Aug 13 2009

Chiropractic

Last Modified: August 29, 2009

Topic Editor: Harriet Hall

Sections:

Topic Overview

Index of SBM Posts

Outside Resources

Summary of Key Research

Topic Overview

Chiropractic was invented by D. D. Palmer on September 18, 1895 when he adjusted the spine of a deaf man and allegedly restored his hearing (a claim that is highly implausible based on what we know of anatomy). Based on this one case, Palmer decided that all disease was due to subluxation: 95% to subluxations of the spine and 5% to subluxations of other bones.

The rationale for chiropractic hinges on three postulates:

  1. Bones are out of place
  2. Bony displacements cause nerve interference
  3. Manipulating the spine replaces the bones, removing the nerve interference and allowing Innate (a vitalistic life force) to restore health.

There is no credible evidence to support any of these claims.

Real subluxations (partial dislocations) show up on x-ray. Chiropractic “subluxations” don’t. In view of the negative x-ray evidence, chiropractic was forced to change its definition of a subluxation from “a bone out of place” to “a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system and general health.”

Chiropractors are divided into straights and mixers. The straights limit themselves to chiropractic adjustments; the mixers add a variety of other methods ranging from massage to outright quackery like applied kinesiology. Upper cervical chiropractors focus on the atlas, the top cervical vertebra.

In over a century, chiropractic research has produced no evidence to support the postulates of chiropractic theory and little evidence that chiropractic treatments provide objective benefits. Research on spinal manipulation is inherently difficult, because double blind studies are impossible and even single blind studies are problematic; a placebo response is hard to rule out.

There is good evidence that spinal manipulation therapy (SMT) is effective for some patients with low back pain but that it is not superior to other treatments. There is controversial evidence of lesser quality supporting the use of manipulation for neck pain and headaches. SMT is not exclusive to chiropractic: it is also used by physical therapists, doctors of osteopathy, and others. There is no acceptable evidence that chiropractic can improve the many other health problems it claims to benefit, from colic to asthma. There is no evidence to support the practice of adjusting the spines of newborns in the delivery room or providing repeated lifelong adjustments to maintain health or prevent disease.

Up to half of patients report short-term adverse effects from manipulation, such as increased local or radiating pain; and there is a rare but devastating complication of neck manipulation: it can injure the vertebrobasilar arteries and cause stroke, paralysis, and death. Some chiropractors do not accept the germ theory of disease and only about half of them support immunization. Many of them discourage proven treatments with drugs and surgery and many want to take on the role of primary health care provider.

In their book Trick or Treatment, Simon Singh and Edzard Ernst reviewed the evidence for chiropractic and concluded: “Chiropractors… might compete with physiotherapists in terms of treating some back problems, but all their other claims are beyond belief and can carry a range of significant risks.”

Index of SBM Posts

 

Outside Resources

Summary of Key Research

Ernst E, Carter PH. A systematic review of systematic reviews of spinal manipulation. J R Soc Med 99:192,196, 2006.  

Summary: A systematic review of systematic reviews published between 2000 and 2005, based on 16 studies that met the criteria. “Overall, the demonstrable benefit of SM seems to be minimal in the case of acute or chronic back pain; controversial in the case of headache; or absent for all other indications… we have found no convincing evidence from systematic reviews to suggest that SM is a recommendable treatment option for any medical condition.”

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Assendelft WJJ, Morton SC, Yu El, Suttorp MJ. Spinal manipulative therapy for low-back pain. Cochrane review 2004. 

Summary: A systematic review of 39 trials found that spinal manipulation was more effective in reducing pain and improving the ability to perform everyday activities than sham therapy and therapies already known to be unhelpful. It was no more or less effective than medication for pain, physical therapy, exercises, back school, or the care given by a general practitioner.

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Gross A, Hoving JL, Haines T, Goldsmith CH, Kay TM, Aker P, Bronfort G. Manipulation and mobilization for mechanical neck disorders. Cochrane Review, 2004. 

Summary: A systematic review of 33 trials showed that multimodal care with mobilization and manipulation combined with exercise was superior to no treatment, that manipulation was not superior to mobilization, and that manipulation and mobilization alone were not superior to placebo, control groups and other treatments. 

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Gouveia LO, Castanho P, Ferreira JJ. Safety of chiropractic interventions: a systematic review. Spine 34(11) E405-13. 2009.

Summary:  A systematic review of 46 studies found that 33-60% of patients receiving spinal manipulation treatment report short-term adverse effects such as increased pain, radiation of pain, headaches, vertigo and even loss of consciousness. It acknowledged that serious complications occur but was unable to reliably estimate their incidence. This study was discussed at http://www.sciencebasedmedicine.org/?p=509 

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Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ. Risk of vertebrobasilar stroke and chiropractic care: Results of a population-based case-control and case-crossover study. Spine 33(4suppl):S176.83. 2008. 

Summary:  Patients with vertebrobasilar strokes were not more likely to have recently seen a chiropractor than to have seen a primary care provider. The authors interpret this to mean that patients were seeking care for symptoms of stroke. That interpretation is not supported by the data. For an extensive critique of this study, see  http://www.sciencebasedmedicine.org/?p=170 

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Rothwell, DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: A Population-based case-control study. Stroke 32:1054, 2001. 

Summary: Patients with a vertebrobasilar artery stroke who were under the age of 45 were 5 times as likely as controls to have visited a chiropractor during the week preceding their stroke.

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Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educationsl booklet for the treatment of patients with low back pain. NEJM, 339:Vol 15:1021-1029, 1998.

Summary: “For patients with low back pain, the McKenzie method of physical therapy and chiropractic manipulation had similar effects and costs, and patients receiving these treatments had only marginally better outcomes than those receiving the minimal intervention of an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question.”

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