In the bizarre world of chiropractic, the war between vitalistic subluxationists and reformers has reached a new climax. The World Federation of Chiropractic (WFC) has just announced that its president, Laurie Tassell, has resigned. The move follows what the International Chiropractor’s Association (ICA) called a “blatant offensive behaviour on a public stage” that “speaks for itself” and “cannot be excused under any circumstances.” The ICA’s alleged an embarrassing display of unprofessional and disruptive behaviour of presenters and attendees at the WFC Conference in Berlin in March 2019. It involved attacks on subluxationist chiropractors and included the throwing of water bottles onto the stage and clapping and cheering as the management of subluxation was denigrated.
The ICA President, Stephen Welsh, subsequently demanded that:
- The current Chair of the WFC Research Council be immediately removed from his current position and denied future participation in any activities on behalf of the WFC.
- An additional member of the WFC Research Council be publicly reprimanded and sanctioned and prohibited from the opportunity to serve in any leadership role at the WFC for at least 5 years.
- The sponsoring organization that coordinated, reviewed and permitted the alleged questionable presentations be sanctioned for conduct not reflecting the professional, inclusive and collegial respect for the values embedded in the WFC Strategic Plan, Governing Documents and the WFC Official Policy Statements.
According to Welsh, and others who attended, the Chair of the WFC Research Council, Greg Kawchuk DC, Ph.D, compared bringing a child to a vitalistic chiropractor to bringing them to a Catholic priest at a children’s school.
The WFC has now announced the appointment of Vivian Kil DC as Interim President to take over from Tassel. Kil is a graduate of the AECC, full-time clinician and the owner of a multidisciplinary clinic in the Netherlands. Kil is an advocate for chiropractors as practitioners of so called “primary spine care”. She stated her vision as follows:
- That we will (the chiropractic profession) set aside our differences within the profession, unite as a profession, and agree that becoming the source of nonsurgical, nonpharmacological, primary, spine care expertise and management should be a primary common goal.
- That for us to do the necessary work to fulfill this role and do it with the entire profession, every chiropractor will be involved and not just a small active group of leaders.
- And finally, that we will become the source of nonsurgical, nonpharmacological, primary, spine care expertise and management worldwide.
In my view, the problem of the chiropractic profession is unsolvable. Giving up Palmer’s obsolete nonsense of vitalism, innate intelligence, subluxation etc. is an essential precondition for joining the 21st century. Yet, doing so would abandon any identity chiropractors will ever have and render them physiotherapists in all but name. Neither solution bodes well for the future of the profession.
The Canadian Chiropractic Association (CCA)… published a report to support clearer understanding of the chiropractic profession… Here are a few crucial quotes (in bold print) from this document (my are comments in normal print).
Put simply, chiropractors are spine, muscle and nervous system experts specifically trained to diagnose the underlying cause and recommend treatment options to relieve pain, restore mobility and prevent re occurrence without surgery or pharmaceuticals…
By this definition, I am a chiropractor! – and so are osteopaths, physiotherapists, several other SCAM practitioners, and most doctors.
… there is a concept in the pharmaceutical industry known as a risk-benefit analysis which is used to assess how much benefit a medication has compared to the potential risk. The riskier the medication, the less likely it will become mainstream.(2)
The concept of risk/benefit analysis applies to all medicine. It needs, of course, good knowledge of both the risks and the benefits. The second sentence of this paragraph is nonsense and suggests that the CCA fails to understand the concept.
Spinal manipulations should be recommended for patients when a similar risk-benefit assessment has been conducted. This assessment on the safety of chiropractic treatments is performed via the patient intake form and physical examination.
As there is no reporting system of adverse effects of spinal manipulations, a risk/benefit analysis is impossible. The second sentence of this paragraph is nonsense; there are no examinations that tell us about the risks of spinal manipulation.
Adverse reactions lasting less than 24 hours include headaches, stiffness, fatigue, local pain, prickling sensation, nausea, hot skin/flushing, and fainting. In up to 50% of patients, one or more of these have been reported over the span of a lifetime.(3, 4)
Perhaps adverse reactions last ON AVERAGE 24 hours; they can last up to 3 days. About half of all patients experience such reactions.
