It does not happen often, but when it does, it should be aknowledged. I am speaking of papers from chiropractors that make sense. If you are interested in chiropractic, I do encourage you to read the articles of which I will here only present bits of the conclusions:
The chiropractic profession is weighed down by the burden of historical theories regarding spinal manipulative therapy (SMT), which, for some in the profession, have all the characteristics of dogmatic articles of faith. In our opinion, the unlimited scope of practice, which is still advocated by some chiropractors, and which has not been met with unequivocal political rejection, an over-reliance on SMT in the management of MSK disorders, and an over-emphasis on the technical intricacies of SMT represent weaknesses within chiropractic. We argue that these are obstacles to professional development and the major causes of professional stagnation both intellectually and in the market place.
We also discussed what we consider to be threats to the chiropractic profession. Science, the impact of EBM, and accountability to authorities and third party-payers all pose threats to the traditional chiropractic paradigm and, thus, to those within the profession, who practice within such a paradigm. In the marketplace, competition from other professions that provide care of patients with MSK disorders, including SMT, and are better positioned to be integrated into the wider health-care system/market represent a threat. Moreover, finally, the internal schism in chiropractic represents a threat to professional development, as it prevents the profession moving forward in unison with a coherent external message.
We have described those weaknesses and threats, knowing full well, that we do so from our perspective of chiropractic as EBM with a limited MSK scope of practice, i.e. from outside the subluxation frame of reference.
We recognize that for those who look at SMT from the perspective of traditional, subluxation-based chiropractic, things will look very different: What we identify as weaknesses may be seen by others as the pillars of chiropractic practice, and what we see as threats could appear as just peripheral and ephemeral distractions to the enduring core of chiropractic ideas. Such is the character of the schism at the heart of chiropractic.
None-the-less, having described what we identify as serious weaknesses and threats arising from the profession’s relationship to SMT, it has not escaped our attention that it also gives rise to several strengths, which serve the profession and its patients well. In turn, it follows that a number of opportunities are presenting themselves for the future of SMT and chiropractic.
The onus is now on the chiropractic profession itself to redefine its raison d’être in a way that plays to those strengths and delivers in terms of the needs of patients and the wider healthcare system/market. We suggest chiropractors embrace and cultivate a role as coordinators of long-term and broad-focused management of musculoskeletal disorders. We make specific recommendations about how the profession, from individual clinicians to political organizations, can promote such a development.
___________________________
For readers in a hurry:
Progress is an inevitable threat to obsolete and useless practices of any kind. In that, chiropractic is no exception.
20 Responses to The threats to chiropractic: science, the impact of EBM, accountability to authorities and third party-payers
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Whenever I see the words “chiropractic” & “science” in the same sentence, I’m reminded of what I saw on a chiropractor’s website that pretty much echoed Humpty Dumpty’s comment to Alice: ““When I use a word,’ Humpty Dumpty said in rather a scornful tone, ‘it means just what I choose it to mean — neither more nor less.’” The chiro’s definition of science:
How do you define “scientific?”
If you define it as the systematic pursuit of knowledge involving the recognition of a problem, the collection of data through observation and experiment and then testing the resulting hypotheses, then today’s chiropractic is quite scientific. Because it’s based on the scientific fact that the nervous system controls and regulates virtually every cell, tissue, organ and system of the body.
Don’t be misled by the “low-tech” nature of chiropractic adjustments! There are a growing number of studies that suggest the chiropractic approach to reducing nerve disturbance along the spine, may enhance the ability of the brain and nerve system to control and regulate the body.
These include published research documenting the results of chiropractic care on asthma, infantile colic, immune function, dysmenorrhea (menstrual cramps), improving vision and brain function, lower back pain, one’s overall health status and many others.
The “scientific” argument is largely a red herring and the sign of a double standard. Medical economist David Eddy, MD, Ph.D., observes that only 15% of medical procedures have ever been scientifically verified, and the other 85% of common medical procedures have no “scientific basis!”
