Chiropractors have a thing about treating children, babies and infants – not, I suspect, because it works but because it fills their bank accounts. To justify this abuse, they seem to go to any lengths – even to extrapolating from anecdote to evidence. This recently published case-report, for instance, described the chiropractic care of a neonate immediately post-partum who had experienced birth trauma.
The attending midwife noted the infant had an asynclitic head presentation at birth and as a result was born with an elongation of the occiput due to cranial molding, bilateral flexion at the elbows and shoulders with decreased range of motion in the cervical spine with tongue and lip tie. Oedema of the occiput with bruising was notable along with hypertonicity of cervical musculature at C1, hypertonicity (bilaterally) of the pectoral and biceps muscles, blanching and tension of lip tie, decreased suck reflex and tongue retraction with sucking, fascial restrictions at the ethmoid bones, at the occipital condyles (bilaterally), as well as at the shoulders and clavicles, bilaterally. An anterior subluxation of left sphenoid was noted.
The infant was cared for with chiropractic including a sphenobasilar adjustment. Following this adjustment, significant reduction in occipital edema was noted along with normal suck pattern and breastfeeding normalized.
The authors concluded that this case report provides supporting evidence that patients suffering from birth trauma may benefit from subluxation-based chiropractic care.
Oh no, this case report provides nothing of the sort! If anything, it shows that some chiropractors are so deluded that they even publish their cases of child abuse. The poor infant would almost certainly have developed at least as well without a chiropractor having come anywhere near him/her. And if the infant had truly been in need of treatment, then not by a chiropractor (who has no knowledge or training in diagnosing or treating a new-born), but by a proper paediatrician.
The current Cochrane review of clinical trials testing the effectiveness of manipulation/mobilisation for neck pain concluded as follows:
Although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.
Such a critical assessment must be tough for chiropractors who gain a substantial part of their income from treating such patients. What is the solution? Simple, convene a panel of chiros and issue recommendations that are more prone to stimulate their cash flow!
Exactly that seems to have just happened.
The purpose of the researchers was to develop best-practice recommendations for chiropractic management of adults with neck pain.
A steering committee of experts in chiropractic practice, education, and research drafted a set of recommendations based on the most current relevant clinical practice guidelines. Additional supportive literature was identified through targeted searches conducted by a health sciences librarian. A national panel of chiropractors representing expertise in practice, research, and teaching rated the recommendations using a modified Delphi process. The consensus process was conducted from August to November 2018. Fifty-six panelists rated the 50 statements and concepts and reached consensus on all statements within 3 rounds.
The statements and concepts covered aspects of the clinical encounter, ranging from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral for patients presenting with neck pain.
The authors concluded that these best-practice recommendations for chiropractic management of adults with neck pain are based on the best available scientific evidence. For uncomplicated neck pain, including neck pain with headache or radicular symptoms, chiropractic manipulation and multimodal care are recommended.
Let’s be clear what this amounts to: a panel of highly selected chiropractors (sponsored by a chiropractic organisation) has reached a consensus (and published it in a chiropractic) which allows them to continue to treat patients with neck pain.
Isn’t that just great?
Now let’s think ahead – what next?
I suggest the following:
- A panel of homeopaths recommending homeopathy.
- A panel of faith healers recommending faith healing.
- A panel of crystal healers recommending crystal healing.
- A panel of colon therapists recommending colonic irrigation.
- A panel of supplement manufacturers recommending to buy supplements.
I am sure you get the gist.
At the heart of this story is Joseph Mercola, a dietary supplement entrepreneur and osteopath.
His website states that:
EVERYONE can benefit from Dr Mercola’s unparalleled knowledge. For expertise in alternative healthcare and high quality supplemental medicine, it’s hard to beat visionary Dr Joseph Mercola. The Chicago-based health wizard has his own website, Mercola.com (‘Take Control of Your Health’), but you can find so many of his health support products right here at Evolution Organics. Our customers swear by them. They love the diversity of the range, and that the products are priced affordably, meaning that everyone can benefit from Dr Mercola’s vast experience and unmatched know-how. And it’s not just men, women and children who can feel better ‘the Dr Mercola way’ – his brand includes health support products for pets, too.
