chiropractic
So-called alternative medicine (SCAM) likes to present itself as a champion of disease prevention. Its advocates routinely claim to promote health before disease develops, to strengthen the body’s defences, and to address root causes rather than symptoms. This rhetoric is highly attractive, because prevention sounds proactive, humane, and economical. Crucially, it is also good for the SCAM practitioner’s bank account. Yet there is a snag: almost none of the preventive claims made for SCAM are supported by reliable evidence, whereas the prevention that works comes overwhelmingly from conventional medicine and science.
To show preventive benefit, an intervention must demonstrably reduce the incidence of symptom, disease, complication, or mortality in properly designed studies. That may require randomised trials, epidemiological studies, large cohorts, reproducible findings, and enough follow-up to show that fewer people actually experienced the given endpoint. Mainstream medicine has repeatedly met this standard. Immunization, blood pressure control, smoking cessation, lipid lowering, cancer screening, and risk-factor modification are all products of biomedical research, not of alternative healing traditions.
SCAM, by contrast, tends to use prevention in a loose, impressionistic, and unfalsifiable way. A practitioner may claim that a treatment “balances energy,” “supports immunity,” or “keeps the body in harmony,” but such phrases do not establish a preventive effect. They are placeholders for evidence, not evidence itself. In practice, the absence of disease after treatment is treated as proof that the treatment worked, even though the same outcome occurs every day without any intervention at all.
Acupuncture is a good example. Its defenders portray it as a preventive system capable of preserving general health or warding off illness, but the evidence base does not support that claim. Some reviews do suggest that acupuncture may help with some pain-related and symptom-focused conditions, yet its preventive value is largely unproven. I am not aware of solid evidence to show that acupuncture prevents anything – but, if I am wrong, please do correct me.
Chiropractic care is even more revealing because preventive claims are often tied to the doctrine of spinal “subluxation” and nervous system dysfunction. Yet the literature on prevention is thin and methodologically weak. I am not aware of solid evidence to show that chiropractic prevents anything – but, if I am wrong, please do correct me.
Herbalism benefits from the romantic appeal of “natural” remedies, but that appeal should not be confused with demonstrated preventive efficacy. Individual plant compounds have certainly inspired real drugs, yet that is a triumph of pharmacology, not of herbalism as a system. When herbal medicines are tested for prevention, results are usually weak, inconsistent, or insufficient to support recommendation. I am not aware of solid evidence to show that herbal medicine prevents anything – but, if I am wrong, please do correct me.
Homeopathy is one of the most extreme cases within SCAM. It is often sold as gentle, individualized, and even preventive, but its basic principles are scientifically implausible, and its clinical evidence is either flawed or negative. Preventive homeopathy, including ideas such as “homeoprophylaxis,” is particularly problematic because it can give people a false sense of security while displacing interventions that genuinely prevent disease, such as vaccination. I am not aware of solid evidence to show that homeopathy prevents anything – but, if I am wrong, please do correct me.
SCAM speaks almost constantly about prevention, but the evidence for actual preventive benefit is close to non-existent. What we know about prevention, what truly reduces disease incidence and improves population health, comes from conventional medicine, epidemiology, public health, and biological science. SCAM will no doubt continue to borrow the language of medicine and prevention, but – as far as I can see – it has failed to supply the proof.
During outbreaks of Ebola Virus Disease (EVD), public health organizations like the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) combat “infodemics”, i.e. surges of false information and unproven so-called alternative medicine (SCAM) polluting social media (Bedrosian et al., 2016; Fung et al., 2016; Obol & Nzedibe, 2024). Because these SCAMs are ineffective and frequently dangerous, authorities issue warnings against their use. Here are just a few of the many claims that can be found:
- Bathing in or drinking hot, highly saturated saltwater solutions can sweat out or kill the Ebola virus (Fung et al., 2016). Public health agencies strongly advise against this practice. It does nothing to prevent or treat EVD and can cause severe illness and death from acute hypernatremia (Vijaykumar et al., 2019).
- Solutions containing silver nanoparticles act as powerful natural antimicrobials capable of neutralizing the Ebola virus inside the body (Fung et al., 2016). The WHO has explicitly stated that Nano Silver is an unproven compound with no demonstrated efficacy against Ebola. Authorities recommend avoiding these products, as silver accumulation can cause irreversible organ damage and a condition called argyria (which permanently turns the skin blue/gray).
