spinal manipulation
Yes, it’s CAW again!
How best should we celebrate?
- I could show you how often we had to discuss the harm chiropractic does to patients.
- I could tell you about the contraproductive advice chiropractors tend to issue to anyone who wants to hear it.
- I could list the fatalities chiropractic manipulations have caused.
- I could write about the unethical transgressions many chiropractors commit.
- I could elaborate on the financial fraud some chiropractors are involved in.
- I could write about the dishonest cherry-picking that chiropractors like to engage in.
But that would not be nice, and they would say that I have an axe to grind, a chip on my shoulder, that I am incompetent, don’t know what I am writing about, in the pocket of BIG PHARMA, etc.
So, I decided to celebrate the CAW by reporting on a chiropractic success story, a type of article that chiropractors like: a case report of a patient cured by chiropractic treatments.
Chronic low back pain (CLBP) has been the leading cause of disability globally for the past few decades, resulting in decreased quality of life physically and emotionally. This case report is, according to its authors, important in the medical literature to add to studies reporting successful conservative treatment of CLBP and chronic neck pain (CNP). Triage, diagnosis, and understanding of economical and conservative therapeutics can, the authors stress, benefit patients; providers as well as institutions and third party payors benefit from improved outcomes.
A 39-year old male presented with severe CLBP who had experienced no long-term success with prior chiropractic spinal manipulative therapy (SMT). After symptoms began to worsen in spite of receiving SMT, the patient sought treatment for his pain, abnormal spine alignment, and poor sagittal alignment at a local spine facility. History and physical examination demonstrated altered spine and postural alignment including significant forward head posture and reduced cervical and lumbar lordosis and coronal plane abnormalities. Treatment consisted of a multi-modal regimen focused on strengthening postural muscles, specific spine manipulation directed toward abnormal full-spine alignment, and specific Mirror Image traction aiming to improve spine integrity by realigning the spine toward a more normal position. The treatment consisted of 36 treatments over three months. All original tests and outcome measures were repeated following care.
Objective and subjective outcome measures, patient-reported outcomes, and radiographic mensuration demonstrated improvement at the conclusion of treatment and maintained at 1-year follow-up re-examination.
The authors concluded that this is case demonstrates that the CBP orthopedic chiropractic treatment approach may represent an effective method to treat abnormal spinal alignment and posture. This study adds to the literature regarding conservative methods of treating spine pain and spinal disorders.
What, you are NOT impressed?
- You even claim that the patient’s symptoms worsend despite long-term SMT?
- You insist that such a case poves nothing and certainly does not justify the conclusion?
- You point out that one of the authors is a compensated researcher for CBP Non-Profit, Inc., while another one is a compensated consultant and researcher for Chiropractic BioPhysics, NonProfit, Inc. and one is the CEO of Chiropractic BioPhysics® (CBP®)?
- And you note that this paper was funded by Chiropractic BioPhysics?
Let me tell you this: you are a spoilt sport! We are, after all, in the realm of chiropractic research where things are different. What is normally called promotion florishes here as research, and the rules of science, ethics or even common sense are suspended.
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!”
“Dr. Arleen Scholten” – rings a bell?
Yes!
She is the chiropractor who treated John Lawler who then tragically died. Since Scholten was found not guilty of any wrong-doing by the General Chiropractic Council (GCC), she is practising unabated. These days, she seems to be particularly fond of treating children. Here are some excerpts from what she claims on her website:
Subluxations, or misalignments, within the spine can disrupt the vital communication between the brain and the body. These subluxations induce stress on the nervous system, potentially leading to a diminished function in the affected area. Infants, children, and adults can all experience spinal subluxations. Birth trauma, minor or major traumas, and developmental stress can all cause subluxations in infants and children. During the initial five years of life, the body generates more neural pathways than at any other time. It is crucial to optimize this production through pediatric chiropractic care, as these early years are pivotal for each child’s potential…
Chiropractic adjustments are safe for patients of all ages, including newborns… Over time, chiropractic practitioners have received valuable feedback from parents and young patients, highlighting significant and unexpected improvements in various aspects of their lives, including:
- Sleep patterns
- Behavior and attitude
- Immune system functionality
Additionally, patients have reported improvements in conditions such as ADD/ADHD, colic, torticollis, ear infections, bed-wetting, digestive issues, allergies, asthma, seizures, and more.