However, an article in the Washington Post tells a different story; allow me to quote a few excerpts:
The National Vaccine Information Center was founded in 1982 by Barbara Loe Fisher, who has said that her son was injured by a vaccine. The group claimed credit this year for helping to defeat legislation in a dozen states that would have made it harder for parents to opt out of vaccinating their children. At the beginning of last year’s flu season, Fisher and Mercola appeared in a YouTube video urging people to be skeptical about flu shots. Mercola claimed that vaccines have been associated with “deaths and permanent neurological complications,” and he said vitamin D supplements were among “far more effective, less expensive and less risky alternatives.” … Fisher said in an interview that Mercola has asked for nothing in exchange for his donations and that the National Vaccine Information Center does not sell or advertise Mercola’s products on its site. “I do not take funding for a quid pro quo,” she said. “When [Mercola] called me, he said, ‘I admire your work. I’d like to help you.’ ” The center’s homepage, which the group says was visited more than 1.2 million times last year, displays Mercola.com’s logo. An affiliated website run by Fisher’s group refers numerous times to Mercola.com as one of the most popular health and wellness websites…
In recent years, the center has been at the forefront of a movement that has led some parents to forgo or delay immunizing their children against vaccine-preventable diseases such as measles… The Northern Virginia-based National Vaccine Information Center lists Mercola.com as a partner on its homepage and links to the website, where readers can learn about and purchase Mercola’s merchandise…Asked if his companies benefit from his donations to the anti-vaccine group, Mercola said in an email that “being an adversary to powerful industries is not a positive for a business like mine.” …
On this blog, I have repeatedly warned that many so-called alternative medicine (SCAM) practitioners recommend against vaccinations. Specifically implicated are:
- Physicians practising integrative medicine
- Doctors of anthroposophical medicine
We knew about the ‘ideology’ and the misinformation pushing SCAM-related anti-vaccination sentiments. The article in the Washington Post is a stark reminder of the financial interests behind all this. As a result, SCAM-use is associated with low vaccination-uptake (as we have discussed ad nauseam – see for instance here, here, here and here). Anyone who needs more information will find it by searching this blog. Anyone claiming that this is all my exaggeration might look at papers which have nothing to do with me (there are plenty more for those who are willing to conduct a Medline search):
- Lehrke P, Nuebling M, Hofmann F, Stoessel U. Attitudes of homeopathic physicians towards vaccination. Vaccine. 2001;19:4859–4864. doi: 10.1016/S0264-410X(01)00180-3. [PubMed]
- Halper J, Berger LR. Naturopaths and childhood immunizations: Heterodoxy among the unorthodox. Pediatrics. 1981;68:407–410. [PubMed]
- Colley F, Haas M. Attitudes on immunization: A survey of American chiropractors. Journal of Manipulative and Physiological Therapeutics. 1994;17:584–590. [PubMed]
So-called alternative medicine (SCAM) could easily be described as a business that exists mainly because it profits from the flaws of conventional medicine. I know, this is not a good definition, and I don’t want to suggest it as one, but I think it highlights an important aspect of SCAM.
Let me explain.
If we ask ourselves why consumers feel attracted to SCAM, we can identify a range of reasons, and several of them relate to the weaknesses of conventional medicine as it is practised today. For instance:
- People feel the need to have more time with their clinician in order to discuss their problems more fully. This means that their GP does not offer them sufficient time, empathy and compassion they crave.
- Patients are weary of the side-effects of drugs and prefer treatments that are gentle and safe. This shows that they realise that conventional medicine can cause harm and they hope to avoid this risk.
- Patients find it often hard to accept that their symptoms are ‘nothing to worry about’ and does not require any treatment at all. They prefer to hear that the clinician knows exactly what is wrong and can offer a therapy that puts it right.
Conventional medicine and the professionals who administer it have many flaws. Most doctors have such busy schedules that there is little time for building an empathetic therapeutic relationship with their patients. Thus they often palm them off with a prescription and fail to discuss the risks in sufficient detail. Even worse, they sometimes prescribe drugs in situations where none are needed and where a reassuring discussion would be more helpful. It is too easy to excuse such behaviours with work pressures; such flaws are serious and cannot be brushed under the carpet in this way.
Recently, the flawed behaviour of doctors has become the focus of media attention in the form of
- opioid over-prescribing
- over-use of anti-biotics.
In both cases, SCAM providers were quick to offer the solution.
- Acupuncturists and chiropractors claim that their treatments are sensible alternatives to opioids. Yet, there is no good evidence that either acupuncture or chiropractic have analgesic effects that are remotely comparable to those of opioids. They only are seemingly successful in cases where opioids were not needed in the first place.