- Consuming large quantities of specific botanical items, such as raw onions, ginger, or alligator peppers, can stave off infection (Nsoesie & Oladeji, 2020). These “natural cures” possess no therapeutic effects capable of stopping viral replication of the filovirus family. Relying on them creates a false sense of security, which delays life-saving, evidence-based triage and supportive care (Fridman et al., 2025; Nsoesie & Oladeji, 2020).
- Ebola has been attributed to spiritual curses or witchcraft that can only be reversed by traditional spiritual cleansing (Bedrosian et al., 2016). Public health organizations work alongside local communities to pivot away from these practices. Delaying medical intervention to seek traditional spiritual healing drastically increases community transmission and prevents patients from receiving SOTA antiviral therapies and fluid replacement, lowering survival rates (Obol & Nzedibe, 2024).
- A homeopath market “e-remedies” online, claiming that the “energy signature” of a remedy could be digitized into an audio file (Moffitt, 2018). He claimed that listening to a specific, hissing MP3 file could stimulate the body’s immune system to fight off Ebola. This prompted an investigation by the Medical Board of California into the doctor’s license for promoting unscientific and unproven online remedies (Moffitt, 2018).
- Some chiropractors claim that spinal manipulations can prevent Ebola infections, because misalignments interfere with the nervous system. Since the nervous system coordinates the immune responses, these misalignments weaken the body’s ability to recognize and destroy the Ebola virus (Terry Chiropractic Boulder). People “have nothing to fear but fear itself” regarding outbreaks if they keep their spines properly aligned to maximize their natural innate immunity. Global public health authorities and mainstream scientific institutions strongly reject these claims. There is zero credible scientific evidence demonstrating that manual spinal manipulation enhances immune competence or protects an individual against Ebola (Côté et al., 2020).
Ebola infection requires immediate, professional medical treatment. Treatments include monoclonal antibody therapeutics along with intensive supportive care. Relying on internet remedies significantly delays proper clinical treatment and increases the risk of mortality.
References
Bedrosian, S. R., Young, E. C., Smith, L. A., Cox, J. D., Manning, C., Pechta, L., Telfer, J. L., Gaines-McCollom, M., Harben, Kathy, Holmes, Wendy, Lubell, K. M., McQuiston, J. H., Nordlund, Kristen, O’Connor, John, Reynolds, B. S., Schindelar, J. A., Shelley, Gene, & Daniel, K. L. (2016). Lessons of Risk Communication and Health Promotion — West Africa and United States. MMWR Supplements, 65(3), 68–74. https://doi.org/10.15585/mmwr.su6503a10
Fridman, I., Boyles, D., Chheda, R., Baldwin-SoRelle, C., Smith, A. B., & Elston Lafata, J. (2025). Identifying Misinformation About Unproven Cancer Treatments on Social Media Using User-Friendly Linguistic Characteristics: Content Analysis. JMIR Infodemiology, 5, e62703. https://doi.org/10.2196/62703
Fung, I. C.-H., Fu, K.-W., Chan, C.-H., Chan, B. S. B., Cheung, C.-N., Abraham, T., & Tse, Z. T. H. (2016). Social Media’s Initial Reaction to Information and Misinformation on Ebola, August 2014: Facts and Rumors. Public Health Reports®, 131(3), 461-473. https://doi.org/10.1177/003335491613100312
Moffitt, M. (2018). State doubts Los Gatos doctor can cure ebola with hissing MP3 files. SFGATE. https://www.sfgate.com/bayarea/article/dr-bill-gray-medical-license-homeopathy-treatment-12954925.php
Nsoesie, E. O., & Oladeji, O. (2020). Identifying patterns to prevent the spread of misinformation during epidemics. Harvard Kennedy School Misinformation Review. https://doi.org/10.37016/mr-2020-014
Obol, S. J., & Nzedibe, O. (2024). Critical perspective on infodemic and infodemic management in previous Ebola outbreaks in Uganda. Frontiers in Public Health, 12. https://doi.org/10.3389/fpubh.2024.1375776
Terry Chiropractic Boulder. (2014). Hold On Ebola: How Bolstering Your Immune System Can Help You Avoid Disease. https://terrychiropracticboulder.com/blog/hold-on-ebola-how-bolstering-your-immune-system-can-help-you-avoid-disease/
Vijaykumar, S., Jin, Y., & Pagliari, C. (2019). Outbreak communication challenges when misinformation spreads on social media. Revista Eletrônica de Comunicação, Informação e Inovação em Saúde, 13(1). https://doi.org/10.29397/reciis.v13i1.1623
I came across an interesting article about chiropractic. Let me try to summarise it for you:
Texas’s system for disciplining chiropractors has become much less transparent, making it harder for patients to know whether a provider has faced regulatory action or not. Disciplinary cases reported by the Texas Board of Chiropractic Examiners and the National Practitioner Data Bank have dropped sharply even as the number of licensed chiropractors has risen, which prompted patient advocates to ask whether the public is being misled.