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Allow me to add a few comments on these claims:
- Subluxations only exist in the imagination of chiropractors.
- Therefore, they cannot disturb vital communication between the brain and the body.
- Nor can they induce stress on the nervous system.
- Nobody experiences chiropractic subluxations because they are a chiropractic invention to fool patients and take their money.
- Pediatric chiropractic care does not enhance a child’s potential.
- Chiropractic adjustments are not safe; as we have often discussed on this blog, they cause not merely very frequent mild, transient adverse effects but also serious and often permanent complications of unknown frequency.
- Feedback received by chiropractors is a far cry from amounting to reliable evidence.
- Chiropractic does not improve sleep patterns.
- It does not alter behavior and attitude.
- It also does not enhance immune system functionality.
- Nor does it affect ADD/ADHD, colic, torticollis, ear infections, bed-wetting, digestive issues, allergies, asthma, seizures.
Some of these conditions can be potentially serious. Treating them with chiropractic would needlessly prolong the suffering; in a worst case scenarion, it could even cost the life of a child. This, I feel, begs the question: is one death not enough, ‘Dr.’ Scholten?
She has already once been let off the hook by the GCC, I wonder whether the ‘Advertising Standards Authority’ will be as lenient, or whether they could step in and prevent a further tragedy.
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!
I has been reported that a man is pleading to steer clear of chiropractors. Last year, Tyler Stanton endured “the worst pain I had ever experienced in my life,” a hospital stay, and the beginning of an ongoing struggle that has left him unable to work. All started immediately after a chiropractor cracked his neck — and something popped.
After adjusting Stanton’s back, the chiropractor moved on to his neck. “It didn’t crack on the first time. 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. I knew immediately that something was wrong.” Stanton recalled that when he tried to sit up, the room began to spin. “My equilibrium was just completely f—ked. I was instantly, profusely sweating.”
After laying on the table for half an hour, Stanton made the short trip back to his home, where he became “violently ill.” Throwing up uncontrollably and unable to see straight, he got into bed, hoping rest would alleviate his symptoms. The following morning, Stanton woke up to “the worst pain I had ever experienced in my life. The entire right side of my body was numb. It was really scary.”
He was taken to the hospital, where he was diagnosed with a herniated disc between the C5 and C6 vertebrae in his neck. Due to the acute pain he was experiencing, he stayed in the hospital for several weeks. “They ended up giving me epidural injections into my spine, and they didn’t even make a dent into the pain,” he said. Ultimately, doctors gave him two choices: spinal fusion therapy or physical therapy to manage his discomfort.
Fearful of the consequences of surgery, Stanton opted for PT. “I had a pharmacy of pain medication to help the nerves be less inflamed so I can get mobility and feeling back into the right side of my body. Essentially, I just had to go home and lay down for about two more months.”
Unable to work, Stanton burned through his savings, and six months into his recovery, he is just beginning to regain sensation in his right arm. “I still deal with pain. I’m still limited in what I can do physically. It just destroyed me. Mentally, financially, physically, all of it.” With limited mobility and mounting medical bills, Stanton is consulting with lawyers and considering legal action. “I kinda feel like I just don’t have another choice because this really just derailed my entire life overnight,” he said.
While proponents say chiropractors help alleviate pain, many doctors describe the field as pseudoscience — and warn that it can actually lead to serious problems. ““There are reports of severe side effects with chiropractic treatment, including blood clot formation, herniated discs, fractures, artery dissection, stroke, paralysis, and death,” explained Gbolahan Okubadejo, MD, a spinal surgeon and the head of The Institute for Comprehensive Spine Care. Dr. Charles R. Wira III, an emergency medicine doctor at Yale Medicine, told the Huffington Post that there’s a known link between chiropractic neck manipulations and major artery tears that can cause strokes. “Thankfully, overall the incidence of neck dissections are small,” he said. “But intentional and aggressive manipulations of the neck merits strong consideration for concern.” Cardiologist Dr. Danielle Belardo said she was “heartbroken” to see a young patient with “dissection of the vertebral artery” following a neck adjustment. “How can we live in a world where it’s legal to perform something with zero evidence for benefit (neck adjustment from a chiro) when there are such incredibly dangerous and life changing risks?” she wrote on Twitter. “[My patient] trusted a licensed healthcare practitioner to provide care that has more benefit than harm. This is a disgrace.”