- Homeopaths claim that their remedies can easily replace antibiotics. Yet, there is not a jot of evidence that homeopathics have antibiotic activity. They only are seemingly successful in cases where the antibiotic was not needed in the first place.
In both instances, SCAM is trying to profit from the weaknesses of conventional medicine. In both cases, the offered solutions are clearly bogus. Yet, in both cases, scientifically illiterate politicians are seriously considering the alleged solutions. Few seem to be smart enough to take a step backwards and contemplate the only viable solution to these problems. If doctors over-prescribe, they need to be stopped; and the best way to stop them is to give them adequate support, more time with their patients and adequate recognition of the importance of reassuring and talking to patients when they need it.
To put it differently:
The best way to reduce the use of bogus SCAMs is to make conventional medicine less flawed.
Recently, we discussed the findings of a meta-analysis which concluded that walking, which is easy to perform and highly accessible, can be recommended in the management of chronic LBP to reduce pain and disability.
At the time, I commented that
this will hardly please the legions of therapists who earn their daily bread with pretending their therapy is the best for LBP. But healthcare is clearly not about the welfare of the therapists, it is/should be about patients. And patients should surely welcome this evidence. I know, walking is not always easy for people with severe LBP, but it seems effective and it is safe, free and available to everyone.
My advice to patients is therefore to walk (slowly and cautiously) to the office of their preferred therapist, have a little rest there (say hello to the staff perhaps) and then walk straight back home.
Now, there is new evidence that seems to confirm what I wrote. An international team of researchers requested individual participant data (IPD) from high-quality randomised clinical trials of patients suffering from persistent low back pain. They conducted descriptive analyses and one-stage IPD meta-analysis. They received IPD for 27 trials with a total of 3514 participants.
For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) -10.7 (-14.1 to -7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) -10.2 (-13.2 to -7.3)) at short-term follow-up.
Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers-these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care.
But you cannot dismiss so-called alternative medicine (SCAM), just like that, I hear my chiropractic and other manipulating friends exclaim – at the very minimum, we need direct comparisons of the two approaches!!!
Alright, you convinced me; here you go:
The purpose of this systematic review was to determine the effectiveness of spinal manipulation vs prescribed exercise for patients diagnosed with chronic low back pain (CLBP). Only RCTs that compared head-to-head spinal manipulation to an exercise group were included in this review. Only three RCTs met the inclusion criteria. The outcomes used in these studies included Disability Indexes, Pain Scales and function improvement scales. One RCT found spinal manipulation to be more effective than exercise, and the results of another RCT indicated the reverse. The third RCT found both interventions offering equal effects in the long term. The author concluded that there is no conclusive evidence that clearly favours spinal manipulation or exercise as more effective in treatment of CLBP. More studies are needed to further explore which intervention is more effective.
But I am!
Exercise is preferable to chiropractic and other manipulating SCAMs because:
- It is cheaper.
- It is safer.
- It is readily available to anyone.
- And you don’t have to listen to the bizarre and often dangerous advice many chiros offer their clients.
Maintenance Care is an approach whereby patients have chiropractic manipulations even when symptom-free. Thus, it is an ideal method to keep chiropractors in clover. Previous reviews concluded that evidence behind this strategy is lacking. Since then, more data have emerged. It was therefore timely to review the evidence.
Fourteen original research articles were included in the review. Maintenance Care was defined as a secondary or tertiary preventive approach, recommended to patients with previous pain episodes, who respond well to chiropractic care. Maintenance Care is applied to approximately 30% of Scandinavian chiropractic patients. Both chiropractors and patients believe in the efficacy of Maintenance Care. Four studies investigating the effect of chiropractic Maintenance Care were identified, with disparate results on pain and disability of neck and back pain. However, only one of these studies utilized all the existing evidence when selecting study subjects and found that Maintenance Care patients experienced fewer days with low back pain compared to patients invited to contact their chiropractor ‘when needed’. No studies were found on the cost-effectiveness of Maintenance Care.
The authors concluded that knowledge of chiropractic Maintenance Care has advanced. There is reasonable consensus among chiropractors on what Maintenance Care is, how it should be used, and its indications. Presently, Maintenance Care can be considered an evidence-based method to perform secondary or tertiary prevention in patients with previous episodes of low back pain, who report a good outcome from the initial treatments. However, these results should not be interpreted as an indication for Maintenance Care on all patients, who receive chiropractic treatment.
