chiropractic
Most chiropractors claim they can effectively treat a wide range of conditions. I have looked far and wide but I fail to see sound evidence to show that this assumption is true. On a good day, I might agree that chiropractic works for back pain (but this would need to be a very good day and I would need to close at least one eye) – and that’s basically it! Unsurprisingly, chiropractors vehemently disagree with me. Yet, they have an all too obvious conflict of interest in that question and, therefore, they are unlikely to be objective.
One regular commentator of this blog recently reminded me that the UK ‘ADVERTISING STANDARDS AUTHORITY’ (ASA) state on their website that based on all evidence submitted and reviewed to date, the ASA and CAP accept that chiropractors may claim to treat the following conditions:
- Ankle sprain (short term management)
- Cramp
- Elbow pain and tennis elbow (lateral epicondylitis) arising from associated musculoskeletal conditions of the back and neck, but not isolated occurrences
- Headache arising from the neck (cervicogenic
- Joint pains
- Joint pains including hip and knee pain from osteoarthritis as an adjunct to core OA treatments and exercise
- General, acute & chronic backache, back pain (not arising from injury or accident)
- Generalised aches and pains
- Lumbago
- Mechanical neck pain (as opposed to neck pain following injury i.e. whiplash)
- Migraine prevention
- Minor sports injuries
- Muscle spasms
- Plantar fasciitis (short term management)
- Rotator cuff injuries, disease or disorders
- Sciatica
- Shoulder complaints (dysfunction, disorders and pain)
- Soft tissue disorders of the shoulder
- Tension and inability to relax
This is an impressive yet very odd list:
- Why is ‘joint pain’ listed twice?
- Can lateral epicondylitis arise from musculoskeletal conditions of the back and neck?
- What exactly are ‘generalised aches and pains’?
- Isn’t lumbago and backache the same?
- Are ‘minor sports injuries’ (including a cut, bruise or haematoma?) a category that is well-defined?
- What is a ‘soft tissue disorders of the shoulder’
But let’s not be pedantic. Let’s assume these are all defined conditions that need to be treated. The problem still remains that there is hardly any good evidence that they can be effectively treated by chiropractic spinal manipulation (in case you disagree, please post the evidence in the comments section).
And here we come to the crux of the matter, I think.
Chiropractors would say that they use so much more than spinal manipulations.
- For a sport injury, they might apply an ice-pack.
- For the inability to relax, they might give a massage.
- For rotator cuff problems, they might administer exercises.
- For tennis elbow, they might recommend immobilizing the joint.
- Etc., etc.
But that’s not chiropractic!
Yes, it is what we do, insist the chiropractors.
I do not doubt it, but survey after survey shows that chiropractors treat almost all their patients with spinal manipulation. And the history of chiropractic is purely based on spinal manipulation. Yes, today they also use treatments borrowed from other disciplines, yet spinal manipulation is the treatment that defines them.
Let me try an example to make my point clear. Imagine a surgeon who specialises in an obsolete type of operation (e.g. ligation of the mammary artery as a treatment of coronary artery disease). Following the chiro-logic, he could claim that:
- my approach is not ineffective because I do so much more than just operate,
- I also prescribe medications,
- I give dietary advice,
- I give nutritional advice,
- I recommend relaxation,
- I suggest regular exercise.
And the results would, of course, show that many of his patients benefit from all this.
Does that mean our surgeon provides effective care for his patients?
Similarly, crystal healing could be seen as being effective, because some crystal healers tell their obese patients to eat less and exercise more?
So, the above-cited list of claims that the ASA now allows UK chiropractors to make is either way too long or much too short – in any case, it is nonsense. If we base it on the proven effectiveness of spinal manipulation, it must be very short indeed. If we base it on everything chiropractors might do in addition, it is far too short; in this case, it should include everything in the medical textbooks from AIDS to ZOSTER (I cannot imagine many conditions for which life-style advice, exercise or cryotherapy [for pain-control] etc. would not be helpful).
My conclusions from all this are as follows:
- Chiropractors have tried to reinvent themselves by borrowing some treatments from other healthcare professions.
- They have done this, I suspect, to avoid being judged by their largely ineffective hallmark intervention, spinal manipulation. The move may be commercially clever, but it is nevertheless transparently nonsensical and wholly unconvincing.
- Chiropractors must be judged not by the treatments they borrowed and might use occasionally, but by the only therapy that is inherent to chiropractic: spinal manipulation.
