physiotherapists
This multicentre pragmatic randomized controlled trial evaluated the effectiveness and cost-effectiveness of physiotherapy, chiropractic care, and the combination of physiotherapy and chiropractic care compared with information and advice for the treatment of patients with nonspecific chronic low-back pain (CLBP) in Sweden.
Eighty-eight participants with nonspecific CLBP were randomly assigned to receive physiotherapy, chiropractic care, combination treatment, or information and advice. The Oswestry Disability Index (ODI), health-related quality of life (HRQoL), quality-adjusted life-years (QALYs), working status, and costs were the main outcome measures.
The study revealed no statistically significant differences in any of the outcome measures when physiotherapy, chiropractic care, and combination treatment with information and advice were compared (p > 0.05). The ODI changes between baseline and the 6-month follow-up ranged from 6.13 to 12.56 across the treatment groups, indicating reduced disability in all groups. Compared with the other treatment options, the combination treatment resulted in the greatest QALY gain (0.418) and lowest cost (SEK 3,081).
The authors concluded that, compared with alternative standalone treatment options, the combination treatment strategy resulted in greater QALY gain and lower costs from a heath care perspective. Although the study did not detect statistically significant differences in outcomes or costs among the treatment options, the combination treatment showed promising potential for cost-effectiveness. Given the small sample size and low statistical power of the study, further clinical trials with fewer treatment arms and a focus on the combination group are warranted to confirm these findings. The insights gained from this study are important for informing the design and conduct of future clinical studies investigating the effectiveness, costs and cost-effectiveness of treatments for CLBP.
I have said it countless times before – but I will say it again: we are all not very effective in curing CLBP. In terms of effectiveness, it therefore hardly matters what treatment we opt for. In this situation, our preference should be guided not by the (in)effectiveness of the therapy but by its
- safety,
- cost,
- availability.
If you apply these criteria, one thing seems very clear:
CHIROPRACTIC CANNOT BE THE TREATMENT OF CHOICE FOR CLBP.
Back pain has become a widespread issue that significantly affects many aspects of the lives of those afflicted. Hydrotherapy has gained attention in the medical and sports communities and has been recognized as a valuable treatment method. The aim of the current research was to determine the effect of hydrotherapy on pain intensity and balance in people with non-specific chronic back pain.
For this systematic review, Persian and English articles were searched for between 2014 and 2024 in Google Scholar, Scopus, PubMed, SID, ISC, and Magiran databases. Finally, 21 relevant articles were selected based on the inclusion and exclusion criteria. The effect of hydrotherapy on pain intensity and balance in people with chronic non-specific low back pain was investigated.
The results of 2 studies showed that hydrotherapy and the Williams flexion model significantly reduced pain and increased dynamic balance. Three studies suggested that hydrotherapy exercises have positive effects on reducing pain and improving balance in people with chronic non-specific low back pain. One study indicated that hydrotherapy does not affect the electrical activity of the back muscles and that the improvement of pain depends on other factors. In addition, the results of 4 studies showed that hydrotherapy exercises and massage therapy help reduce pain, where 6 studies showed that specific movements in water and strengthening the core muscles are also beneficial.
The authors concluded that, based on the studies reviewed in the present research on hydrotherapy, this method can be considered one of the effective approaches for reducing pain intensity and improving balance in individuals with non-specific chronic back pain.
Great, yet another method that is effective for back pain!
The evidence is as good as for many other approaches.
Hold on, there are many caveats!!!
- Due to the nature of the treatment, most primary studies do not control for placebo effects (JUST LIKE STUDIES OF CHIROPRACTIC, FOR INSTANCE).
- The treatment is not a uniform modality but includes several different therapies which makes it impossible to say what actually works and what not (JUST LIKE STUDIES OF CHIROPRACTIC, FOR INSTANCE).
- The primary studies are burdened with many more methodological flaws (JUST LIKE STUDIES OF CHIROPRACTIC, FOR INSTANCE).
- The research is done mostly by investigators who want to show that their treatment works (JUST LIKE STUDIES OF CHIROPRACTIC, FOR INSTANCE).
- The effect sizes tend to be small (JUST LIKE STUDIES OF CHIROPRACTIC, FOR INSTANCE).
I could continue, but you probably get the drift.
So, if you have back pain, should you see a chiropractor (osteopath, acupuncturist, homeopath, other SCAM practitioner who claims his/her therapy works for sore backs) or a practitioner of hydrotherapy?
A difficult choice?