I have to admit, I have problems with these conclusions.
- Maintenance Care is not normally defined as secondary or tertitary prevention. It also includes primary prevention, which means that chiropractors recommend it for just about anyone. By definition it is long term care, that is not therapeutically necessary, but performed at regular intervals to help prevent injury and enhance quality of life. This form of care is provided after maximal therapeutic benefit is achieved, without a trial of treatment withdrawal, to prevent symptoms from returning or for those without symptoms to promote health or prevent future problems.
- I am not convinced that the evidence would be positive, even if we confined it to secondary and tertiary prevention.
To explain my last point, let’s have a look at the 4 RCT and check whether they really warrant such a relatively positive conclusion.
FIRST STUDY For individuals with recurrent or persistent non-specific low back pain (LBP), exercise and exercise combined with education have been shown to be effective in preventing new episodes or in reducing the impact of the condition. Chiropractors have traditionally used Maintenance Care (MC), as secondary and tertiary prevention strategies. The aim of this trial was to investigate the effectiveness of MC on pain trajectories for patients with recurrent or persistent LBP.
This pragmatic, investigator-blinded, two arm randomized controlled trial included consecutive patients (18–65 years old) with non-specific LBP, who had an early favorable response to chiropractic care. After an initial course of treatment, eligible subjects were randomized to either MC or control (symptom-guided treatment). The primary outcome was total number of days with bothersome LBP during 52 weeks collected weekly with text-messages (SMS) and estimated by a GEE model.
Three hundred and twenty-eight subjects were randomly allocated to one of the two treatment groups. MC resulted in a reduction in the total number of days per week with bothersome LBP compared with symptom-guided treatment. During the 12 month study period, the MC group (n = 163, 3 dropouts) reported 12.8 (95% CI = 10.1, 15.5; p = <0.001) fewer days in total with bothersome LBP compared to the control group (n = 158, 4 dropouts) and received 1.7 (95% CI = 1.8, 2.1; p = <0.001) more treatments. Numbers presented are means. No serious adverse events were recorded.
MC was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific LBP but it resulted in a higher number of treatments. For selected patients with recurrent or persistent non-specific LBP who respond well to an initial course of chiropractic care, MC should be considered an option for tertiary prevention.
SECOND STUDY Back and neck pain are associated with disability and loss of independence in older adults. Whether long‐term management using commonly recommended treatments is superior to shorter‐term treatment is unknown. This randomized clinical trial compared short‐term treatment (12 weeks) versus long‐term management (36 weeks) of back‐ and neck‐related disability in older adults using spinal manipulative therapy (SMT) combined with supervised rehabilitative exercises (SRE).
Eligible participants were ages ≥65 years with back and neck disability for ≥12 weeks. Coprimary outcomes were changes in Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores after 36 weeks. An intent‐to‐treat approach used linear mixed‐model analysis to detect between‐group differences. Secondary analyses included other self‐reported outcomes, adverse events, and objective functional measures.
THIRD STUDY A prospective single blinded placebo controlled study was conducted. To assess the effectiveness of spinal manipulation therapy (SMT) for the management of chronic nonspecific low back pain (LBP) and to determine the effectiveness of maintenance SMT in long-term reduction of pain and disability levels associated with chronic low back conditions after an initial phase of treatments. SMT is a common treatment option for LBP. Numerous clinical trials have attempted to evaluate its effectiveness for different subgroups of acute and chronic LBP but the efficacy of maintenance SMT in chronic nonspecific LBP has not been studied. Sixty patients, with chronic, nonspecific LBP lasting at least 6 months, were randomized to receive either (1) 12 treatments of sham SMT over a 1-month period, (2) 12 treatments, consisting of SMT over a 1-month period, but no treatments for the subsequent 9 months, or (3) 12 treatments over a 1-month period, along with “maintenance spinal manipulation” every 2 weeks for the following 9 months. To determine any difference among therapies, we measured pain and disability scores, generic health status, and back-specific patient satisfaction at baseline and at 1-, 4-, 7-, and 10-month intervals. Patients in second and third groups experienced significantly lower pain and disability scores than first group at the end of 1-month period (P = 0.0027 and 0.0029, respectively). However, only the third group that was given spinal manipulations (SM) during the follow-up period showed more improvement in pain and disability scores at the 10-month evaluation. In the nonmaintained SMT group, however, the mean pain and disability scores returned back near to their pretreatment level.SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.