- And spinal manipulation is certainly not effective for a wide range of conditions.
I would warn every parent who thinks that taking their child to a chiropractor is a good idea. For this, I have three main reasons:
- Chiropractic has not been shown to be effective for any paediatric condition.
- Chiropractors often advise parents against vaccinating their children.
- Chiropractic spinal manipulations can cause harm to kids.
The latter point seems to be confirmed by a recent PhD thesis of which so far only one short report is available. Here are the relevant bits of information from it:
Katie Pohlman has successfully defended her PhD thesis, which focused on the assessment of safety in pediatric manual therapy. As a clinical research scientist at Parker University, Dallas, Texas, she identified a lack of prospective patient safety research within the chiropractic population in general and investigated this deficit in the paediatric population in particular.
Pohlman used a cross-sectional survey to assess the barriers and facilitators for participation in a patient safety reporting system. At the same time, she also conducted a randomized controlled trial comparing the quantity and quality of adverse event reports in children under 14 years receiving chiropractic care.
The RCT recruited 69 chiropractors and found adverse events reported in 8.8% and 0.1% of active and passive surveillance groups respectively. Of the adverse events reported, 56% were considered mild, 26% were moderate and 18% were severe. The frequency of adverse events was more common than previously thought.
This last sentence from the report is somewhat puzzling. Our systematic review of the risks of spinal manipulation showed that data from prospective studies suggest that minor, transient adverse events occur in approximately half of all patients receiving spinal manipulation. The most common serious adverse events are vertebrobasilar accidents, disk herniation, and cauda equina syndrome. Estimates of the incidence of serious complications range from 1 per 2 million manipulations to 1 per 400,000. Given the popularity of spinal manipulation, its safety requires rigorous investigation.
The 8.8% reported by Pohlman are therefore not even one fifth of the average incidence figure reported previously in all age groups.
What could be the explanation for this discrepancy?
There are, of course, several possibilities, including the fact that infants cannot tell the clinician when their pain has increased. However, the most likely one, in my view, lies in the fact that RCTs are wholly inadequate for investigating risks because they typically include far too few patients to generate reliable incidence figures about adverse events. More importantly, clinicians included in such studies are self-selected (and thus particularly responsible/cautious) and are bound to behave most carefully while being part of a clinical trial. Therefore it seems possible – I would speculate even likely – that the 8.8% reported by Pohlman is unrealistically low.
Having said that, I do feel that the research by Kathie Pohlman is a step in the right direction and I do applaud her initiative.
The 2018 World Federation of Chiropractic ACC Education Conference was held on 24-27 October in London. It resulted in several consensus statements developed by the attendees. I happen to know this from a short report that has just been published; it can be found here.
Of the 10 points made in this consensus, I find only the following noteworthy:
“Chiropractic education programs have an ethical obligation to support an evidence-based teaching and learning environment.”
Perhaps it is me – English is not my first language – but I find the phraseology used in this sentence strangely complicated and confusing. I have been a teacher of medical students for most of my life, but I am not sure what an ‘evidence-based teaching and learning environment’ is. I know what ‘evidence-based’ means, of course. However, what exactly is:
- a teaching environment?
- a learning environment?
- and how does ‘evidence-based’ apply to either of the two?
Is there evidence that some environments are better suited than others for teaching?
Is there evidence that some environments are better suited than others for learning?
I suppose the answer must be YES!
The environment, i. e. the space and conditions in which teaching and learning happen should, for instance, be/include:
- quiet,
- not cramped,
- not too cold,
- not too hot,
- equipped with ergometric chairs and desks,
- well-lit,
- there should be visual aids,
- access to computers,
- a library,
- good mentoring and support,
- etc.
So, the consensus of the education conference wanted to optimise the environmental conditions of teaching and learning for chiropractic lecturers and students? Most laudable, I must say!
But still, it seems like a missed opportunity for an ‘Education Conference’ not to have stated something about the content of teaching and learning. Personally, I find it a pity that they did not state: Chiropractic education programs have an ethical obligation to be evidence-based.
Or is that what they really wanted to say?
Naaahh … come to think of it … they cannot possibly make such a demand.
Why?
Because, in this case, they would have to teach students not to become chiropractors.