A rule change adopted in 2019 that narrowed what the chiropractic board can publicly disclose seems at the heart of this. According to board executive director Boyd Bush, the result is that roughly 70 cases, mostly minor administrative matters such as late license renewals, are no longer appearing in the public-facing record. Bush argues the change was intended to prevent chiropractors from suffering disproportionate consequences, such as losing patients or paying higher insurance premiums, for technical violations that do not directly affect patient care.
That explanation contrasts with the view of patient advocate Ware Wendell of Texas Watch, who says the public needs clearer, more usable information when choosing care. His concern is that a chiropractor can have regulatory action behind the scenes while still appearing to have “no board action taken” in public-facing materials, leaving patients unaware of relevant history.
Moreover, not all chiropractor-related enforcement is handled by the chiropractic board. In some cases, the Texas Medical Board has issued cease-and-desist orders against chiropractors accused of practicing medicine without a license, including claims involving neurology expertise, stem cell therapy, diabetes treatment, thyroid disorders, and chronic degenerative diseases. That overlap between boards adds confusion and can make it even harder for the public to interpret what level of discipline or risk a practitioner has faced.
A broader policy debate sits behind the story. Lawmakers tried to reduce inter-board oversight last session through Senate Bill 268, but Governor Greg Abbott vetoed it, citing public health and safety concerns. The Texas Chiropractic Association, meanwhile, says complaints should be handled by the boards with direct oversight, while a 2017 Sunset Advisory Commission review had already criticized the chiropractic board for slow complaint resolution and weak enforcement.
The article closes by noting that the board says it has improved the backlog, but the transparency issue is likely to return in the next legislative session. Evidently, a tension exists between protecting chiropractors from over-penalization for minor offenses and ensuring patients can see meaningful disciplinary history before seeking treatment.
On this blog, we have discussed repeatedly that dishonesty and transgressions are by no means rare events in the realm of chiropractic. I think it is time that this profession gets its act together, puts more emphasis on ethics during education/training, and becomes transparent, even if it might not enhance their public image in the short-term.
Spinal manipulative therapies, including chiropractic and osteopathic maneuvers, are widely practiced for musculoskeletal complaints. However, serious complications such as cerebrospinal fluid (CSF) leak with subsequent intracranial hypotension (IH) have been described. The pathophysiological mechanism is presumed to involve mechanical stress on the spinal dura during high-velocity movements, leading to dural tears, particularly in the cervicothoracic region.
A team of Italian neuroscientists conducted a scoping review in accordance with the PRISMA extension for Scoping Reviews (PRISMA-ScR) guidelines, through a comprehensive search of PubMed and Scopus. They complemented the review with an illustrative case from their own institution.
The researchers identified 21 eligible papers, including 21 patients with IH following spinal manipulation. Most patients were women (81%), aged 29-54 years, and the majority underwent cervical maneuvers.
SMT techniques vary, most often involving high-velocity cervical maneuvers. The most frequent were axial tension with rotation in seven cases (33.3%), unspecified cervical manipulation in four cases (19%), and thoracic spinal manipulation in two cases (9.5%). Less common single-case techniques included rotation with hyperextension, combined cervical and thoracic mobilization, axial tension with lateral flexion, and occipital/shoulder tension technique (n = 1 case each).
Symptom onset was typically within the first week, and all presented with orthostatic headache, often accompanied by nausea, neck pain, tinnitus, or visual disturbances. Neuroimaging consistently revealed features of IH, with pachymeningeal enhancement and subdural collections as the most frequent findings; spinal imaging frequently demonstrated extradural CSF collections. Management was conservative in about one-third of cases, but most required epidural blood patching, which was effective in the majority. Surgical repair was necessary in rare, refractory cases, particularly in the presence of structural spinal abnormalities. Overall prognosis was favorable, with 95% of patients achieving full recovery.