FORTH STUDY Evidence indicates that supervised home exercises, combined or not with manual therapy, can be beneficial for patients with non-specific chronic neck pain (NCNP). The objective of the study is to investigate the efficacy of preventive spinal manipulative therapy (SMT) compared to a no treatment group in NCNP patients. Another objective is to assess the efficacy of SMT with and without a home exercise program.Ninety-eight patients underwent a short symptomatic phase of treatment before being randomly allocated to either an attention-group (n = 29), a SMT group (n = 36) or a SMT + exercise group (n = 33). The preventive phase of treatment, which lasted for 10 months, consisted of meeting with a chiropractor every two months to evaluate and discuss symptoms (attention-control group), 1 monthly SMT session (SMT group) or 1 monthly SMT session combined with a home exercise program (SMT + exercise group). The primary and secondary outcome measures were represented by scores on a 10-cm visual analog scale (VAS), active cervical ranges of motion (cROM), the neck disability index (NDI) and the Bournemouth questionnaire (BQ). Exploratory outcome measures were scored on the Fear-avoidance Behaviour Questionnaire (FABQ) and the SF-12 Questionnaire. Our results show that, in the preventive phase of the trial, all 3 groups showed primary and secondary outcomes scores similar to those obtain following the non-randomised, symptomatic phase. No group difference was observed for the primary, secondary and exploratory variables. Significant improvements in FABQ scores were noted in all groups during the preventive phase of the trial. However, no significant change in health related quality of life (HRQL) was associated with the preventive phase. This study hypothesised that participants in the combined intervention group would have less pain and disability and better function than participants from the 2 other groups during the preventive phase of the trial. This hypothesis was not supported by the study results. Lack of a treatment specific effect is discussed in relation to the placebo and patient provider interactions in manual therapies. Further research is needed to delineate the specific and non-specific effects of treatment modalities to prevent unnecessary disability and to minimise morbidity related to NCNP. Additional investigation is also required to identify the best strategies for secondary and tertiary prevention of NCNP.
I honestly do not think that the findings from these 4 small trials justify the far-reaching conclusion that Maintenance Care can be considered an evidence-based method… For that statement to be evidence-based, one would need to see more and better studies. Therefore, the honest conclusion, I think, is that maintenance care is not supported by sound evidence for effectiveness; as chiropractic manipulations are costly and not risk-free, its risk/benefit balance fails to be positive. Therefore, this approach cannot be recommended.
This survey investigated how many chiropractors in the Canadian province of Alberta promote a theory of subluxation, which health ailments or improvements were linked to subluxation, and whether the subluxation discourse was used to promote chiropractic for particular demographics.
Using the search engine on the Canadian Chiropractic Associations’ website, the researchers made a list of all clinics in Alberta. They then used Google searches to obtain a URL for each clinic with a website, totalling 324 URLs for 369 clinics. They then searched on each website for “subluxation” and performed content analysis on the related content.
One hundred twenty-one clinics’ websites (33%) presented a theory of vertebral subluxation. The ailments and improvements discussed in relation to subluxation were wide-ranging; they included the following:
- back pain,
- bed wetting
- blood pressure,
- ear infection,
- heart disease,
- hormonal imbalance,
- learning problems,
- menstrual cramps,
- Parkinson’s disease,
- problems with hearing,
- problems with vision,
- prostate cancer,
- respiratory disease,
- sleeping problems,
- spinal decay,
- sudden infant death syndrome,
- and many more.
The marketing of chiropractic for children was observed on 8% of the clinic websites.
The researchers concluded that, based on the controversy surrounding vertebral subluxation, the substantial number of clinic websites aligning their practice with vertebral subluxation should cause concern for regulatory bodies.
Why do so many chiropractors cling so tightly to the long obsolete concept of subluxation? The way I see it there are at least three reasons:
- If they abandoned subluxation, they would quickly become physiotherapists, only with a much reduced scope of practice.
- Using the subluxation myth avoids the need of the knowledge of any complicated pathophysiology.
- Subluxation is ever so good for business, as it renders chiropractic manipulation a cure all.