Lumbar spinal stenosis (LSS) is a common reason for spine surgery. Several non-surgical LSS treatment options are also available, but their effectiveness remains unproven. The objective of this study was to explore the comparative clinical effectiveness of three non-surgical interventions for patients with LSS:
- medical care,
- group exercise,
- individualised exercise plus manual therapy.
All interventions were delivered during 6 weeks with follow-up at 2 months and 6 months at an outpatient research clinic. Patients older than 60 years with LSS were recruited from the general public. Eligibility required anatomical evidence of central canal and/or lateral recess stenosis (magnetic resonance imaging/computed tomography) and clinical symptoms associated with LSS (neurogenic claudication; less symptoms with flexion). Analysis was intention to treat.
Medical care consisted of medications and/or epidural injections provided by a physiatrist. Group exercise classes were supervised by fitness instructors. Manual therapy/individualized exercise consisted of spinal mobilization, stretches, and strength training provided by chiropractors and physical therapists. The primary outcomes were between-group differences at 2 months in self-reported symptoms and physical function measured by the Swiss Spinal Stenosis questionnaire (score range, 12-55) and a measure of walking capacity using the self-paced walking test (meters walked for 0 to 30 minutes).
A total of 259 participants were allocated to medical care (n = 88), group exercise (n = 84), or manual therapy/individualized exercise (n = 87). Adjusted between-group analyses at 2 months showed manual therapy/individualized exercise had greater improvement of symptoms and physical function compared with medical care or group exercise. Manual therapy/individualized exercise had a greater proportion of responders (≥30% improvement) in symptoms and physical function (20%) and walking capacity (65.3%) at 2 months compared with medical care (7.6% and 48.7%, respectively) or group exercise (3.0% and 46.2%, respectively). At 6 months, there were no between-group differences in mean outcome scores or responder rates.
The authors concluded that a combination of manual therapy/individualized exercise provides greater short-term improvement in symptoms and physical function and walking capacity than medical care or group exercises, although all 3 interventions were associated with improvements in long-term walking capacity.
In many ways, this is a fairly rigorous study; in one important way, however, it is odd. One can easily see why one group received the usual standard care (except perhaps for the fact that standard medical care should also include exercise). I also understand why one group attended group exercise. Yet, I fail to see the logic in the third intervention, individualised exercise plus manual therapy.
Individualised exercise is likely to be superior to group exercise. If the researchers wanted to test this hypothesis, they should not have added the manual therapy. If they wanted to find out whether manual therapy is better that the other two treatments, they should not have added individualised exercise. As it stands, they cannot claim that either manual therapy or individualised exercise are effective (yet, I am sure that the chiropractic fraternity will claim that this study shows their treatment to be indicated for LSS [three of the authors are chiropractors and the 1st author seems to have a commercial interest in the matter!]).
Manual therapy procedures used in this trial included:
- lumbar distraction mobilization,
- hip joint mobilization,
- side posture lumbar/sacroiliac joint mobilization,
- and neural mobilization.
Is there any good reason to assume that these interventions work for LSS? I doubt it!
And this is what makes the new study odd, in my view. Assuming I am correct in speculating that individualised exercise is better than group exercise, the trial would have yielded a similarly positive result, if the researchers had offered, instead of the manual therapy, a packet of cigarettes, a cup of tea, a chocolate bar, or swinging a dead cat. In other words, if someone had wanted to make a useless therapy appear to be effective, they could not have chosen a better trial design.
And why do I find such studies objectionable?
Mainly because they deliberately mislead many of us. In the present case, many non-critical observers might conclude that manual therapy is effective for LSS. Yet, the truth could well be that it is useless or even harmful (assuming that the effect size of individualised exercise is large, adding a harmful therapy would still render the combination effective). To put it bluntly, such trials
- could harm patients,
- might waste money,
- and hinder progress.
Most chiropractors claim that their manipulations prevent illness, not just spinal but also non-spinal conditions. But is there any sound evidence for that assumption? A team of chiropractic researchers wanted to find out. Specifically, the objective of their systematic review was to investigate if there is any evidence that spinal manipulations/chiropractic care can be used in primary prevention (PP) and/or early secondary prevention in diseases other than musculoskeletal conditions.
Of the 13.099 titles scrutinized by the authors, 13 articles were included. These were
- 8 clinical studies,
- 5 population studies.
These studies dealt with various issues such as
- diastolic blood pressure,
- blood test immunological markers,
- and mortality.