Let me help you:
- the evidence is flimsy for all;
- the costs for chiro etc. tend to be high;
- the risks of chiro etc. can be considerable;
Best to choose a treatment that is inexpensive and low-risk … which means?
Yes, you got it: you might as well choose hydrotherapy!
This paper aimed to systematically review the current literature comparing hands-off approaches with hands-on approaches from a biopsychosocial perspective of pain processing in people suffering from chronic primary neck pain (CPNP).
An electronic search was conducted on PubMed, Web of Science, Scopus, and Cochrane Library. Initial searches were carried out in November 2022, with electronic database searches repeated on November 25, 2024. Eligibility criteria which were randomized controlled trials comparing hands-off approaches alone or in combination with hands-on approaches and hands-on approaches alone in people with CPNP were checked by two independent authors. The risk of bias was assessed using the revised Cochrane Risk of Bias Tool (RoB). The strength of conclusion was determined using the evidence-based guideline development approach.
Fifteen studies with a total of 1029 participants were included in this review. The RoB was rated as low RoB for two studies, some concerns for two studies and high RoB for 11 studies. Pain processing was assessed by pain intensity (100 % of the studies), pain sensitivity (53 % of the studies), pain-related participation in social roles (46 % of the studies), pain-related emotions (26 % of the studies), and pain-related beliefs (6 % of the studies).
Limited quality of evidence was found for the hands-off approaches alone being more effective on pain intensity than hands-on approaches alone in the long term. Limited- to moderate-quality of evidence was found for hands-off approaches combined with hands-on approaches, being more effective than hands-on approaches alone in improving pain intensity, pain sensitivity, pain-related participation in social roles, pain-related emotions, and pain-related beliefs in the short-, mid- or long-term.
The authors concluded that the current findings suggest that hands-off approaches alone are superior to hands-on approaches in the long term, at least for pain intensity. Hands-off approaches in combination with hands-on approaches were also more effective than hands-on approaches for pain processing. However, substantial heterogeneity warrants a cautious interpretation of these results. More high-quality, randomized, controlled trials with homogenous data collection and larger sample sizes are needed.
We probably all know what “hands-on” therapies are; they comprise, for instance, manipulation, mobilisation or massage. But what precisely are “hands-off” approaches for treating neck pain? “Hands-off” approaches for treating neck pain generally refer to methods that don’t involve direct manual manipulation of the spine or aggressive interventions. There are many different options; here are some examples:
- rest,
- exercise,
- heat or cold therapies,
- medications,
- life-style modifications’
- ergonomics,
- stress management,
- mind-body therapies.
This review suggests that an ill-defined bunch of “hands -off” treatments are preferable to those that involve manual manipulations. The review is not focussed on safety issues which would even more clearly favour the former over the latter.
As we are not told which “hands-off” approaches are better than others, we cannot draw many meaningful conclusions from this finding – except, of course, for the one I have mentioned more often than I care to remember:
Don’t ever let a chiropractor (or osteopath) touch your neck!
Carissa Klundt, a 41 year old mom-of-three from Las Vegas, decided to start treatmentsto fix her sore back. She had attended three appointments with her chiropractor before a substitute practitioner stepped in to perform her spinal adjustments on the fourth. Carissa was immediately concerned when she felt a sharp pain in her neck after the chiropractor performed one particular cracking procedure. She experienced pain after the appointment but initially brushed it off as a ‘strained muscle’. When she began ‘blacking out’, her husband insisted she went to a hospital.
There, doctors confirmed that Carissa had suffered a tear in the inner lining of the vertebral artery – a condition known as a vertebral artery dissection (VAD). Doctors warn chiropractic neck manipulation heightens the risk of otherwise rare VADs. It is estimated that one in 20,000 spinal manipulations results in the condition.
Carissa was rushed to the intensive care unit at a specialist hospital as medics feared the VAD could trigger a stroke. After she was discharged, Carissa had a long road to recovery, facing constant pain, and mobility issues. She didn’t suffer a stroke, but was diagnosed with aphasia, due to reduced blood flow to the brain from the torn artery. The condition impairs a person’s ability to express and understand language, whether spoken, written, or signed.
Adamant her visit to the chiropractor nearly cost her her life, Carissa is warning others to be wary of alternative medicine. Detailing what originally led her to visit a chiropractor, she said: ‘I went to my chiropractor because I’d been having a lot of strain in my chest and my back and a friend had recommended one.