D. D. Palmer, the magnetic healer who invented chiropractic about 120 years ago, claimed that a vital energy, which he called the “innate”, controls all body functions. In the presence of “vertebral subluxation,” it cannot work adequately, he postulated. In other words, subluxations block the flow of the innate which, in turn, is the cause of all disease. Palmer therefore developed spinal manipulations to correct such subluxations and de-block the flow of the innate. Palmer defined chiropractic as a system of healing based on the premise that the body requires unobstructed flow through the nervous system of innate intelligence. This effectively makes the adjustment of subluxation a panacea.
To put it simply: subluxation is the carte blanche required for making unlimited bogus claims, while ripping off the public.
- In 2017, Mr Lawler, aged 79 at the time, has a history of back problems, including back surgery with metal implants and suffers from pain in his leg.
- His GP recommends to consult a physiotherapist.
- As waiting lists are too long, Mr Lawler sees a chiropractor shortly after his 80th birthday who calls herself ‘doctor’ and who he assumes to be a medic specialising in back pain.
- The chiropractor uses a spinal manipulation of the neck with the drop table.
- There is no evidence that this treatment is effective for pain in the leg.
- No informed consent is obtained from the patient.
- This is acutely painful and brakes the calcified ligaments of Mr Lawler’s upper spine.
- Mr Lawler is immediately paraplegic.
- The chiropractor who had no training in resuscitation is panicked tries mouth to mouth.
- Bending the patient’s neck backwards the chiropractor further compresses his spinal cord.
- When ambulance arrives, the chiropractor misleads the paramedics telling them nothing about a forceful neck manipulation with the drop and suspecting a stroke.
- Thus the paramedics do not stabilise the patient’s neck which could have saved his life.
- Mr Lawler dies the next day in hospital.
- The chiropractor is arrested immediately by the police but then released on bail.
- The expert advising the police is a prominent chiropractor.
- One bail condition is not to practise, pending a hearing by the GCC.
- The GCC decide not to take any action.
- The police therefore release the bail conditions and she goes back to practising.
- The interim suspension hearing of the GCC is being held in September 2017.
- The deceased’s son wants to attend but is not allowed to be present at the hearing even though such events are normally public.
- The coroner’s inquest starts in 2019.
- In November 2019, a coroner rules that Mr Lawler died of respiratory depression.
- The coroner also calls on the GCC to bring in pre-treatment imaging to protect vulnerable patients.
- The GCC announce that they will now continue their inquiry to determine whether or not chiropractor will be struck off the register.
The son of the deceased is today quoted stating that the GCC “seems to be a little self-regulatory chiropractic bubble where chiropractors regulate chiropractors.”
I sympathise with this statement. On this blog, I have repeatedly voiced my concerns about the GCC – see here, for instance – which I therefore do not need to repeat. My opinion of the GCC is also coloured by a personal experience which I will quickly recount now:
A long time ago (I estimate 10 – 15 years), the GCC invited me to give a lecture and I accepted. I do not remember the exact subject they had given me, but I clearly recall elaborating on the risks of spinal manipulation. This was not too well received. When I had finished, a discussion ensued in which I was accused of not knowing my subject and aggressed for daring to ctiticise chiropractic. I had, of couse, given the lecture assuming they wanted to hear my criticism. In the end, I left with the impression that this assumption was wrong and that they really just wanted to lecture, humiliate and punish me for having been a long-term critic of their trade.
I therefore can fully understand of David Lawler’s opinion about the GCC. To me, they certainly behaved as though their aim was not to protect the public, but to defend chiropractors from criticism.
Yes, chiropractic spinal manipulation shows promise to alleviate symptoms of infant colic! At least, this is the result of an overview of systematic reviews of so-called alternative medicines (SCAMs) for infant colic. Here I focus merely on the part that deals with chiropractic spinal manipulation. The authors of the overview come to this result based mainly on the statement:
Spinal manipulation was assessed in six reviews [22, 23, 25,26,27,28]. Two multiple CAM reviews assessed manipulation but did not pool the results [22, 25]. Both found three trials to be effective [68, 69, 72, 73, or] with the exception of one .
And here are the references they cite (all the primary studies are on chiropractic manipulation):
22.Perry R, Hunt K, Ernst E. Nutritional supplements and other complementary medicines for infantile colic: a systematic review. Pediatrics. 2011;127:720–33.