Only two clinical studies could be used for data synthesis. None showed any effect of spinal manipulation/chiropractic treatment.
The authors’ conclusions were straight forward: we found no evidence in the literature of an effect of chiropractic treatment in the scope of PP or early secondary prevention for disease in general. Chiropractors have to assume their role as evidence-based clinicians and the leaders of the profession must accept that it is harmful to the profession to imply a public health importance in relation to the prevention of such diseases through manipulative therapy/chiropractic treatment.
Many chiropractors have adopted the ‘dental model’ in their practice, proposing to prevent all sorts of conditions through treatment of spinal subluxations before symptoms arise. Some call this approach ‘maintenance care’ and liken it to the need for servicing a car. They tell their patients that regular consultations will prevent problems in the future. It seems obvious that this can be a nice little earner. In 2009, I reviewed the evidence on chiropractic maintenance treatment. Here is the abstract:
Most chiropractors advise patients to have regular maintenance treatments with spinal manipulation, even in the absence of any symptoms or diseases. This article evaluates the evidence for or against this approach. No compelling evidence was found to indicate that chiropractic maintenance therapy effectively prevents symptoms or diseases. As spinal manipulation has repeatedly been associated with considerable harm, the risk benefit balance of chiropractic maintenance care is not demonstrably positive. Therefore there are no good reasons to recommend it.
The new review confirms that this approach is useful only for filling the pockets of chiropractors.
The inevitable question arises: WHEN WILL CHIROPRACTORS STOP MISLEADING THE PUBLIC FOR THEIR PERSONAL GAIN?
On their website, the UK ‘ROYAL COLLEGE OF CHIROPRACTORS (RCC) published a short statement regarding the safety of chiropractic. Here it is in full:
Experiencing mild or moderate adverse effects after manual therapy, such as soreness or stiffness, is relatively common, affecting up to 50% of patients. However, such ‘benign effects’ are a normal outcome and are not unique to chiropractic care.
Cases of serious adverse events, including spinal or neurological problems and strokes caused by damage to arteries in the neck, have been associated with spinal manipulation. Such events are rare with estimates ranging from 1 per 2 million manipulations to 13 per 10,000 patients; furthermore, due to the nature of the underlying evidence in relation to such events (case reports, retrospective surveys and case-control studies), it is very difficult to confirm causation (Swait and Finch, 2017).
For example, while an association between stroke caused by vertebral artery damage or ‘dissection’ (VAD) and chiropractor visits has been reported in a few case-control studies, the risk of stoke has been found to be similar after seeing a primary care physician (medical doctor). Because patients with VAD commonly present with neck pain, it is possible they seek therapy for this symptom from a range of practitioners, including chiropractors, and that the VAD has occurred spontaneously, or from some other cause, beforehand (Biller et al, 2014). This highlights the importance of ensuring careful screening for known neck artery stroke risk factors, or signs or symptoms that there is an ongoing problem, is performed prior to manual treatment of patients (Swait and Finch, 2017). Chiropractors are well trained to do this on a routine basis, and to urgently refer patients if necessary.
END OF QUOTE
The statement reads well but it might not be entirely free from conflicts of interest. Yet, in the name of accuracy, completeness and truthfulness, I take the liberty of making a few slight alterations. Here is my revised version:
Experiencing mild or moderate adverse effects after chiropractic spinal manipulations, such as pain or stiffness (usually lasting 1-3 days and strong enough to impair patients’ quality of life), is very common. In fact, it affects around 50% of all patients.
Cases of serious adverse events, including spinal or neurological problems and strokes often caused by damage to arteries in the neck, have been reported after spinal manipulation. Such events are probably not frequent (several hundred are on record including about 100 fatalities). But, as we have never established proper surveillance systems, nobody can tell how often they occur. Furthermore, due to our reluctance of introducing such surveillance, some of us are able to question causality.
An association between stroke caused by vertebral artery damage or ‘dissection’ (VAD) and chiropractic spinal manipulation has been reported in about 20 independent investigations. Yet one much-criticised case-control study found the risk of stoke to be similar after seeing a primary care physician (medical doctor). Because patients with VAD commonly have neck pain, it is possible they seek therapy for this symptom from chiropractors, and that the VAD has occurred spontaneously, or from some other cause, beforehand (Biller et al, 2014). Ensuring careful screening for known neck artery stroke risk factors, or signs that there is an ongoing problem would therefore be important (Swait and Finch, 2017). Sadly, no reliable screening tests exist, and neck pain (the symptom that might be indicative of VAD) continues to be one of the conditions most frequently treated by chiropractors.