Ultimately, the proof is in the pudding. Ask our delighted patients whether chiropractic is scientific.
References:
Gray’s Anatomy, Henry Gray F.R.S.Smith, R. Where is the wisdom? BMJ 1991; 303(Oct 5): 798-799.
Paul Shekelle, MD, MPH, Head of a back study of RAND Corporation, Santa Monica, CA, 1992, Medicine, Monopolies and Malice, pp. 49, 199, 208.
John Carey, Medical Guesswork. Business Week, May 29, 2006, 73-79.
***
Does one laugh, cry or upchuck in response to such a statement?
Good grief. It’s as if the authors have taken their blinkers off and reviewed all of Prof. Ernst’s publications on chiropractic over the last three decades and finally got the message.
From the first paper: https://chiromt.biomedcentral.com/articles/10.1186/s12998-024-00531-6
QUOTE
“…we fear many in the profession are oblivious to the burning platform on which, we are convinced, it stands…threats to the chiropractic profession are largely self-inflicted…”
So true. Chiropractic regulators, educational establishments, and trade bodies have long pretended that major problems don’t exist. In fact, a good example is highlighted in the paper:
QUOTE
“When the chiropractic umbrella organization, the World Federation of Chiropractic (WFC), advise chiropractors to ‘refrain from any communication that suggests spinal adjustment/manipulation may protect patients from contracting COVID-19 or will enhance their recovery’, they are seen to promote EBM and responsible clinical practice. However, when the WFC also ‘champions the rights of chiropractors to practice according to their training and expertise’, it is effectively attempting to have it both ways.”
More self-infliction here:
QUOTE
“…internal conflict has been tolerated for a century, but has always been a source of internal tension and external criticism. The widespread adoption of EBM principles reflects a general move away from authority-based to science-based health-care, which means that the internal schism in chiropractic is becoming increasingly challenging to glaze over. Although the internal conflict in chiropractic has always been a problem, we believe it has now become an existential threat, especially for those that subscribe to EBM and an MSK-limited scope of practice.”
Surely UK chiropractors must have known it would only be a matter of time before their house of cards started to tumble? For example:
QUOTE
“In spite of strong mutual suspicion and distrust, the profession united under a group formed specifically to pursue regulation and secured the Chiropractors Act (1994)…Regulation for a new profession will literally ‘legitimise it’, establishing its members within the community, making them feel more valued. In turn, this brings greater opportunity for more clients and a healthier bank balance.” Michael C. Copland-Griffiths, former Chairman of the General Chiropractic Council (European Journal of Oriental Medicine, Vol.2 No.6, 2004)
Ref. https://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1437-statutory-regulation-the-chiropractic-experience.html
From the second paper: https://chiromt.biomedcentral.com/articles/10.1186/s12998-024-00532-5
QUOTE
“Contextual factors, which generally consist of cognitive cues embedded in therapeutic encounters, are becoming increasingly evidenced as important for positive clinical outcomes, both in health-care in general and in MSK disorders specifically.
Interestingly, Ben Goldacre (Bennett Professor of Evidence-Based Medicine and director of the Bennett Institute for Applied Data Science at the University of Oxford) has this to say on that subject:
QUOTE
“Whether mainstream medics would want to go back to the old ways and embrace the placebo-maximising wiles of the alternative therapists is an easy question: no thanks. The didactic, paternalistic, authoritative, mystifying mantle has passed to the alternative therapist, and to wear it requires one thing most doctors are uncomfortable with, dishonesty.”
Ref. https://www.theguardian.com/science/2005/aug/29/badscience.health
But this appears to be the most salient point in the second paper:
QUOTE
“…We admit to being somewhat pessimistic that the chiropractic profession is actually able to unify and change to assume the role we have outlined [a role as an MSK manager], and we suspect that the window of opportunity to do so is already closing rapidly. In some parts of the world, it is firmly shut already.”
In other words, it seems like the authors know they are already flogging a dead horse.
https://www.youtube.com/watch?v=asd18jqzm-A This is from s recent podcast from Physio mattters.