After visiting a chiropractor to help relieve some of her symptoms, Carissa felt a sharp pang of pain in her neck during her fourth session. Carissa said: ‘As soon as it happened, I knew something was wrong. You do hear a crack anyway when you get an adjustment but I knew something had gone wrong. There was a pain in my neck. I got home and felt like I was going to throw up. I had no idea a VAD could even happen. Because I work in health, fitness and wellness, I was active after [the appointment]. I was teaching classes, I went to a salon – I did everything wrong. A few weeks after seeing the chiropractor, I was seeing things and blacking out and my husband said ‘we’re taking you to the ER’.’
After undergoing a CAT scan, doctors told Carissa that she had suffered a VAD and transferred her to an ICU at a specialist hospital. Carissa said: ‘I knew straight away that it was from the chiropractor – that’s where the pain all started from. ‘They said I could’ve had a stroke. If I hadn’t gone to hospital, I would’ve had a stroke. I could’ve so easily died. It traumatized my whole family. For the first month I was pretty much in bed. I was exhausted, sleeping for 17 hours a day. I needed help walking. I was in constant pain.’
Carissa says her life was put on pause after suffering the artery tear and is now spreading awareness of the signs and symptoms of the life-threatening condition. Touching on her health status years on, she concludes: ‘I still have lingering symptoms now – it’s a whole lifestyle change. I’ll never ski again, I’ll never go on a rollercoaster, I’m not teaching classes anymore. There’s still a residual fear of it happening again. I’m doing well now but it’s been a long recovery process. My life was really put on pause. I absolutely regret going to the chiropractor. It’s not about blaming anyone, it’s just about spreading more awareness. I want people to understand what the symptoms are and that this is a life-threatening condition. I never thought anything like this could happen to me. I was healthy, active and deeply in tune with my body.’
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Yes, I know!
Yet another case with insufficient details to draw firm conclusions. My chiro friends will not be happy. This is not evidence!, they will say. And right they are! So, let’s look at some more reliable evidence. Here are 3 recent and relevant abstracts:
- 1st abstract: Vertebral artery dissection (VAD) has been observed in association with chirotherapy of the neck. However, most publications describe only single case reports or a small number of cases. We analyzed data from neurological departments at university hospitals in Germany over a three year period of time of subjects with vertebral artery dissections associated with chiropractic neck manipulation. We conducted a country-wide survey at neurological departments of all medical schools to identify patients with VAD after chirotherapy followed by a standardized questionnaire for each patient. 36 patients (mean age 40 + 11 years) with VAD were identified in 13 neurological departments. Clinical symptoms consistent with VAD started in 55% of patients within 12 hours after neck manipulation. Diagnosis of VAD was established in most cases using digital subtraction angiography (DSA), magnetic resonance angiography (MRA) or duplex sonography. 90% of patients admitted to hospital showed focal neurological deficits and among these 11 % had a reduced level of consciousness. 50% of subjects were discharged after 20 +/- 14 hospital days with focal neurological deficits, 1 patient died and 1 was in a persistent vegetative state. Risk factors associated with artery dissections (e. g. fibromuscular dysplasia) were present in only 25% of subjects. In summary, we describe the clinical pattern of 36 patients with vertebral artery dissections and prior chiropractic neck manipulation.
- 2nd abstract: Background: Vertebral artery dissections (VAD) are a rare but important cause of ischemic stroke, especially in younger patients. Many etiologies have been identified, including MVAs, cervical fractures, falls, physical exercise, and cervical chiropractic manipulation. The goal of this study was to investigate the subgroup of patients who suffered a chiropractor-associated injury and determine how their prognosis compared to other-cause VAD. Methods:We conducted a retrospective chart review of 310 patients with vertebral artery dissections who presented at our institution between January 2004 and December 2018. Variables included demographic data, event characteristics, treatment, radiographic outcomes, and clinical outcomes measured using the modified Rankin Scale.Findings: Overall, 34 out of our 310 patients suffered a chiropractor-associated injury. These patients tended to be younger (p = 0.01), female (p = 0.003), and have fewer comorbidities (p = 0.005) compared to patients with other-cause VADs. The characteristics of the injuries were similar, but chiropractor-associated injuries appeared to be milder at discharge and at follow-up. A higher proportion of the chiropractor-associated group had injuries in the 0–2 mRS range at discharge and at 3 months (p = 0.05, p = 0.04) and no patients suffered severe long-term neurologic consequences or death (0% vs. 9.8%, p = 0.05). However, when a multivariate binomial regression was performed, these effects dissipated and the only independent predictor of a worse injury at discharge was the presence of a cervical spine fracture (p < 0.001). Interpretation: Chiropractor-associated injuries are similar to VADs of other causes, and apparent differences in the severity of the injury are likely due to demographic differences between the two populations.