Exact numbers on adverse events from chiropractic manipulation are difficult to extract due to variables such as research design, inclusion criteria and study selection. There is still a lot of research to be conducted on the role of spinal manipulation in individuals with serious adverse events.
The frequency of adverse events is unknown because there is no adequate reporting scheme.
Chiropractic treatment is a safe option for the prevention, assessment, diagnosis and management of musculoskeletal conditions and associated neurological system. Canadian chiropractors have over 4,200 hours of core competency training in the musculoskeletal system. It is up to each individual patient and their healthcare provider to assess the safety of chiropractic treatments and potential risks associated, and decide if spinal manipulation is right for them.
There is no good evidence that chiropractic treatment is safe.
There is no good evidence that chiropractic treatment is effective for disease prevention.
Chiropractic treatment is an option for assessment and diagnosis??? This is another nonsensical claim.
Chiropractic treatment is an option for associated neurological system??? Another nonsense!
Each individual patient and their healthcare provider assessing the safety is not an option.
References used in the quotes:
The references cited are pitiful!
In conclusion, I suggest the CCA re-read their statement and revise it according to the evidence, common sense and the rules of the English language. As it stands, it’s just too embarrassing – even for chiropractic standards!
Spinal manipulation has regularly been associated with serious complications, most commonly strokes due to arterial dissections. But there are several other possibilities as well.
A new and unusual case report a serious complication after spinal manipulation has just been published:
A 54-year-old Indian gentleman, presented to hospital with exertional dyspnoea and chest heaviness for the past 6 months which had increased in the last 6 days. Dyspnoea increased on lying down. He was diagnosed as pneumonia on the basis of X-ray and chest CT scan, received treatment for the same and responded to the therapy.
However, breathlessness and hypercapnia persisted. He had unexplained hypercapnia for which extensive investigations were carried out. Neurological and cardiac assessments were essentially normal. On revisit clinical examination, he was found to have paradoxical diaphragmatic movement with respiration. Ultrasound of chest detected no diaphragmatic movement. Detailed history elicited that patient was fond of neck massage and neck cracking wherein his barber would bend his neck with jerk to either side after a haircut.
After considering all possible aetiologies, the authors concluded that this was a case of diaphragm palsy induced by barber neck manipulation, leading to Type-2 respiratory failure. The fact that the vital clues to the diagnosis were elicited by detailed history and thorough examination reinforces that history and clinical examination for doctors shall remain a very important tool for clinical diagnosis.
My chiropractor friends will be relieved, no doubt, to read that, in this incident, a barber rather than a chiropractor caused this unusual incident. Putting my tongue slightly in the direction of my cheek, the story shows me one thing: one does not necessarily have to be a graduate of a chiro-school to cause severe complications with neck manipulations. Occasionally, osteopaths, physiotherapists, doctors and even barbers are capable of the same feast.
Chiropractic spinal manipulative therapy (CSMT) for migraine?
There is no good evidence that it works!
On the contrary, there is good evidence that it does NOT work!
A recent and rigorous study (conducted by chiropractors!) tested the efficacy of chiropractic CSMT for migraine. It was designed as a three-armed, single-blinded, placebo -controlled RCT of 17 months duration including 104 migraineurs with at least one migraine attack per month. Active treatment consisted of CSMT (group 1) and the placebo was a sham push manoeuvre of the lateral edge of the scapula and/or the gluteal region (group 2). The control group continued their usual pharmacological management (group 3). The results show that migraine days were significantly reduced within all three groups from baseline to post-treatment. The effect continued in the CSMT and placebo groups at all follow-up time points (groups 1 and 2), whereas the control group (group 3) returned to baseline. The reduction in migraine days was not significantly different between the groups. Migraine duration and headache index were reduced significantly more in the CSMT than in group 3 towards the end of follow-up. Adverse events were few, mild and transient. Blinding was sustained throughout the RCT. The authors concluded that the effect of CSMT observed in our study is probably due to a placebo response.
One can understand that, for chiropractors, this finding is upsetting. After all, they earn a good part of their living by treating migraineurs. They don’t want to lose patients and, at the same time, they need to claim to practise evidence-based medicine.
What is the way out of this dilemma?