The authors’ illustrative case highlights the potential for severe complications such as subdural hematomas and recurrence if the underlying leak is not addressed:
A 65-year-old patient without a previous history of headache presented with a progressively worsening headache, with orthostatic features, poorly responsive to medical therapy, that has lasted for the past 20 days. The patient denied any recent trauma. He reported having undergone cervical osteopathic manipulations within the past 3 months for recurrent cervicalgia. A brain MRI without contrast was performed, showing a large bilateral subdural hematoma with significant mass effect on the cortical gyri. The patient was admitted to the emergency department and underwent neurosurgical evacuation of a bilateral chronic subdural hematoma via burr holes. Subsequently, endovascular embolization of the middle meningeal arteries was performed as an adjunctive treatment to reduce the risk of recurrence. The surgical procedure was performed without complications. A cranial CT scan showed a reduction in the volume of the hematoma. Therefore, the patient was discharged. However, after a transient improvement in the symptoms, the patient continued to present a fluctuating headache without positional features, with four to five episodes per month. He was readmitted to our clinic and, upon arrival at the ER, a head CT scan showed an increase in pneumocephalus and a recurrence of the hematoma. The following day, an MRI of the neuraxis with contrast was performed, which revealed radiological findings suggestive of IH: pachimeningeal enhancement, subdural fluid collection, dural venous engorgement, cervical spinal longitudinal extradural collection, and effacement of the suprasellar cistern. The Bern score was 7. Given these findings, a surgical revision of the previous burr holes was performed without periprocedural complications. After the first day, a non-targeted epidural blood patch (EBP) was performed under local anesthesia by injecting 16 mL of autologous blood into the L3–L4 epidural space. The procedure was uneventful. A cranial CT scan showed satisfactory surgical outcomes, highlighting a reduction in the volume of the hematoma and of the pneumoencephalus. The patient was subsequently discharged with complete resolution of the headache.
The authors concluded that clinicians should recognize the possibility of CSF leaks after spinal manipulation, especially in patients with new-onset orthostatic headache.
I feel compelled to point out that, considering the multiple risks of upper spinal manipulations and the almost total lack of evidence of benefit from such treatments, the risk/benefit balance of spinal manipulation is clearly not positive. It follows, I think, that it would be wise for patients not to allow such therapies being carried out, and for healthcare professionals to discourage them.
Pediatric vertebral artery dissection (VAD) following chiropractic cervical manipulation (CCM) is a rare phenomenon. As chiropractic care of pediatric populations increases internationally, it is imperative to increase awareness of this cause of VAD.
This case-report describes a patient encountered in the Department of Neurological Surgery, Indiana University School of Medicine, USA. He was a 20-month-old male who presented nonspecifically with acute onset of
- lethargy,
- vomiting,
- cyanosis,
- respiratory distress.
Cerebrovascular imaging revealed a luminal irregularity in the V4 segment of the right vertebral artery, consistent with dissection. The patient’s guardian later provided history of taking the child for cervical chiropractic corrections immediately prior to the patient’s presentation to the emergency department.
The patient was managed non-operatively. Intubation was performed due to respiratory distress and managed with fluids, vasopressors, antimicrobials, and high-flow oxygen. The patient was extubated four days after presentation, and pressors were discontinued upon achievement of hemodynamic stability. A few days after extubation, the patient was ambulating and able to interact with objects and caretakers. Aspirin therapy was initiated and continued after discharge. The patient was followed with annual appointments and imaging. At two-year follow-up, CTA demonstrated an asymmetrically small right vertebral artery, accompanied by encephalomalacia of the right posterior occipital lobe. MRA demonstrated diffuse narrowing of the V4 segment of the right vertebral artery, albeit less pronounced than prior MRAs. Aspirin was discontinued by an outside following team due to stability of imaging findings. The parents were advised to avoid contact sports to avoid trauma and recurrent stroke.
The authors found 2 further cases of pediatric VAD in the published literature following CCM. Non-specific presentations were noted in both of them. Appropriate diagnosis of pediatric VAD requires increased surveillance in response to a thorough history and an acknowledgment of the plethora of possible patient presentations and etiologies.
The authors concluded that there is an increasing utilization of chiropractors among the pediatric population. In a pediatric patient with nonspecific symptoms, VAD should be considered as a differential diagnosis when there is a history of CCM.