- 3rd abstract: Purpose: The purpose of this study was to determine the frequency of patients seen at a single institution who were diagnosed with a cervical vessel dissection related to chiropractic neck manipulation. Methods: We identified cases through a retrospective chart review of patients seen between April 2008 and March 2012 who had a diagnosis of cervical artery dissection following a recent chiropractic manipulation. Relevant imaging studies were reviewed by a board-certified neuroradiologist to confirm the findings of a cervical artery dissection and stroke. We conducted telephone interviews to ascertain the presence of residual symptoms in the affected patients. Results: Of the 141 patients with cervical artery dissection, 12 had documented chiropractic neck manipulation prior to the onset of the symptoms that led to medical presentation. The 12 patients had a total of 16 cervical artery dissections. All 12 patients developed symptoms of acute stroke. All strokes were confirmed with magnetic resonance imaging or computerized tomography. We obtained follow-up information on 9 patients, 8 of whom had residual symptoms and one of whom died as a result of his injury. Conclusion: In this case series, 12 patients with newly diagnosed cervical artery dissection(s) had recent chiropractic neck manipulation. Patients who are considering chiropractic cervical manipulation should be informed of the potential risk and be advised to seek immediate medical attention should they develop symptoms.
I hope my chiro friends are happy now.
This meta-analysis evaluated and compared the safety and efficacy of spinal manipulation, mobilization, and massage for the management of cervicogenic headache (CGH). Comprehensive searches were conducted in Cochrane, Embase, PubMed, and ClinicalTrials.gov to identify studies investigating the effects of manipulation, mobilization, and massage on pain, disability, and physical function in patients with CGH. Key outcomes included pain severity (visual analog scale, VAS), Neck Disability Index (NDI), Flexion-Rotation Test (FRT), and Headache Disability Inventory (HDI) at various follow-up timepoints.
Fourteen studies totaling 1,297 CGH patients were included. Standard pairwise meta-analysis revealed that sustained natural apophyseal glides (SNAG*) mobilization produced significantly greater improvements compared to non-SNAG interventions in VAS (MD = 1.73, 95%CI: 1.05, 2.40), NDI (MD = 8.55, 95%CI: 2.73, 14.37), FRT (MD = -7.22, 95%CI: -9.38, -5.07), and HDI (MD = 9.29, 95%CI: 3.64, 14.95), with benefits maintained over time. Network meta-analysis showed that for VAS improvement, the surface under the cumulative ranking curve (SUCRA) probabilities were: cervical spine manipulation (CSM, 98.9%), mobilization (67.3%), exercise (21.0%), and massage (12.8%). For NDI, the SUCRA scores were: CSM (82.2%), mobilization (57.2%), exercise (6.7%), and massage (53.9%). CSM exhibited significantly greater VAS reductions compared to exercise, massage, and mobilization, while mobilization was superior to exercise and massage for VAS. For NDI, CSM was significantly better than exercise, but no other between-group differences were observed.
The authors concluded that, in patients with CGH, SNAG mobilization can significantly improve pain and function, with benefits maintained in the long-term. Additionally, CSM may be the most effective short-term intervention for reducing pain and disability compared to mobilization, massage, and exercise, although clinician expertise appears to be an important factor.
The authors note that both components of this study exhibited substantial heterogeneity, with variability in the frequency, duration, and nature of spinal interventions across studies. This lack of standardization complicates the translation of findings to clinical practice. Additionally, while the network meta-analysis allowed for comparative evaluation of several manual therapy modalities, the large differences between sham/control groups precluded the inclusion of SNAG, thereby limiting the comprehensiveness of the analysis.
They also admit that The small sample sizes and potential selection biases in the primary studies significantly limit the ability to generalize their findings to the broader CGH patient population. While the studies provide important insights into the effectiveness of manual therapy interventions, their conclusions should be interpreted cautiously. Larger, more diverse studies with more robust sampling strategies would help improve the external validity and reliability of the findings, allowing for more confident recommendations that can be applied to the wider CGH population in clinical settings.
I agree with these critical thoughts and wonder why the authors nonetheless formulated their conclusions so definitively. In my view, there are not enough reliable data for arriving at such firm conclusions. Furthermore, it is unclear how thay assessed the safety of the various interventions. Considering the well-documented risks of CSM, I would certainly not name it as the manual therapy of first choice.