How can patients challenge this sort of thing. The chiro claims EBM,and regulation !!
https://www.youtube.com/watch?v=asd18jqzm-A how can a patient challenge this. The chiro claims EBM and regulation.!! Teesside Uni runs a chiro course and so does AECC.
https://www.youtube.com/watch?v=asd18jqzm-A
Such an excellent article and the best of responses I have ever had the pleasure to read on this important subject! Thank you Kurt and Blue!
The Chiropractors just keep moving the goal post. If rapid upper neck manipulations weren’t so darn dangerous and utterly useless for health maintenance, it would be humorous.
I agree that the Authors probably do indeed seem to acknowledge the horse is dead.
I look forward to reading both opinion papers in full next Saturday. Meanwhile, I attach a recently published case series in a Q1 journal discussing how correcting a misaligned lumbar spine (spinal subluxation) using chiropractic practices and procedures improves pain, quality of life and urine dysfunction.https://www.mdpi.com/2077-0383/13/7/2024
Fedorchuk CA, Fedorchuk CG, Lightstone DF.
Improvement in Pain, Quality of Life, and Urinary Dysfunction following Correction of Lumbar Lordosis and Reduction in Lumbar Spondylolistheses Using Chiropractic BioPhysics® Structural Spinal Rehabilitation: A Case Series with >1-Year Long-Term Follow-Up Exams.
Journal of Clinical Medicine. 2024; 13(7):2024.
DOI: https://doi.org/10.3390/jcm13072024
The red line in A was not drawn in the same manner as the red line in B&C.
In both figures, pre-treatment A is quite different (in terms of colour, exposure, contrast, and image noise) from post-treatment B; yet B and C, which are separated by 4 years, are remarkably similar.
I find it difficult to believe that 4. A and 4. B are images of the same person.
Retired medical radiologist here. Sorry for a long comment, but Pete Attkins’s reference and questions about their X-ray images got me going.
I read with increasing pain this “interesting” (hm…) article by Fedorchuk & al. (2024).
Spondylolisthesis means a vertebra has slipped a bit, usually forward, in relation to the next vertebra below. This is due to disk degeneration leading to too little cartilage substance and elasticity to maintain the normal distance between the vertebrae. I can’t remember having ever seen a degenerated disk regenerate, as they must do if the alleged radiographic results of this article could be true.
1. I’m surprised at the very low quality of the plain X-ray images in this paper. Even before I retired 12 years ago we could do much better.
2. The red lines: They are supposed to show the straight line between the upper and lower posterior corners of each vertebrae. These corners are present on both the left and the right side, more or less superimposed in the images. The lines are approximately parallel with and somewhat posterior to the anterior wall of the spinal canal. (In this part of the canal there is no spinal chord, only nerve roots. These have plenty of space in the canal, but may be squeezed and generating symptoms if the transverse area of the canal gets very reduced, as for example by a very extensive spondylolisthesis, or a tumour. A plain X-ray can never exclude a tumour. The paper does not tell whether tumours have been excluded as origin of pain in these patients.)
Drawing those red lines is subject to considerable inexactness and inconsistency due not only to subjective influence, for example wishful thinking, but also to ever so small rotational differences in the patient’s position. Very often one or more vertebra is somewhat rotated too, further complicating the line positioning. However, we do (or did) draw such lines in the routine assessments of spondylolistheses. We went on to CAT scan or MRI in the more severe cases.
3. In figure 4 A, the lowest part of the image is so underexposed that one can’t really see what contours they think they saw when drawing the red lines, allegedly showing a spondylolisthesis between L4 nd L5. Not very convincing. (This patient weighed only 60 kilos, so there is no excuse for accepting such a badly underexposed image. Very obese patients, though, may be a challenge even for strong X-rays.)
4. The green lines? The upper parts possibly seem to be supposed to delineate the posterior wall of the spinal canal. The lower parts … strange choices. If they still delineated the posterior wall of the spinal canal, the apparent post-treatment narrowing of the canal seems rather a bit alarming.
