the third best in Brazil among the private colleges).

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