*The SNAG technique involves the application of graded mobilization along the treatment plane of the selected cervical facet joint, from the mid-range to the end-range, with the joint position maintained.
It has been reported that members of the U.S. House and Senate are proposing the Chiropractic Medicare Coverage Modernization Act, ensuring reimbursement for all medically necessary services provided by chiropractors. However, the American College of Radiology and American Society of Neuroradiology have now joined over 90 other groups led by the AMA to announce their disapproval. They shared their concerns in a recent letter to the two bills’ sponsors, which ASNR promoted in an update published Tuesday.
“Our organizations are concerned that permitting chiropractors to bill Medicare for the full and likely expanded scope of their license in a given state will lead to an unnecessary redistribution of scarce Medicare resources,” the American Medical Association, all 50 state physician societies, ACR and ASNR recently wrote to lawmakers. Doing so, they added, will likely take funds from medical groups, redistributing them “to nonphysician practitioners for services that they lack sufficient training and expertise to perform. Such expansion would increase overall Medicare costs and jeopardize the health and safety of Medicare patients.”
Supporters of the bill claim the legislation would provide a path for Medicare recipients to better manage pain without resorting to opioids. Currently, the program only covers chiropractic care deemed “medically necessary, subjecting beneficiaries to “burdensome red tape requirements.” The Chiropractic Medicare Coverage Modernization Act seeks to remove these obstacles, bringing coverage rules more in line with rules imposed by private payers.
The radiology societies said they “greatly value the contribution of chiropractors.” However, they’re troubled the legislation would authorize them to use the title “physician” under the Medicare Part B program and be paid the same rate as MDs and DOs. Removing the current “manual manipulation” of the spine limitation in the program opens the door for chiropractors to provide other services “they have not been specifically trained to provide.” Physicians are required to complete upward of 16,000 hours of clinical training, while chiropractic students only must meet a minimum of 4,200 instructional hours.
“Given their relatively limited education and training, chiropractors’ scope of practice is appropriately restricted under Medicare to treatment by means of manual manipulation, i.e., by the use of the hands,” the radiology societies wrote. “This limitation is aligned with chiropractic training and the treatments that chiropractors most often provide involving common musculoskeletal complaints such as back pain.”
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Needless to say what I think about this bill! Chiropractors are not sufficiently trained in medicine, science or ethics to expand their services in the proposed way. One could, of course, train them to practice real medicine. Then most of them would probably give up spinal manipulation and become physicians like MDs.
This is the path that US osteopath have chosen a long time ago.
Would that be desirable?
No, I don’t see a point in having several different types of physicians. It can only confuse patients, lead to uncertainty and to suboptimal healthcare.
A popular ‘TikTok creator’ claims that he became bedridden for months after a chiropractic adjustment to his neck left him with a herniated disc, causing him “the worst pain I’ve ever experienced” and the loss of his life savings in medical bills. Tyler Stanton, a Nashville-based ‘content creator’ stated that he’s been recovering from an injury sustained when a chiropractor adjusted his neck.
In a TikTok video Stanton said he’d been working out a lot before his birthday because “I wanted to be in the best shape of my life.” He’d been feeling some tightness in his back, so he went to see a chiropractor. At first, the chiropractor struggled to “get my back to crack,” but finally he was able to do it. Stanton said when they had the same trouble with his neck, “on the second time where he tried to crack my neck, he put a lot of force behind it, and I heard one huge and painful pop,” Stanton explained. “I knew immediately that something was wrong … the whole room was spinning. My equilibrium was just completely f—ked. I was like instantly, like, profusely sweating.”
It took him a half hour of lying down to “be good enough to walk out the door,” but as soon as he got home, he began “violently throwing up, uncontrollably. I can’t see straight.” Stanton says he went promptly to bed even though it was the middle of the day, and when he woke up the next morning moving to turn his phone alarm off caused him “the worst pain I’ve ever experienced in my entire life.” Stanton described it as “static” all over the “entire right side of my body. It was really scary, I had no idea what was happening, but I knew something was really wrong.”
He went to the hospital, where it was determined that the chiropractor had “herniated my C6,” the disc at the base of the neck. Over the next month, he spent a few weeks “on and off” in the hospital, because the “pain was so bad.” He received epidural injections, and “they didn’t even make a dent into the pain. Like, it literally did nothing.”
At this point, his options were surgery — which he said, “I’ve heard so many horror stories about that” — or physical therapy and learning to live with a herniated disc. He chose the second option, explaining he has a “a pharmacy” at home of pain medication. “I ended up just having to go home and lay down for about two more months. It took, like, three months to get my feeling back in my arm.”