The authors’ statement that “pediatric vertebral artery dissection (VAD) following chiropractic cervical manipulation (CCM) is a rare phenomenon” should be taken with a pinch of salt. As there is no monitoring, the frequency of adverse effects and complications is essentially unknown. Crucially. the risks of CCM for children is by no means confined to VADs. For a fuller account, I recomment reading my book which has an entire chapter on this very subject.
The key messages about CCM for kids might be summarised in the following simple three facts:
- CCM has no true benefit for children.
- Thus the risk/benefit balance fails to be positive.
- Therefore we should discourage partents from taking their kids to see chiropractors.
The ‘Smallwood Report‘, entitled “The Role of Complementary and Alternative Medicine in the NHS” was published in October 2005. It recommended greater integration of so-called alternative medicine (SCAM) into the UK’s National Health Service and to address “effectiveness gaps” in treating chronic and psychosocial conditions, claiming potential cost savings.
Its core recommendations were:
- NICE assessment: Urged Health Ministers to task the National Institute for Health and Clinical Excellence (NICE) with a full review of the cost-effectiveness of therapies like acupuncture, chiropractic, osteopathy, herbal medicine, and homeopathy.
- Targeted applications: Suggested these SCAM options for lower back pain (manipulative therapies over conventional), asthma (homeopathy), common colds (echinacea), and other chronic issues where orthodox medicine falls short, potentially reducing absenteeism and NHS costs by hundreds of millions.
- Implementation steps: Promote GP referrals to SCAM, target deprived communities, prioritize research on cost-effectiveness/safety, address regulatory barriers, and use case studies showing reduced GP visits and secondary care savings.
At the time, I called its evidence “grossly misleading,” citing ignored Cochrane reviews showing no superiority for most of the claims. Many critics agreed with me, and the Lancet editor Richard Horton famoulsy called it “dangerous nonsense”.
As the recommendations were pure BS, it is comforting to note that – 20 years later – they have been largely ignored.
NICE assessments:
NICE has issued selective endorsements—e.g., acupuncture and manipulative therapies for low back pain—but stopped short of broad SCAM evaluations, often citing “insufficient evidence” or requiring further trials, directly countering the report’s call for comprehensive cost-effectiveness reviews. No large-scale NICE program emerged to validate the report’s claimed savings (hundreds of millions annually), and guidelines frequently dismiss or deprioritize unproven modalities like homeopathy.
NHS integration status:
- Limited GP referrals: Sporadic pilots exist (e.g., acupuncture in some pain clinics, osteopathy/chiropractic for musculoskeletal issues), often GP-led and adjunctive, but not systematic; social prescribing now favors mindfulness over traditional SCAM.
- Funding barriers: Most Integrated Care Boards (ICBs) classify SCAM as “low priority” absent robust evidence, funding only exceptional cases in palliative or pain management pathways; many services closed due to austerity post-2010.
- No deprived-community focus: The report’s equity push for high-need areas saw negligible uptake, with barriers like clinician resistance and regulatory hurdles persisting.
The report’s optimistic case studies (e.g., Glastonbury) proved anecdotal and unscaled, undermined by critiques highlighting flawed evidence (e.g., ignored Cochrane reviews). Today, NHS policy emphasizes evidence-based conventional care, with SCAM relegated to private or niche settings – realization sits at ~10-20% for endorsed therapies, 0% for broader vision.
In other words, ignoring the report has saved the NHS many millions. More importantly, it has prevented UK evidence-based healthcare from getting watered down by ineffective therapies.
Could that also have happened without my loud protests (e.g. here and here) at the time?
Nobody can know for sure?
But when I feel a little bit down, I tell myself that I had an important role in saving the UK millions!
The aim of this study was to determine the effectiveness of spinal manipulation and clinician-supported biopsychosocial self-management vs medical care for adults with increased risk of chronic disabling LBP.
This 2 × 2 factorial randomized clinical trial enrolled participants in 3 research clinics at the Universities of Minnesota and Pittsburgh from November 2018 to May 2023; final follow-up was in June 2024. Adults with acute or subacute LBP at moderate to high risk of chronicity based on the STarT Back tool were randomized to 1 of 4 groups, with interventions lasting up to 8 weeks. Statistical analysis was conducted from November 2024 to June 2025.
These interventions were:
- Spinal manipulation therapy (n = 201),
- supported self-management (n = 305),
- combined supported self-management with spinal manipulation (n = 193),
- guideline-based medical care (n = 301).
Physical therapists and chiropractors provided spinal manipulation and supported self-management.