5. But wait, it gets even worse: According to the figure legends, “The green line represents a normal, ideal sagittal cervical alignment and the red line represents the actual posterior tangent lines of the T12-S1 vertebrae”. Really? CERVICAL? Here in the lumbar region! Sensational effects of neck manipulation!
Even if we reformulate this to “normal, ideal sagittal LUMBAL alignment”, it still makes no sense to me. “Ideal sagittal alignment”??? Is it just a nice line based on the authors’ ideals but not following any visible contours in the images? Mind blowing.
One can only sigh. The article is so stuffed with sciency abbreviations and numbers that the head spins. Obviously, even the three authors couldn’t manage a proper proofreading (cervical/lumbar) before submitting. And what did the peer reviewers do? One must wonder how many more mistakes there are in the text. It can’t be trusted.
Despite a traditional mention of limitations (“This case series is limited in being able to draw conclusions about correlation, causation, or applying the patients’ findings to broader spectra of varying demographics. … … Larger studies and clinical trials involving patients with lumbar spondylolisthesis …, structural spinal rehabilitation, and control groups with long-term follow-ups are needed.”) the authors don’t hesitate to conclude that “This case provides evidence showing the impact of spinal alignment on pain, urinary dysfunction, and HRQOL.”
Why am I not surprised?
Wowsa…Thanks very much for the medical analysis and insight on this Olle! This is where having a multiple of experts in their qualified fields is so valuable.
The Devil’s in the details.
Interesting reading, Olle
Presumably the radiographic “analysis” by the chiros can be concluded to be fanciful nonsense in which case, the patients were subjected to (presumably) considerable doses of X-Rays for zero diagnostic purpose.
Which is profoundly unethical and, TBH, criminal.
Yes, a lot of radiation. It’s even worse than you might think: They don’t seem to know how to mask off the non-spine part of the body. I have seen even in textbooks for chiropractors how they X-ray the whole body in one giant shot from skull to pelvis. A young female victim of neck manipulation (personal corresp.) by such a chiropractor who also had published a textbook with horrifying pictures, confirmed that she was made to stand up in the nude, even facing the X-ray source giving the chiropractor a good look at her front nude during the procedure. Due to the mammary glands’ high sensitivity for ionizing irradiation, we (real medical radiologists) always have the patients turn their back towards the source, and we narrow the slit to only expose the spine, not all around it. And of course they have a gown to cover themselves.
Look here: I found this random chiropractor clinic proudly (?) showing an example of their X-ray “skills”: https://www.corechiropractic.net/articles/radiographic-examination-x-ray/
See how they not only included all the soft tissues around the spine, but also the air outside the body!
Please search and find more examples of the same kind. It seems to be common practice.
Yes, unethical and criminal.
Olle states: “Yes, unethical and criminal.”
This is especially true since what they’re supposedly looking for (the chiroquacktic subluxation) doesn’t even exist!
Some years ago, just to satisfy my curiosity, I took advantage of an offer from a “doctor” of chiropractic for a free exam. As soon as he said he needed to take an x-ray I thanked him for his time & walked out of the office.
You do not believe that this laudable clinical outcome is possible. My observation is that the X-ray images may have been better produced. However, not being privy to the BMI of the patients, I still note the significant reduction in the +Z translation of the patient’s lumbar vertebra detailed in the comparative radiographs. I would suggest that you submit an LTE to this Q1 journal to answer this alleged criminal experiment mentioned by another replyer. The analysis performed by the authors is evidence-based and investigated and published in another Q1 journal.https://journals.lww.com/spinejournal/abstract/2001/06010/radiographic_analysis_of_lumbar_lordosis_.3.aspx
Check this out!
https://drcourtneykahla.com/3-reasons-i-dont-take-insurance-as-a-chiropractor-hint-its-in-your-favor/
Just when you think it can’t possibly get any worse…it does.
Has anyone here on this site ever heard of any charges ever being filed against such abuse?