He thought of legal action, as the injury “really hurt me financially … my savings just evaporated … I still deal with pain. I’m still limited on what I can do physically. It just destroyed me mentally, financially, physically — all of it.”
In a later update Stanton said that it’s been hard for him to create content since he herniated his disc. “People asking me why I keep disappearing and why I stopped posting … I didn’t really want to say much about it because one thing I’ve learned over the years being on the internet is that if you have a following, no one cares if you’re sad,” he said. “To be honest with you, I love to come on here and make you guys laugh, but it’s hard to when s—t just ain’t funny.”
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Having treated many patients with herniated discs, I can confirm: it’s not funny!
Having read about many cases of serious complications after chiropractic manipulations, I assume that this one – like so many others – will not enter into the medical literature where sufficient details might be provided to allow a fuller evaluation – doctors are simply too busy to write up the events and findings for publication. The case will also not appear in any system that monitors adverse events, because chiropractors have in their ~120 Years history not been able to establish such a thing. The result will be that this event – as so many like it – will pass virtually undocumented and unnoticed.
And this suits whom exactly?
Yes, it suits the chiros who can continue to falsely claim that, as there are just few records to the contrary,
“our maipulations are entireely safe!”
Yes, this was the (rather sensationalist) headline of a recent article in the Daily Mail that I allegedly wrote. Its unusual genesis might interest some of you.
I was contacted by a journalist who asked for a telephone interview on the subject of chiropractic as well as my recent book. I agreed under the condition that we do this not over the phone but in writing via email. So, he sent me his questions and I supplied the responses; here they are:
· What’s the absolute worst case scenario of seeing a chiropractor?
The worst that can happen is that you die. Certain manipulations that chiropractors regularly do can injure an artery that supplies part of the brain. This would then result in a stroke; and a stroke can of course be fatal. This is what happened, for example, to the American model Katie May. She had pinched a nerve in her neck on a photoshoot and consulted a chiropractor who manipulated her neck. This caused a tear to an artery in her upper spine. The result was a massive stroke of which she died a few days later.
· How did you first become interested in the topic?
I learned hands on spinal manipulation as a junior doctor. Later, as the head of the department of Physical Medicine and Rehabilitation at the University of Vienna, we used such techniques routinely. In 1993, I became chair of Complementary Medicine in Exeter, and my task was to scientifically investigate alternative therapies such as chiropractic. Recently, I decided to summarize all our research in a book.
· What did you learn from your research?
In essence, our investigations found that almost all the claims that chiropractors make are unsubstantiated. Their manipulations are not nearly as effective as they claim. More worryingly, they are also not free of risks. About 50% of patients who see a chiropractor suffer from side effects after spinal manipulation. These are usually not severe and disappear after 2 or 3 days. But, in addition, very serious complications like stroke, death, bone fractures, paralysis can also occur. Chiropractors say that these are rare, and I hope they are right, but the truth is that nobody knows because there is no system of monitoring such events. We once asked British neurologists to report cases of neurological complications occurring within 24 hours of cervical spine manipulation over a 12-month period. This unearthed a total of 35 cases. Particularly striking was the fact that none of these cases had previously been reported anywhere. So, the underreporting was exactly 100%. This tells me that, when chiropractors claim there are just a few such incidents, in truth there might be a few hundred or even thousand.
· Is there an especially shocking finding?
What I find particularly unnerving is the way chiropractors regularly disregard medical ethics. Take the issue of informed consent, for example. It means that we all have to fully inform patients about the treatment we plan to give. In the case of chiropractic spinal manipulation, it would need to include that the therapy is of doubtful effectiveness, that other options are more likely to help, and that the treatment carries very frequent minor as well as probably rare major risks. I do understand why chiropractors do often not provide this information – it would chase away most patients and thus impact of their income. At the same time, I feel that chiropractors should not be allowed to violate fundamental principles of medical ethics. This is not in the interest of patients!!!
· Why do you think patients are so keen on chiropractors?
I am not sure that they really are so keen; some are but the vast majority are not. Our own research suggests that, depending on the country, between 7 and 33% of the population see chiropractors. This means that between 93 and 67% have enough sense to avoid chiropractors.
· But what does the evidence actually show about the efficacy of chiropractic?