23.Bruyas-Bertholo V, Lachaux A, Dubois J-P, Fourneret P, Letrilliart L. Quels traitements pour les coliques du nourrisson. Presse Med. 2012;41:e404–10.
24.Harb T, Matsuyama M, David M, Hill RJ. Infant colic—what works: a systematic review of interventions for breast-fed infants. J Pediatr Gastroenterol Nutr. 2016;62(5):668–86.
25.Gutiérrez-Castrellón P, Indrio F, Bolio-Galvis A, et al. Efficacy of Lactobacillus reuteri DSM 17938 for infantile colic. Systematic review with network meta-analysis. Medicine. 2017;96(51):e9375.
26.Dobson D, Lucassen PLBJ, Miller JJ, Vlieger AM, Prescott P, Lewith G. Manipulative therapies for infantile colic. Cochrane Database of Systematic Reviews. 2012;(Issue 12. Art. No.: CD004796)
27.Gleberzon BJ, Arts J, Mei A, McManus EL. The use of spinal manipulative therapy for pediatric health conditions: a systematic review of the literature. J Can Chiropr Assoc. 2012;56(2):128–41.
28.Carnes D, Plunkett A, Ellwood J, et al. Manual therapy for unsettled, distressed and excessively crying infants: a systematic review and meta-analyses. BMJ Open. 2018;8:e019040.
68.Wiberg J, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled trial with a blinded observer. J Manip Physiol Ther. 1999;22(8):517–22.
69.Mercer C. A study to determine the efficacy of chiropractic spinal adjustments as a treatment protocol in the Management of Infantile Colic [thesis]. Durban: Technikon Natal,Durban University; 1999.
70.Mercer C, Nook B. The efficacy of chiropractic spinal adjustments as a treatment protocol in the management of infantile colic. In: Presented at: 5th Biennial Congress of the World Federation of Chiropractic. Auckland; 1999. p. 170-1.
71.Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomized controlled trial of infantile colic treated with chiropractic spinal manipulation. Arch Dis Child. 2001;84(2):138–41.
And here is the relevant part of the overview’s conclusion:
Spinal manipulation shows promise to alleviate symptoms of colic, although concerns remain as positive effects were only demonstrated when crying was measured by unblinded parent assessors.
I have several concerns about this new overview:
- My comments on the Canes paper are here and do not need repeating.
- My comments on the Dobson paper (according to the overview authors, it is the best of all the reviews) are also available and need no repeating.
- Reference 22 is a systematic review I did together with the lead author of the new overview while she was one of my co-workers at Exeter. It is not focussed on spinal manipulation, but on all SCAMs. Here is the relevant passage from our conclusions regarding spinal manipulation: The evidence for … manual therapies does not indicate an effect.
How the review authors could come to the verdict that spinal manipulation shows promise is thus more than a little mysterious. If we consider the following, it gets positively bewildering. Even the most rudimentary of searches on Medline will deliver a 2009 systematic review by myself entitled ‘Chiropractic spinal manipulation for infant colic: a systematic review of randomised clinical trials‘. It was the first systematic review on the subject but was not included in the new overview.
I do not know.
Here are my conclusions from this paper:
Collectively these RCTs fail to demonstrate that chiropractic spinal manipulation is an effective therapy for infant colic. The largest and best reported study failed to show effectiveness (11). Numerous weaknesses of the primary data would prevent ﬁrm conclusions, even if the results of all RCTs had been unanimously positive.
And here is what my review stated about the three primary RCTs assessed in all the other review authors:
The trial by Wiberg et al. (10) did not attempt to blind the infants’ parents who acted as the evaluators of the therapeutic success. The paper provides little details about the recruitment process, but it is fair to assume that patients were asked to participate in a trial of spinal manipulation. Thus one might expect a degree of disappointment in parents of the control group whose children did not receive this treatment. This, in turn, could have impacted on the parents’ subjective judgements. In any case, there is no control for placebo effects which can be very different for a physical intervention compared with an oral placebo – dimethicone was administered as a placebo and the authors stress that it is ‘no better than placebo treatment’.
The RCT by Olafsdottir et al. (11) is by far the best-reported study of all the included RCTs. In many ways, it is a replication of Wiberg’s investigation (10) but on a larger scale with twice the sample size. It is the only study where a serious attempt was made to control for the placebo effects of spinal manipulations. For these reasons, its results seem more reliable than those of the other RCTs.