Stanton hopes his story can serve as a warning for others. “I think it’s important that I share this story because I just don’t want what happened to me to happen to someone else,” he said. “Please don’t go to the chiropractor, OK? If I can do anything with my platform to share the story and save somebody from experiencing what I had to experience, then hopefully, something positive can come out of what I went through. Please hear me when I say this: Please be careful. This is the last thing that you want to experience.”
In a disturbing parallel, a young woman who felt a “crack to her neck” during a gym workout in 2021 died weeks later after going to a chiropractor to treat her neck pain. In 2022, a Georgia woman became paralyzed after a routine neck adjustment ended up rupturing her spinal arteries in several spots. In 2023, an Australian man suffered a stroke after cracking his neck in an ill-advised attempt to cure his chronic back pain.
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None of these are proper case reports in a medical sense, of course. Such publications are relatively rare.
I wonder why.
Could it be related to the fact that many chiropractors are in denial and, as a profession, they still have no adequate monitoring system for adverse event?
Patients with headaches often seek so-called alternative medicine (SCAM), including chiropractic care. Chiropractic spinal manipulation is one of the most commonly used techniques for these patients; however, its effectiveness remains unclear. This systematic review aimed to evaluate the effectiveness of chiropractic spinal manipulation in reducing headache days, episode duration, episode intensity, and medication intake in patients with headaches.
MEDLINE (Pubmed), PEDro, SCOPUS, Cochrane Library and Web of Science databases were searched from inception to April 2024. PICO search strategy was used to identify randomized controlled trials applying chiropractic spinal manipulations versus sham manipulation, no additional intervention, or other conservative non-pharmacological interventions in patients with headaches. Eligible studies and data extraction were conducted independently by two reviewers. Quality of the studies was assessed with Physiotherapy Evidence Database scale, and risk of bias with Cochrane Collaboration tool. Certainty of the evidence was evaluated using GRADE approach.
Eight studies ranging from low to high methodological quality were included. The results were categorized into three subgroups: chiropractic manipulation versus sham, chiropractic manipulation versus control, and chiropractic manipulation versus deep friction massage. Among the five studies comparing chiropractic manipulation to sham, two found a significant reduction in the number of headache days. Of the three studies comparing chiropractic manipulation to another control, one reported a decrease in headache episode duration. No significant differences were observed for any other variable across the subgroups. The certainty of evidence was downgraded to very low.
We concluded that it is uncertain if chiropractic spinal manipulation is more effective than sham, control, or deep friction massage interventions for patients with headaches.
These conclusions might not surprise many readers. Yet, in at least one way, they are quite surprising: the version of the article we submitted to the ‘European Journal of Integrative Medicine’ had a substantially different conclusion; it was as follows:
What happened?
You may well ask!
The journal wanted us to change our conclusion! Because the main authors of our paper needed, for academic reasons, to publish without any further delay, they agreed to the demand. As far as I remember, such a thing is unprecedented in my ~50 years of publishing research in medical journals.
PS
It is also the last time I will have any dealings with the European Journal of Integrative 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.
The aim of this recent review was to investigate the efficacy of non-surgical and non-interventional treatments for adults with low back pain compared with placebo. It included all randomised controlled trials evaluating non-surgical and non-interventional treatments compared with placebo or sham in adults (≥18 years) suffering from non-specific low back pain.
Random effects meta-analysis was used to estimate pooled effects and corresponding 95% confidence intervals on outcome pain intensity (0 to 100 scale) at first assessment post-treatment for each treatment type and by duration of low back pain—(sub)acute (<12 weeks) and chronic (≥12 weeks). Certainty of the evidence was assessed using the Grading of Recommendations Assessment (GRADE) approach.