The 2 primary outcomes averaged over a follow-up of 1 year were monthly low back disability (Roland-Morris Disability Questionnaire) and weekly pain intensity (numerical rating scale). Secondary analysis examined the proportion of participants achieving a 50% or higher reduction in the primary outcome measures.
Among the 1000 participants randomized (mean [SD] age, 47 [16] years; 58% female), 93% completed the trial. The omnibus test for differences across the 4 treatment groups was statistically significant for disability (P = .001; supported self-management, 4.7; spinal manipulation, 5.5; combined supported self-management with spinal manipulation, 4.8; medical care, 5.9) but not pain intensity (P = .16; supported self-management, 2.8; spinal manipulation, 3.0; combined supported self-management with spinal manipulation, 2.8; medical care, 3.0). Averaged over 12 months, LBP disability was significantly lower compared with medical care for supported self-management (mean difference, −1.2 [95% CI, −1.9 to −0.5]) and supported self-management with spinal manipulation (mean difference, −1.1 [95% CI, −1.9 to −0.3]) but not spinal manipulation alone (mean difference, −0.4 [95% CI, −1.2 to 0.4]). Group differences in pain intensity were not statistically significant; point estimates ranged from −0.2 to 0. Both supported self-management groups had higher proportions of patients achieving a 50% or greater reduction in disability (supported self-management, 67%; spinal manipulation, 54%; combined supported self-management with spinal manipulation, 65%; medical care, 54%).
The authors concluded that for patients with acute or subacute LBP at increased risk of chronic disabling LBP, clinician-supported biopsychosocial self-management showed statistically significant but small reductions in disability, but not pain, vs medical care over 1-year follow-up, and spinal manipulation alone showed no significant difference for either outcome.
These findings are very bad news for chiropractors (the profession that uses spinal manipulations more than any other): spinal manipulation does not generate effects that are in the least convincing. This is particularly remarkable, since the study was not blinded. It means that, even the undoubtedly powerful placebo effect associated with spinal manipulation did not render the outcome more favourable.
I said it many times, and I will say it again: For LBP, many therapies generate similarly marginally positive effects but no treatment is truly convincing. In this situation, we should choose one that is at least inexpensive and free of severe adverse effects. And that evidently cannot be spinal manipulation!
Von Willebrand disease (VWD) is the most common inherited bleeding disorder and predisposes patients to hemorrhagic complications following trauma or invasive procedures. Chiropractic spinal manipulation is widely used for musculoskeletal pain; however, serious complications have been reported, particularly in patients with underlying coagulopathies.
Iliopsoas hematoma with secondary femoral neuropathy is an uncommon but potentially disabling condition. A team of US doctors present a clinical case highlighting this rare complication following chiropractic manipulation in a patient with VWD and review the relevant literature. They describe the clinical course and follow-up of a 32-year-old female patient with known VWD who developed acute neurological deficits after chiropractic manipulation. Imaging findings were analyzed using radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). Hematoma volume was calculated using the ABC/2 formula, which has been well validated and shows a high correlation with volumes calculated using planimetric techniques.
After chiropractic manipulation, the patient developed severe lumbar and inguinal pain, followed by progressive weakness and sensory impairment of the left lower limb. Imaging revealed a large left iliopsoas hematoma measuring approximately 896 cc, causing femoral nerve compression. Management included coagulation factor replacement, pain control, and interventional radiology-guided drainage, resulting in significant hematoma reduction and neurological improvement. At the six-month follow-up, residual neuropathy and muscle atrophy persisted, although functional recovery was evident.
The uthors concluded that patients with VWD are at high risk for severe hemorrhagic complications even after seemingly minor manipulative therapies. Chiropractic spinal manipulation may precipitate life-threatening or disabling bleeding events in this population. Early recognition, appropriate imaging, correction of the coagulopathy, and multidisciplinary management are crucial to optimize outcomes. This case highlights the importance of patient counseling, risk stratification, and caution when considering alternative therapies in individuals with inherited bleeding disorders.
The list of complications, including fatal ones, after chiropractic manipulations is long – very long. That they can cause iliopsoas hematoma with secondary femoral neuropathy was new to me. The lesson here seems relatively simple: if you have a bleeding abnormality, avoid chiropractic manipulations at all costs!
This, of course, raises an interesting question:
Considering that ~25% of the general population have some sort of clotting abnormality, do chiropractors routinely check whether their pations have normal blood clotting?