The RCT by Browning and Miller (12) is a comparison of two manual techniques both of which are assumed by the authors to be effective. Thus it is essentially a non-inferiority trial. Yet, it is woefully underpowered for such a design. Even if it had the necessary power, its results would be difﬁcult to interpret because none of the two interventions have been proven to be effective. Thus, one would still be uncertain whether both interventions are similarly ineffective or effective. As it stands, the result simply seems to demonstrate that symptoms of infant colic lessen over time possibly as a result of non-speciﬁc therapeutic effects, the natural history of the disease, concomitant treatments, social desirability or a combination of these factors.
So, what should we conclude from all this? I am not sure – except for one thing, of course: I would not call the evidence for chiropractic spinal manipulation promising.
RE: Review of chiropractic spinal care for children under 12 years
The Australian Medical Association (AMA Victoria) appreciates the opportunity to respond to the Safer Care Victoria (SCV) consultation on chiropractic manipulation of children under 12 years.
The AMA is pleased that SCV has decided to review this practice which is manifestly unsafe and unwarranted.
Chiropractic spinal manipulation on children has received recent media attention and prompted community concerns about its safety, appropriateness and the professional duties of those undertaking it. Most notably, in February this year medical experts and the Victorian Government condemned the controversial practice of infant spine manipulation after footage emerged of a Melbourne chiropractor treating a two-week old baby on the chiropractor’s own site.
Treatment of infants and very young children
We are aware that chiropractors are treating children for problems such as “infantile colic” by manipulative therapies. There is no credible evidence for this, it is a dangerous practice in itself and it potentially impedes the proper assessment and management of an infant. Additionally, it preys on often tired parents by the promise of a frequently false unequivocal diagnosis and false “quick fix”. This is plainly unconscionable and dangerous behaviour.
In preparing our response, we engaged with doctors across many specialities who have offered valuable insights into the matters being considered as part of this review. It is our very firm view that the risk of undertaking spinal manipulation on small infants is of no benefit and is potentially extremely dangerous. Newborn babies are extremely fragile and AMA Victoria warns that damage done to a baby or infant may not be immediately obvious to parents, and may not manifest until many years later. This is supported by a study conducted by the American Academy of Pediatrics  which found serious adverse events may be associated with paediatric spinal manipulation.1
Another critical issue is that it is very unlikely that parents are providing informed consent to such procedures. For parents to provide informed consent, they would need to be fully advised of the risks including, for example:
• the diagnosis of “infant colic” is a catch all for a range of symptoms with different aetiologies;
• the potential drastic short and long term consequences of spinal manipulation on their baby;
• there are no scientific safety and efficacy studies undertaken; and
• there is no credible scientific evidence for manipulation.
Chiropractors should also be directing parents to general practitioners for the proper holistic assessment and care of the child and family.
Additionally, infants and very young children cannot provide assent for a procedure for which there is no evidence they require and which may leave them with long term consequences. Consideration of whether such potentially dangerous therapies, which are not underpinned by a strong evidence-base, should be supported by private health insurance rebates is also warranted.
Treatment of children under 12 years of age
Although there is limited evidence that some musculoskeletal treatments are effective in adults, there is no credible scientific evidence that manipulation, mobilisation or any applied spinal therapy in children under 12 years of age is warranted or safe.
AMA Victoria does not support clinical interventions unless there is scientific evidence that such treatments are useful in treating the illness. AMA Victoria also supports patients being fully informed on the illness and the risks and benefits to any treatment. When the risks are to be borne by a non-assenting child, the requirement of evidence and consent is especially important.
AMA Victoria strongly advocates that chiropractic (and other health professionals) spinal care for children under 12 years of age is dangerous, unwarranted and must cease immediately.
If you would like to discuss any aspect of our response, please contact Ms Nada Martinovic, Senior Policy Advisor on (03) 9280 8773 or email@example.com.
Associate Professor Julian Rait OAM AMA VICTORIA PRESIDENT
1 Sunita, V., et al., Adverse Events Associated with Pediatric Spinal Manipulation: A Systemic Review, Pediatrics, 2007: 119; 275-283.
I am truly delighted that the AMA Victoria agrees with many points I have tried to make previously (see for instance here, here and here). The statement is unsurpassed in its directness and strength. My congratulations to Prof Raith – very well done!
Let’s hope that professional bodies of other regions and counties will swiftly follow suit with equal clarity.