They only need to publish a review in which they dilute the irritatingly negative result of the above trial by including all previous low-quality trials with false-positive results and thus generate a new overall finding that alleges CSMT to be evidence-based.
This new systematic review of randomized clinical trials (RCTs) evaluated the evidence regarding spinal manipulation as an alternative or integrative therapy in reducing migraine pain and disability.
The searches identified 6 RCTs eligible for meta-analysis. Intervention duration ranged from 2 to 6 months; outcomes included measures of migraine days (primary outcome), migraine pain/intensity, and migraine disability. Methodological quality varied across the studies. The results showed that spinal manipulation reduced migraine days with an overall small effect size as well as migraine pain/intensity.
The authors concluded that spinal manipulation may be an effective therapeutic technique to reduce migraine days and pain/intensity. However, given the limitations to studies included in this meta-analysis, we consider these results to be preliminary. Methodologically rigorous, large-scale RCTs are warranted to better inform the evidence base for spinal manipulation as a treatment for migraine.
Bob’s your uncle!
Perhaps not perfect, but at least the chiropractic profession can now continue to claim they practice something akin to evidence-based medicine, while happily cashing in on selling their unproven treatments to migraineurs!
But that’s not very fair; research is not for promotion, research is for finding the truth; this white-wash is not in the best interest of patients! I hear you say.
Who cares about fairness, truth or conflicts of interest?
Christine Goertz, one of the review-authors, has received funding from the NCMIC Foundation and served as the Director of the Inter‐Institutional Network for Chiropractic Research (IINCR). Peter M. Wayne, another author, has received funding from the NCMIC Foundation and served as the co‐Director of the Inter‐Institutional Network for Chiropractic Research (IINCR)
And who the Dickens are the NCMIC and the IINCR?
At NCMIC, they believe that supporting the chiropractic profession, including chiropractic research programs and projects, is an important part of our heritage. They also offer business training and malpractice risk management seminars and resources to D.C.s as a complement to the education provided by the chiropractic colleges.
The IINCR is a collaborative effort between PCCR, Yale Center for Medical Informatics and the Osher Center for Integrative Medicine at Brigham and Women’s Hospital and Harvard Medical School. They aim at creating a chiropractic research portfolio that’s truly translational. Vice Chancellor for Research and Health Policy at Palmer College of Chiropractic Christine Goertz, DC, PhD (PCCR) is the network director. Peter Wayne, PhD (Osher Center for Integrative Medicine at Brigham and Women’s Hospital and Harvard Medical School) will join Anthony J. Lisi, DC (Yale Center for Medical Informatics and VA Connecticut Healthcare System) as a co-director. These investigators will form a robust foundation to advance chiropractic science, practice and policy. “Our collective efforts provide an unprecedented opportunity to conduct clinical and basic research that advances chiropractic research and evidence-based clinical practice, ultimately benefiting the patients we serve,” said Christine Goertz.
Really: benefiting the patients?
You could have fooled me!
Exactly 20 years ago, I published a review concluding that the generally high and possibly growing prevalence of complementary/alternative medicine use by children renders this topic an important candidate for rigorous investigation. Since then, many papers have emerged, and most of them are worrying in one way or another. Here is the latest one.
This Canadian survey assessed chiropractic (DC) and naturopathic doctors’ (ND) natural health product (NHP) recommendations for paediatric care. It was developed in collaboration with DC and ND educators, and delivered as an on-line national survey. NHP dose, form of delivery, and indications across paediatric age ranges (from newborn to 16 years) for each practitioner’s top five NHPs were assessed. Data were analysed using descriptive statistics, t-tests, and non-parametric tests.
Of the 421 respondents seeing one or more paediatric patients per week, 172 (41%, 107 DCs, 65 NDs) provided 440 NHP recommendations, categorized as:
- vitamins and minerals (89 practitioners, 127 recommendations),
- probiotics (110 practitioners, 110 recommendations),
- essential fatty acids (EFAs: 72 practitioners, 72 recommendations),
- homeopathics (56 practitioners, 66 recommendations),
- botanicals (29 practitioners, 31 recommendations),
- other NHPs (33 practitioners, 34 recommendations).