As it happens our most recent summary has just been published. It concluded that “it is uncertain if chiropractic spinal manipulation is more effective than sham, control, or deep friction massage interventions for patients with headaches” [Is chiropractic spinal manipulation effective for the treatment of cervicogenic, tension-type, or migraine headaches? A systematic review – ScienceDirect]. For other conditions the evidence tends to be even less convincing. The only exception might be chronic low back pain, according to another recent summary [Analgesic effects of non-surgical and non-interventional treatments for low back pain: a systematic review and meta-analysis of placebo-controlled randomised trials | BMJ Evidence-Based Medicine]. But here too, I would argue that other treatments are safer and cheaper.
· Are some chiropractors worse than others?
The profession is divided into 2 groups, the ‘straights’ and the ‘mixers’. The former believe in all the nonsense their founding father, DD Palmer, proclaimed 120 years ago, including that spinal manipulation is the only treatment for virtually all our ailments, and that vaccinations must be avoided at all cost. The mixers have realized that Palmer was a charlatan of the worst kind, focus on musculoskeletal conditions and use treatments borrowed from physiotherapy. Needless to say that the mixers might be bad, but the straights are even worse.
· What can patients do to keep safe?
Avoid chiropractors, go to a library and read my book.
· If you have backpain or joint pain what can you do instead?
There is lots people can do but advice has to be individualized. By far the best is to prevent back pain from happening. Here advice might include more exercise, loosing weight, changing your mattress, avoiding certain things like heavy lifting, etc. If you are acutely suffering, see a physio or a doctor, keep moving and be aware that over 90% of back pain disappears within a few days regardless of what you do.
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I had insisted that I see his edits before this gets published, and a little while later I received the edited version. To my big surprise, the journalist had transformed the interview into an article allegedly authored by me. I told him that I was uncomfortable with this solution, and we agreed that he would make it clear that the article was merely based on an interview with me. I then revised the article in question and the result was the mentioned article published still naming me as its author but with a footnote: “As told in an interview with Ethan Ennals”
Never a dull day when you research so-called alternative medicine!
In a recent post, I mentioned a new report which allegedly claimed that “employing chiropractors in the [English] health service could save £1.5 billion“. Thanks to ‘Blue Wode’, we can now read the original report, and I had a critical look at it. Here are some quotes of crucial passages from the report:
The objective of this analysis was to establish how chiropractors could help to address the unmet need of people with MSK [musculoskeletal] conditions, who are currently absent from work due to these conditions, on NHS MSK physiotherapy waiting lists …
To assess the available evidence on the relative effectiveness of chiropractors, physiotherapists and osteopaths a pragmatic literature review was undertaken. This consisted of a rapid, pragmatic search of existing literature evidence to explore the effectiveness of chiropractic interventions (in terms of productivity/return to work) compared with physiotherapists and/or osteopaths … The strategies were not designed to be ‘comprehensive’ but focused to target records for relevant studies whilst retrieving record numbers that were manageable within the project timescales and available resources…
The results of the analysis are based on the assumption that there are equivalent work-related outcomes associated with MSK physiotherapy and chiropractic care…
1,270 records were retrieved from the database searches and 41 records were sent by the BCA. 101 duplicates were removed, and the remaining 1,210 references were screened for inclusion. 18 studies met the eligibility criteria and were included in data extraction (see Appendix B for the study flow diagram). Included studies had the following study designs: five systematic reviews [29-32] (of which one was only a summary [33]), three non-systematic reviews [34, 35] with one running a meta analysis [36], five randomised controlled trials [37-41], three cohort studies [42-44], and two case series studies [26, 45]…
A pragmatic review of literature found that evidence of the effectiveness of chiropractors in helping people with MSK conditions to get back to work is sparse and poor quality. There is weak evidence to suggest that chiropractors treating MSK conditions would be able to achieve equivalent return-to-work outcomes as physiotherapists. If more robust evidence could be developed, it is feasible that chiropractors could be used to address supply shortages in treatment for MSK conditions. This would require the NHS to consider closely the clinical governance arrangements it would need to put in place to ensure patient safety. It would also need to review the type of treatment and advice that chiropractors were able to provide for people with MSK conditions.
The initial analysis carried out for this study estimated that there are almost 1.6 million people unable to work due to an MSK condition in the UK. Spare capacity in the chiropractic profession indicates that around 114,000 more people per year could be treated by chiropractors. This represents around 7% of the current waiting list. Chiropractors have an average waiting time of 1.5 weeks compared with a minimum of 11 weeks for physiotherapists.