I do not expect the RCC to adopt my improved version. In case I am wrong, let me state this: I am entirely free of conflicts of interest and will not charge a fee for my revision. In the interest of advancing public health, I herewith offer it for free.
The Spanish Ministries of Health and Sciences have announced their ‘Health Protection Plan against Pseudotherapies’. Very wisely, they have included chiropractic under this umbrella. To a large degree, this is the result of Spanish sceptics pointing out that alternative therapies are a danger to public health, helped perhaps a tiny bit also by the publication of two of my books (see here and here) in Spanish. Unsurprisingly, such delelopments alarm Spanish chiropractors who fear for their livelihoods. A quickly-written statement of the AEQ (Spanish Chiropractic Association) is aimed at averting the blow. It makes the following 11 points (my comments are below):
1. The World Health Organization (WHO) defines chiropractic as a healthcare profession. It is independent of any other health profession and it is neither a therapy nor a pseudotherapy.
2. Chiropractic is statutorily recognised as a healthcare profession in many European countries including Portugal, France, Italy, Switzerland, Belgium, Denmark, Sweden, Norway and the United Kingdom10, as well as in the USA, Canada and Australia, to name a few.
3. Chiropractic members of the AEQ undergo university-level training of at least 5 years full-time (300 ECTS points). Chiropractic training is offered within prestigious institutions such as the Medical Colleges of the University of Zurich and the University of Southern Denmark.
4. Chiropractors are spinal health care experts. Chiropractors practice evidence-based, patient-centred conservative interventions, which include spinal manipulation, exercise prescription, patient education and lifestyle advice.
5. The use of these interventions for the treatment of spine-related disorders is consistent with guidelines and is supported by high quality scientific evidence, including multiple systematic reviews undertaken by the prestigious Cochrane collaboration15, 16, 17.
6. The Global Burden of Disease study shows that spinal disorders are the leading cause of years lived with disability worldwide, exceeding depression, breast cancer and diabetes.
7. Interventions used by chiropractors are recommended in the 2018 Low Back Pain series of articles published in The Lancet and clinical practice guidelines from Denmark, Canada, the European Spine Journal, American College of Physicians and the Global Spine Care Initiative.
8. The AEQ supports and promotes scientific research, providing funding and resources for the development of high quality research in collaboration with institutions of high repute, such as Fundación Jiménez Díaz and the University of Alcalá de Henares.
9. The AEQ strenuously promotes among its members the practice of evidence-based, patient-centred care, consistent with a biopsychosocial model of health.
10. The AEQ demands the highest standards of practice and professional ethics, by implementing among its members the Quality Standard UNE-EN 16224 “Healthcare provision by chiropractors”, issued by the European Committee of Normalisation and ratified by AENOR.
11. The AEQ urges the Spanish Government to regulate chiropractic as a healthcare profession. Without such legislation, citizens of Spain cannot be assured that they are protected from unqualified practitioners and will continue to face legal uncertainties and barriers to access an essential, high-quality, evidence-based healthcare service.
END OF QUOTE
I think that some comments might be in order (they follow the numbering of the AEQ):
- The WHO is the last organisation I would consult for information on alternative medicine; during recent years, they have published mainly nonsense on this subject. How about asking the inventor of chiropractic? D.D. Palmer defined it as “a science of healing without drugs.” Chiropractors nowadays prefer to be defined as a profession which has the advantage that one cannot easily pin them down for doing mainly spinal manipulation; if one does, they indignantly respond “but we also use many other interventions, like life-style advice, for instance, and nobody can claim this to be nonsense” (see also point 4 below).
- Perfect use of a classical fallacy: appeal to authority.
- Appeal to authority, plus ignorance of the fact that teaching nonsense even at the highest level must result in nonsense.
- This is an ingenious mix of misleading arguments and lies: most chiros pride themselves of treating also non-spinal conditions. Very few interventions used by chiros are evidence-based. Exercise prescription, patient education and lifestyle advice are hardy typical for chiros and can all be obtained more authoratively from other healthcare professionals.