Indications for the NHP recommendations were tabulated for NHPs with 10 or more recommendations in any age category:
- 596 total indications for probiotics,
- 318 indications for essential fatty acids,
- 138 indications for vitamin D,
- 71 indications for multi-vitamins.
Good evidence regarding the efficacy, safety, and dosing for NHP use in children is scarce or even absent. Therefore, the finding that so many DCs and NDs recommend unproven NHPs for use in children is worrying, to say the least. It seems to indicate that, at least in Canada, DCs and NDs are peddling unproven, mostly useless and potentially harmful children.
In an earlier, similar survey the same group of researchers had disclosed that the majority of Canadian DCs and NDs seem to see infants, children, and youth for a variety of health conditions and issues, while, according to their own admission, not having adequate paediatric training.
Is this a Canadian phenomenon? If you think so, read this abstract:
This systematic review is aimed at estimating the prevalence of complementary and alternative medicine (CAM)-use by paediatric populations in the United Kingdom (UK).
AMED, CINAHL, COCHRANE, EMBASE and MEDLINE were searched for English language peer-reviewed surveys published between 01 January 2000 and September 2011. Additionally, relevant book chapters and our own departmental files were searched manually.
Eleven surveys were included with a total of 17,631 paediatric patients. The majority were of poor methodological quality. Due to significant heterogeneity of the data, a formal meta-analysis was deemed inappropriate. Ten surveys related to CAM in general, while one was specifically on homeopathy. Across all surveys on CAM in general, the average one-year prevalence rate was 34% and the average lifetime prevalence was 42%. In surveys with a sample size of more than 500, the prevalence rates were considerably lower than in surveys with the sample size of lower than 500. Herbal medicine was the most popular CAM modality, followed by homeopathy and aromatherapy.
Many paediatric patients in the UK seem to use CAM. Paediatricians should therefore have sufficient knowledge about CAM to issue responsible advice.
This means, I fear, that children are regularly treated by SCAM practitioners who are devoid of the medical competence to do so, and who prescribe or recommend treatments of unknown value, usually without the children needing them.
Why are regulators not more concerned about this obvious abuse?
The purpose of this recently published survey was to obtain the demographic profile and educational background of chiropractors with paediatric patients on a multinational scale.
A multinational online cross-sectional demographic survey was conducted over a 15-day period in July 2010. The survey was electronically administered via chiropractic associations in 17 countries, using SurveyMonkey for data acquisition, transfer, and descriptive analysis.
The response rate was 10.1%, and 1498 responses were received from 17 countries on 6 continents. Of these, 90.4% accepted paediatric cases. The average practitioner was male (61.1%) and 41.4 years old, had 13.6 years in practice, and saw 107 patient visits per week. Regarding educational background, 63.4% had a bachelor’s degree or higher in addition to their chiropractic qualification, and 18.4% had a postgraduate certificate or higher in paediatric chiropractic.
The authors from the Anglo-European College of Chiropractic (AECC), Bournemouth University, United Kingdom, drew the following conclusion: this is the first study about chiropractors who treat children from the United Arab Emirates, Peru, Japan, South Africa, and Spain. Although the response rate was low, the results of this multinational survey suggest that pediatric chiropractic care may be a common component of usual chiropractic practice on a multinational level for these respondents.
A survey with a response rate of 10%?
An investigation published 9 years after it has been conducted?
Who at the AECC is responsible for controlling the quality of the research output?
Or is this paper perhaps an attempt to get the AECC into the ‘Guinness Book of Records’ for outstanding research incompetence?
But let’s just for a minute pretend that this paper is of acceptable quality. If the finding that ~90% of chiropractors tread kids is approximately correct, one has to be very concerned indeed.
I am not aware of any good evidence that chiropractic care is effective for paediatric conditions. On the contrary, it can do quite a bit of direct harm! To this, we sadly also have to add the indirect harm many chiropractors cause, for instance, by advising parents against vaccinating their kids.
This clearly begs the question: is it not time to stop these charlatans?
What do you think?
Spinal manipulative therapy (SMT), especially hyperextension and rotation. have often been associated with cervical artery dissection (CAD), a tear in the internal carotid or the vertebral artery resulting in an intramural haematoma and/or an aneurysmal dilatation. But is the association causal? This question is often the subject of fierce discussions between chiropractors and the real doctors.