If the spare chiropractor capacity was used to address MSK conditions preventing people from working, then this could improve workforce productivity by reducing the time people are waiting for treatment. Adopting a simple analysis, assuming that all of the spare capacity could be used in the most efficient way, the estimated value of the improvement in productivity is £612 million per year. Using the Markov model to factor in a wider range of potential outcomes provides a more conservative, more robust estimated value of £399 million per year. If minimum rather that median wages are used to value the productivity gain based on an 11 week wait then it would reduce to £258 million.
A range of factors may increase or decrease the potential productivity gains. If the 11-week waiting time for physiotherapists is an under-estimate and the waiting times are 18 or 24 weeks, then the productivity gain would increase to £713 million and £1 billion respectively.
This analysis focused on productivity costs only, but people may also potentially have better health outcomes and lower treatment costs if they are treated more quickly.
Recommendations
Key recommendations emerging from this research are:
- The NHS should consider commissioning pilot research studies to generate evidence to make the case for the use of chiropractors in providing treatment for people with MSK conditions to allow them to return to work more quickly.
- The NHS should consider how the potential use of chiropractors to provide treatment and advice for people with MSK conditions can help to address the demand, capacity and financial challenges facing the health and social care system. This would need to be within the constraints of clinical guidelines and governance, to ensure safety and effective outcomes.
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And here are a few critical points:
- What on earth is a “pragmatic literature review”; was the term invented to disguise tha fact that the review is not systematic and thus is a bonanza in cherry-picking? I had a look at the cited literature and can confirm that any critical assessment of chiropractic has been excluded.
- “The results of the analysis are based on the assumption that there are equivalent work-related outcomes associated with MSK physiotherapy and chiropractic care.” Are you kidding me? I thought the aim was to “assess the available evidence on the relative effectiveness of chiropractors, physiotherapists and osteopaths”. How can you then assume equivalent outcomes as a basis for conducting the research?
- “Included studies had the following study designs: five systematic reviews [29-32] (of which one was only a summary [33]), three non-systematic reviews [34, 35] with one running a meta analysis [36], five randomised controlled trials [37-41], three cohort studies [42-44], and two case series studies [26, 45].” So, just 5 RCTs are the basis of the evaluations? What did you do with the dozens of other RCTs in this area? Did they perhaps not fit your conclusions?
- “If more robust evidence could be developed, it is feasible that chiropractors could be used to address supply shortages in treatment for MSK conditions.” However, I predict that more robust evidence will show the opposite of what you seem to wish!
- “Ensure patient safety”. Yes, thanks for mentioning safety. The report neglects safety completely. In view of the known risks of chiropractic this seems a serious mistake!
- “The estimated value of the improvement in productivity is £612 million per year.” From my comments above, it follows that this wild and largely unsubstantiated estimate was guided by little more than wishful thinking.
- “This analysis focused on productivity costs only, but people may also potentially have better health outcomes and lower treatment costs if they are treated more quickly.” More likely people experience health outcomes that are very similar to those of doing nothing at all. In this case, it would follow that a lot of money might be saved if we scrap MSK treatments altogether.
This report is a transparent and dilettante attempt to push more chiropractic on the NHS, a move that would not improve much and could even put a few patients in wheelchairs.
A long article on chiropractic casts doubt that chiropractic is useful. Here is an abbreviated version of it:
The chemistry and biology graduate from the University of Georgia, 28-year-old Caitlin Jensen, visited a chiropractor to sort out her lower back pain. During the session, the therapist performed an adjustment. It severed four arteries in her neck. She collapsed shortly after, unable to speak or move. The injury had caused her to suffer a series of strokes. Today, she has regained some movement in her head, legs and arms but she is still unable to speak, is partially blind and relies on a wheelchair.
- One 66-year-old grandmother said a visit to a chiropractor to treat her sore shoulder left her covered in bruises, hearing ringing in her ears and with a splitting pain in her jaw. She was later diagnosed by doctors with trigeminal neuralgia – a chronic pain disorder caused by a trapped or irritated nerve in the neck that causes sudden, electric shock-like pain in the face. She believes the condition – which, three years later, still sometimes leaves her unable to open her mouth wide enough to speak to her grandchildren – was triggered by a chiropractic adjustment of her neck.
- A 55-year-old woman was left with chronic neck and shoulder pain after visiting a chiropractor for a sore back. The pain was so bad she once spent 72 hours immobile and unable to sleep despite taking a concoction of painkillers.
- And a 66-year-old man says his back went into spasm as he was leaving his first chiropractor appointment – which left him hospitalised and bedbound for weeks. The intense treatment, he later learned, had pushed one of the discs of his spine out of place, causing him to lose feeling in his right leg for ever.