Needless and unsafe practices regarding the inappropriate and misuse of x-ray equipment on a patient/victim?
Seems to me there might be something worth looking into here.
My feelings are, that as long as Lawyers keep encouraging people to visit these Chiropractors with whiplash, etc. the end result being countless Chiroquactor visits pumping up the “validity” of injury claims, we will see this Chiro practice continue on into eternity. Follow the money.
And of course there’s the taxes thing to consider. With a Chiropractic Clinic on practically every street corner and mall throughout large cities and even smaller towns scattered across the country, I suppose there is some financial benefit to the government tax collection process.
Of course the medical bills and long term care needs to care for those “few” who end up seriously injured are just the price of doing business I guess.
Ollie, you should consult a really good text on radiology, written by Terry Yochum (Chiropractor) and Lindsay Rowe (Chiropractor and Medical Radiologist (desc.)). It is called, “Essentials of Skeletal Radiology”, before you criticize chiropractic radiography and radiology. You are quoting exceptions to the profession. Yochum and Rowe are the professions Radiologists, so find fault with them.
No, Gibley, they’re not exceptions to the business; it’s mainstream chiroquacktic!
Kenneth J. Young, DC, DACBR, PhD
A Tale of Specialization in 2 Professions: Comparing the Development of Radiology in Chiropractic and Medicine
Journal of Chiropractic Humanities. 2019 Dec 10;26:3-18.
doi:10.1016/j.echu.2019.09.001.
PMID: 31871435;
PMCID: PMC6911919
GibleyGibley, excuse me, but you have a very funny attitude. Here are five questions for you:
(1) Being a medical radiologist who retired more that 10 years ago, why should I bother to buy (for $250) a 20 years old beginner’s textbook (Yochum & Rowe, Essentials of Skeletal Radiology, 3rd. ed., 2004) written by and for chiropractors?
(2) Do you happen to know the difference between medicine and chiropractic?
(3) Have you heard anything about the difference between science and imagination?
Two things of relevance here happened in 1895:
The X-rays were discovered by W.C. Roentgen, a physicist, his first short, scientific paper immediately became seminal, the technique spread rapidly over the whole world, generated tons of studies and further development on an astronomical scale, leading to several Nobel awards, and still continues to develop on an astronomical scale.
Chiropractic was invented [sic!] by D.D. Palmer, a layman who had already been legally convicted of quackery, he wanted to make it a religion with himself as the Creator, the imagined existence of some pathology behind its fundamental dogma has not yet been shown objectively, no high-quality papers have yet been written, no Nobel prize has been awarded …
(4) Can you discern the slight difference between these two events? (Hint: One is science, one is imagination.)
As for “quoting exceptions”, the majority of chiropractic X-ray images then seem to be “exceptions”, if you search the web and glance through the hundreds of images. https://www.google.com/search?sca_esv=c815caab5ae43dfb&sxsrf=ACQVn0-CCP64GIQNkXNWnXQVfGXTEbaG4A:1712663061902&q=chiropractic+radiology&uds=AMwkrPuKiz3kd7jHuta4ar-HNLVt_-WxVhq6S78w8VLe7_HnzllUR5cXKr0D5oNoioUN4TYBnZAy-porFy91mEZre3wqjhSlg75bjmxzsojbW4LLHq-mNC30J3hPUbCx5Uwzv4kJziC93Wlof84wHOTeerwuoezyDED809eKRGui7LcrtM7c3IEtAMDxGj6_D28daOUZ0jV9ycdNwzgecIWez967WszneHORyEr2dMqcHSV_SmD0nrKc223Y8p8tuJEOoLkMhB8NO_yOQXE4FYxHLGNqz5Wug3YB-ggpzWZFo8OQHHe-JN8&udm=2&prmd=ivnbz&sa=X&ved=2ahUKEwjUvLKLh7WFAxVwEhAIHXU3DJgQtKgLegQIKRAB&biw=1866&bih=901&dpr=1
(5) Can you find in this hit list at least one (1) image that has been correctly taken without a terribly wide field of radiation?