The lack of established causality relates to the chicken and egg discussion, i.e., whether the CAD symptoms lead the patient to seek cervical SMT or whether the cervical SMT provokes CAD along with the non-CAD presenting headache and/or neck complaint.
The aim of a new review was to provide an updated step-by-step risk-benefit assessment strategy regarding manual therapy and to provide tools for clinicians to exclude cervical artery dissection.
In light of the evidence provided, the reality, according to the review-authors, is:
- a) that there is no firm scientific basis for direct causality between cervical SMT and CAD;
- b) that the internal carotid artery (ICA) moves freely within the cervical pathway, while 74% of cervical SMTs are conducted in the lower cervical spine where the vertebral artery (VA) also moves freely;
- c) that active daily life consists of multiple cervical movements including rotations that do not trigger CAD, as is true for a range of physical activities;
- d) that a cervical manipulation and/or grade C cervical mobilization goes beyond the physiological limit but remains within the anatomical range, which theoretically means that the artery should not exceed failure strain.
These factors underscore the fact that no serious adverse event (AE) was reported in a large prospective national survey conducted in the UK that assessed all AEs in 28,807 chiropractic treatment consultations, which included 50,276 cervical spine manipulations.
The figure outlines a risk-benefit assessment strategy that should provide additional knowledge and improve the vigilance of all clinicians to enable them to exclude CAD, refer patients with suspected CAD to appropriate care, and consequently prevent CAD from progressing.
It has been argued that most patients present with at least two physical symptoms. The clinical characteristics and recommendations in the figure follow this assumption. This figure is intended to function as a knowledge base that should be implemented in preliminary screening and be part of good clinical practice. This knowledge base will likely contribute to sharpening the attention of the clinicians and alert them as to whether the presenting complaint, combined with a collection of warning signs listed in the figure, deviates from what he or she considers to be a usual musculoskeletal presentation.
Even though this is a seemingly thoughtful analysis, I think it omits at least two important points:
- The large prospective UK survey which included 50,276 cervical spine manipulations might be less convincing that it seems. It recorded about one order of magnitude less minor adverse effects of spinal manipulation than a multitude of previously published prospective surveys. The self-selected, relatively small group of participating chiropractors (32% of the total sample) were both experienced (67% been in practice for 5 or more years) and may not always have adhered to the protocol of the survey. Thus they may have employed their experience to intuitively select low-risk patients rather than including all consecutive cases, as the protocol prescribed. This hypothesis would ﬁrstly account for the unusually low rate of minor adverse effects, and secondly, it would explain why no serious complications occurred at all. Given that about 700 such complications are on record, the low incidence of serious adverse events could well be a gross underestimate.
- The effect of chiropractic spinal manipulative therapy is probably due to a placebo response. This means that it should probably not be done in the first place.
The most regularly reported serious complication of chiropractic neck manipulation is a stroke due to arterial dissection. Atlantoaxial dislocation (a dislocations of the first and second vertebrae which means that the spinal cord is in danger of being compressed which, in turn, would have devastating consequences) has not been previously reported, but is just as serious.
This new case-report described an 83-year-old man with a history of old cerebellar infarction who presented to the emergency department with acute left hemiplegia after a chiropractic manipulation of the neck and back several hours before symptom onset. Mild hypoesthesia was observed on his left limbs. No speech disturbance, facial palsy, or neck or shoulder pain was observed.
Intravenous thrombolytic treatment was given 238 min after symptom onset. Brown-Sequard syndrome (damage to one side of the spinal cord causing paralysis and loss of feeling on one side) subsequently developed 6 h after thrombolysis with a hypo-aesthetic sensory level below the right C5 dermatome. An emergent brain magnetic resonance angiography did not reveal an acute cerebral infarct but rather an atlantoaxial dislocation causing upper cervical spinal cord compression.
Clinical symptoms did not deteriorate after thrombolysis. He received successful decompressive surgery 1 week later, and his muscle power gradually improved, with partial dependency when performing daily living activities two months later.