- Plenty of porkies here too. For instance, the AEQ cite three Cochrane reviews. The first concluded that high-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. The second stated that combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute/subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. And the third concluded that, 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. Hardly the positive endorsement implied by the AEQ!
- Yes, but that is not an argument for chiropractic; in fact, it’s another fallacy.
- Did they forget the many guidelines, institutions and articles that do NOT recommend chiropractic?
- I believe the cigarette industry also sponsors research; should we therefore all start smoking?
- I truly doubt that the AEQ strenuously promotes among its members the practice of evidence-based healthcare; if they did, they would have to discourage spinal manipulation!
- The ‘highest standards of practice and professional ethics’ are clearly not compatible with chiropractors’ use of spinal manipulation. In our recent book, we explained in full detail why this is so.
- An essential, high-quality, evidence-based healthcare service? Chiropractic is certainly not essential, rarely high-quality, and clearly not evidence-based.
Nice try AEQ.
But not good enough, I am afraid.
Many chiropractors tell new mothers that their child needs chiropractic adjustments because the birth is in their view a trauma for the new-born that causes subluxations of the baby’s spine. Without expert chiropractic intervention, they claim, the poor child risks serious developmental disorders.
This article (one of hundreds) explains it well: Birth trauma is often overlooked by doctors as the cause of chronic problems, and over time, as the child grows, it becomes a thought less considered. But the truth is that birth trauma is real, and the impact it can have on a mother or child needs to be addressed. Psychological therapy, physical therapy, chiropractic care, acupuncture, and other healing techniques should all be considered following an extremely difficult birth.
And another article makes it quite clear what intervention is required: Caesarian section or a delivery that required forceps or vacuum extraction procedures, in-utero constraint, an unusual presentation of the baby, and many more can cause an individual segment of the spine or a region to shift from its normal healthy alignment. This ‘shift’ in the spine is called a Subluxation, and it can happen immediately before, during, or after birth.
Thousands of advertisements try to persuade mothers to take their new-born babies to a chiropractor to get the problem sorted which chiropractors often call KISS (kinetic imbalance due to suboccipital strain-syndrome), caused by intrauterine-constraint or the traumas of birth.
This abundance of advertisements and promotional articles is in sharp contrast with the paucity of scientific evidence.
A review of 1993 concluded that birth trauma remains an underpublicized and, therefore, an undertreated problem. There is a need for further documentation and especially more studies directed toward prevention. In the meantime, manual treatment of birth trauma injuries to the neuromusculoskeletal system could be beneficial to many patients not now receiving such treatment, and it is well within the means of current practice in chiropractic and manual medicine.
A more critical assessment of … concluded that, given the absence of evidence of beneficial effects of spinal manipulation in infants and in view of its potential risks, manual therapy, chiropractic and osteopathy should not be used in infants with the kinetic imbalance due to suboccipital strain-syndrome, except within the context of randomised double-blind controlled trials.
So, what follows from all this?
How about this?
Chiropractors’ assumption of an obligatory birth trauma that causes subluxation and requires spinal adjustments is nothing more than a ploy by charlatans for filling their pockets with the cash of gullible parents.
A pain in the neck is just that: A PAIN IN THE NECK! Unfortunately, this symptom is both common and often difficult to treat. Chiropractors pride themselves of treating neck pain effectively. Yet, the evidence is at best thin, the costs are high and, as often-discussed, the risks might be considerable. Thus, any inexpensive, effective and safe alternative would be welcome.
This RCT tested two hypotheses:
1) that denneroll cervical traction (a very simple device for the rehabilitation of sagittal cervical alignment) will improve the sagittal alignment of the cervical spine.
2) that restoration of normal cervical sagittal alignment will improve both short and long-term outcomes in cervical myofascial pain syndrome patients.
The study included 120 (76 males) patients with chronic myofascial cervical pain syndrome (CMCPS) and defined cervical sagittal posture abnormalities. They were randomly assigned to the control or an intervention group. Both groups received the Integrated neuromuscular inhibition technique (INIT); additionally, the intervention group received the denneroll cervical traction device. Alignment outcomes included two measures of sagittal posture: cervical angle (CV), and shoulder angle (SH). Patient relevant outcome measures included: neck pain intensity (NRS), neck disability (NDI), pressure pain thresholds (PPT), cervical range of motion using the CROM. Measures were assessed at three intervals: baseline, 10 weeks, and 1 year after the 10 week follow up.