A total of 301 trials (377 comparisons) provided data on 56 different treatments or treatment combinations. One treatment for acute low back pain: (non-steroidal anti-inflammatory drugs (NSAIDs)), and five treatments for chronic low back pain:
- exercise,
- spinal manipulative therapy,
- taping,
- antidepressants,
- transient receptor potential vanilloid 1 (TRPV1) agonists)
were found to be efficacious. However, effect sizes were small and of moderate certainty. Three treatments for acute low back pain (exercise, glucocorticoid injections, paracetamol), and two treatments for chronic low back pain (antibiotics, anaesthetics) were not efficacious and are unlikely to be suitable treatment options; moderate certainty evidence. Evidence is inconclusive for remaining treatments due to small samples, imprecision, or low and very low certainty evidence.
The authors concluded that the current evidence shows that one in 10 non-surgical and non-interventional treatments for low back pain are efficacious, providing only small analgesic effects beyond placebo. The efficacy for the majority of treatments is uncertain due to the limited number of randomised participants and poor study quality. Further high-quality, placebo-controlled trials are warranted to address the remaining uncertainty in treatment efficacy along with greater consideration for placebo-control design of non-surgical and non-interventional treatments.
This is an important analysis, not least because of the fact that the research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The methodology is sound and the results thus seem reliable.
The findings are in keeping with what we have been discussing at nauseam here: no treatment works really well for back pain. For acute symptoms no so-called alternative medicine (SCAM) at all is efficacious. For chronic pain, spinal manipulation therapy (SMT) have small effects. As SMT is neither cheap nor free of risks, excercise is much preferable.
Considering that most SCAMs are heavily promoted for low back pain (e.g. acupuncture, Alexander technique, cupping, Gua Sha, herbal medicine, homeopathy, massage, mind-body therapies, reflexology, Reiki, yoga), this verdict is sobering indeed!
This systematic review was aimed at assessing whether spinal manipulative therapy (SMT) procedures (i.e., target, thrust, and region) impacted on pain and disability for adults with spine pain.
The investigators searched PubMed and Epistemonikos for systematic reviews indexed up to February 2022 and conducted a systematic search of 5 databases (MEDLINE, EMBASE, CENTRAL [Cochrane Central Register of Controlled Trials], PEDro [Physiotherapy Evidence Database], and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. They included randomized clinical trials (RCTs) from recent systematic reviews and newly identified RCTs published during the review process and employed artificial intelligence to identify potentially relevant articles not retrieved through our electronic database searches. The authors included RCTs of the effects of high-velocity, low-amplitude SMT, compared to other SMT approaches, interventions, or controls, in adults with spine pain. The outcomes were spinal pain intensity and disability measured at short-term (end of treatment) and long-term (closest to 12 months) follow-ups. Risk of bias (RoB) was assessed using version 2 of the Cochrane RoB tool. Results were presented as network plots, evidence rankings, and league tables.
The researchers included 161 RCTs (11 849 participants). Most SMT procedures were equal to clinical guideline interventions and were slightly more effective than other treatments. When comparing inter-SMT procedures, effects were small and not clinically relevant. A general and nonspecific rather than a specific and targeted SMT approach had the highest probability of achieving the largest effects. Results were based on very low- to low-certainty evidence, mainly downgraded owing to large within-study heterogeneity, high RoB, and an absence of direct comparisons.
The authors concluded that there was low-certainty evidence that clinicians could apply SMT according to their preferences and the patients’ preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant.
What does that mean?
It means that it is largely irrelevant which form of SMT is being used; the outcomes are more or less independet of the technique that is applied. You don’t need to be particularly skeptical to go one step further and conclude that:
- The percieved effectiveness of SMT compared to other treatments is due to a placebo effect which is likely to be strong with a therapy involving touch, cracking bones, etc.
- The effects of different types of SMT are all similar because these interventions are little more than theatrical placebos.
- Since these placebos can cause consideraable harm, their risk/benefit balance is not positive.
- Because their risk/benefit balance fails to be positive, SMT cannot be recommended as a treatment in routine care.