A literature review revealed that only 15 patients (including the patient mentioned here) with spinal disorder mimicking acute stroke who received thrombolytic therapy have been reported. Atlantoaxial dislocation may present as acute hemiplegia mimicking acute stroke, followed by Brown-Sequard syndrome. Inadvertent thrombolytic therapy is likely not harmful for patients with atlantoaxial dislocation-induced cervical myelopathy. The neurological deficits of patients should be carefully and continuously evaluated to differentiate between stroke and myelopathy.
The authors of this case report provide no detail about the exact treatment that caused this complication, nor do they elaborate on the type of healthcare professional who administered the cervical manipulation (they focus on the issue of non-indicated thrombolytic therapy). We also do not learn why the patient had neck manipulations in the first place. However, the authors seem confident that the ‘chiropractic manipulation’ was the cause of this atlantoaxial dislocation causing severe upper cervical spinal cord compression.
The patient was treated surgically, with corticosteroids and subsequent rehabilitation. Two months later, his neurological deficits were much improved.
This paper reports a survey amongst European chiropractors during early 2017. Dissemination was through an on-line platform with links to the survey being sent to all European chiropractic associations regardless of European Chiropractors’ Union (ECU) membership and additionally through the European Academy of Chiropractic (EAC). Social media via Facebook groups was also used to disseminate links to the survey.
One thousand three hundred twenty and two responses from chiropractors across Europe representing approximately 17.2% of the profession were collected. Five initial self-determined chiropractic identities were collapsed into 2 groups categorised as orthodox (79.9%) and unorthodox (20.1%); by the latter term, the investigators mean the subluxationists/vitalists.
When comparing the percentage of new patients chiropractors x-rayed, 23% of the unorthodox group x-rayed > 50% of their new patients compared to 5% in the orthodox group. Furthermore, the proportion of respondents reporting > 150 patient encounters per week in the unorthodox group were double compared to the orthodox (22 v 11%). Lastly the proportion of those respondents disagreeing or strongly disagreeing with the statement “In general, vaccinations have had a positive effect on global public health” was 57 and 4% in unorthodox and orthodox categories respectively. Logistic regression models identified male gender, seeing more than 150 patients per week, no routine differential diagnosis, and not strongly agreeing that vaccines have generally had a positive impact on health as highly predictive of unorthodox categorisation.
The authors concluded that despite limitations with generalisability in this survey, the proportion of respondents adhering to the different belief categories are remarkably similar to other studies exploring this phenomenon. In addition, and in parallel with other research, this survey suggests that key practice characteristics in contravention of national radiation guidelines or opposition to evidence based public health policy are significantly more associated with non-orthodox chiropractic paradigms.
N (%) Orthodox
N (%) Unorthodox
Mr William Harvey Lillard was the janitor contracted to clean the Ryan Building where D. D. Palmer’s magnetic healing office was located. In 1895, he became Palmer’s very first chiropractic patient and thus entered the history books. The very foundations of chiropractic are based on this story.
To call the ‘Chiropractor’ a reliable source would probably be stretching it a bit, and there are various versions of the event, even one where BJ Palmer, DD’s son, changed significant details of the story. Nevertheless, it’s a nice story, if there ever was one. But, like many nice stories, it’s just that: a tall tale, a story that might be not based on reality. In this case, the reality getting in the way of a good story is human anatomy.
The nerve supply of the inner ear, the bit that enables us to hear, does not, like most other nerves of our body, run through the spine; it comes directly from the brain: the acoustic nerve is one of the 12 cranial nerves.
But chiropractors never let the facts get in the way of a good story! Thus they still tell it and presumably even believe it. Take this website, for instance, as an example of hundreds of similar sources:
… the very first chiropractic patient in history was named William Harvey Lillard, who experienced difficulty hearing due to compression of the nerves leading to his ears. He was treated by “the founder of chiropractic care,” David. D. Palmer, who gave Lillard spinal adjustments in order to reduce destructive nerve compressions and restore his hearing. After doing extensive research about physiology, Palmer believed that Lillard’s hearing loss was due to a misalignment that blocked the spinal nerves that controlled the inner ear (an example of vertebral subluxation). Palmer went on to successfully treat other patients and eventually trained other practitioners how to do the same.
How often have we been told that chiropractors receive a medical training that is at least as thorough as that of proper doctors? But that’s just another tall story, I guess.