Somehow, I doubt it.
The authors found very low‐certainty evidence (downgraded for study limitations, inconsistency, and imprecision) that SMT may result in a medium reduction in pain compared to no treatment at one month (MD ‐13.99, 95% CI ‐27.33 to ‐0.66; I2 = 89%; 4 studies, 325 participants), but the evidence is very uncertain. They found low‐certainty evidence (downgraded for study limitations and imprecision) that SMT may result in a large improvement in functional status compared to no treatment at one month (SMD ‐0.84, 95% CI ‐1.32 to ‐0.35; I2 = 71%; 4 studies, 312 participants).
SMT versus other conservative interventions
Low‐certainty evidence (downgraded for inconsistency) indicated that SMT may result in little to no difference in pain (MD ‐4.72, 95% CI ‐8.26 to ‐1.17; I2 = 89%; 31 studies, 4109 participants) and may result in a small improvement in functional status (SMD ‐0.25, 95% CI ‐0.38 to ‐0.11; I2 = 73%; 28 studies, 3940 participants) compared to other conservative interventions at one month.
These effects, however, should be interpreted with caution due to the substantial statistical heterogeneity for which there is no clear explanation.
Less than half of the studies (47%) reported on adverse events, of which 12 studies reported these systematically. Adverse events in the SMT group were limited to muscle soreness, stiffness, and/or transient increase in pain. None of the studies registered any serious complications related to either the experimental or control group treatment. The evidence is very uncertain about the adverse effects of SMT.
Authors’ conclusions: When SMT is compared to sham SMT/placebo, it may result in a small improvement in pain and medium improvement in functional status in adults with chronic low back pain. When compared to no treatment, SMT may result in a medium improvement in pain and a large improvement in functional status. When compared to other conservative interventions, SMT may result in little to no difference in pain and a small improvement in functional status. The evidence is of low to very low certainty, largely due to the fact that the effects of SMT were examined in trials conducted in different settings and populations, with different types of SMT technique, dosage, and frequency of treatment. Continuing to conduct RCTs in the same manner will neither strengthen the evidence nor our confidence in it.
Once again, it has been confirmed that most trials of SMT are, because of their failure to report adverse effects, in violation of ethical standards. But the importance of this excellent review lies elsewhere. Despite 76 published RCTs, there is huge uncertainty about the benefits of SAM. What should we make of this fact?
In my view, it highlights that:
- the studies are often of poor quality;
- the effect of SMT are so small that they are negligibel;
- patients with back pain should look for treatments that are safe and effective;
- the choice can therefore not be SMT.
Reliable reporting and publication practices are essential for trustworthy evidence synthesis and clinical decision-making. This analysis aimed to identify latent classes of randomized controlled trials (RCTs) evaluating spinal manipulative therapy (SMT) based on trial reporting and publication practices, and to examine whether these classes influenced treatment effects.
Trials were evaluated on whether they met criteria for trial reporting and publication practices across six domains. Latent class analysis was used to identify trial subgroups. Random-effects meta-regression models assessed whether class membership predicted pooled estimates of treatment effects for pain and disability.
The international team included 239 RCTs and identified four classes: Dated (23 %), older trials (mostly pre-2010) with consistently low proportions of criteria met; Non-contributing (30 %), newer trials that inconsistently met the criteria, had small samples, and short follow-ups; SMT-focused (15 %), which reported SMT details and fidelity more consistently but otherwise resembled the Non-contributing class; and Pragmatic (33 %), consisting of larger trials, meeting most criteria, but often underreported SMT-specific and fidelity details. Reporting practices had larger impact on class membership than publication practices. Despite differences class membership was not associated with treatment effect estimates and explained minimal outcome variability (R2 ∼1 %).
The authors concluded that, although trial reporting and publication practices varied substantially across SMT trials, these differences were not associated with differences in treatment effects. The widespread failure to meet key criteria raises concerns about the interpretability and credibility of the SMT evidence base. To strengthen transparency and scientific value, future trials should adhere more rigorously to reporting guidelines.
What does this mean?
The authors state that editors and peer reviewers should more rigorously enforce established reporting standards, including CONSORT (with its Harms extension), TIDieR, and the CIRCLe SMT checklist.
Undoubtedly, this is true.
But what does it mean for patients?
In my view, it is a reminder for all of us to be skeptical about the claims made by chiropractors, osteopaths and other providers of SMT – even if they claim to be based on evidence.