After 10 weeks of treatment, between group statistical analysis, showed equal improvements for both the intervention and control groups in NRS and NDI. However, at 10 weeks, there were significant differences between groups favouring the intervention group for PPT and all measures of CROM. Additionally, at 10 weeks the sagittal alignment variables showed significant differences favouring the intervention group for CV and SH indicating improved CSA. Importantly, at the 1-year follow-up, between group analysis identified a regression back to baseline values for the control group for the non-significant group differences (NRS and NDI) at the 10-week mark. Thus, all variables were significantly different between groups favouring the intervention group at 1-year follow up.
The authors concluded that the addition of the denneroll cervical orthotic to a multimodal program positively affected CMCPS outcomes at long term follow up. We speculate the improved sagittal cervical posture alignment outcomes contributed to our findings.
Yes, I know, this study is far from rigorous or conclusive. And the evidence for traction is largely negative. But the device has one huge advantage over chiropractic: it cannot cause much harm. The harm to the wallet is less than that of endless sessions chiropractors or other manual therapists (conceivably, a self-made cushion will have similar effects without any expense); and the chances that patients suffer a stroke are close to zero.
The over-use of X-ray diagnostics by chiropractors has long been a concern (see for instance here,and here). As there is a paucity of reliable research on this issue, this new review is more than welcome.
It aimed to summarise the current evidence for the use of spinal X-ray in chiropractic practice, with consideration of the related risks and benefits. The authors, chiropractors from Australia and Canada who did a remarkable job in avoiding the term SUBLUXATION throughout the paper, showed that the proportion of patients receiving X-ray as a result of chiropractic consultation ranges from 8 to 84%. I find this range quite staggering and in need of an explanation.
The authors also stated that current evidence supports the use of spinal X-rays only in the diagnosis of trauma and spondyloarthropathy, and in the assessment of progressive spinal structural deformities such as adolescent idiopathic scoliosis. MRI is indicated to diagnose serious pathology such as cancer or infection, and to assess the need for surgical management in radiculopathy and spinal stenosis. Strong evidence demonstrates risks of imaging such as excessive radiation exposure, over-diagnosis, subsequent low-value investigation and treatment procedures, and increased costs. In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The authors state that the use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.
The problem, however, is that many chiropractors do not abide by those guidelines. The most recent data I am aware of suggests that only about half of them are even aware of radiographic guidelines for low back pain. The reasons given for obtaining spinal X-rays by chiropractors are varied and many are not supported by evidence of benefit. These include diagnosis of pathology or trauma; determination of treatment options; detection of contraindications to care; spinal biomechanical analysis; patient reassurance; and medicolegal reasons.
One may well ask why chiropractors over-use X-rays. The authors of the new paper provide the following explanations:
- lack of education,
- ownership of X-ray facilities,
- and preferred chiropractic technique modalities (i. e. treatment techniques which advocate the use of routine spinal X-rays to perform biomechanical analysis, direct appropriate treatment, and perform patient reassessment).
Crucially, the authors state that, based on the evidence, the use of X-ray imaging to diagnose benign spinal findings will not improve patient outcomes or safety. For care of non-specific back or neck pain, studies show no difference in treatment outcome when routine spinal X-rays have been used, compared to management without X-rays.
A common reason suggested by chiropractors for spinal X-ray imaging is to screen for anomalies or serious pathology that may contraindicate treatment that were otherwise unsuspected by the clinical presentation. While some cases of serious pathology, such as cancer and infection, may not initially present with definitive symptoms, X-ray assessment at this early stage of the disease process is also likely to be negative, and is not recommended as a screening tool.
The authors concluded that the use of spinal X-rays in chiropractic has been controversial, with benefits for the use of routine spinal X-rays being proposed by some elements of the profession. However, evidence of these postulated benefits is limited or non-existent. There is strong evidence to demonstrate potential harms associated with spinal X-rays including increased ionising radiation exposure, over-diagnosis, subsequent low-value investigation and treatment procedures, and increased unnecessary costs. Therefore, in the vast majority of cases who present to chiropractors, the potential benefit from spinal X-rays does not outweigh the potential harms. Spinal X-rays should not be performed as a routine part of chiropractic practice, and the decision to perform diagnostic imaging should be informed by evidence based clinical practice guidelines and clinician judgement.
So, if you consult a chiropractor – and I don’t quite see why you should – my advice would be not to agree to an X-ray.
