Chiropractic: The More We Look, the Less We Find

Edzard Ernst recently commented on two Cochrane reviews involving chiropractic, which drew my attention to these reviews. I have to admit finding the results a little surprising.

In general, the total body of evidence fails to support most of the claims chiropractors make about the nature of illness and the beneficial effects of chiropractic. However, there has been some decent research evidence to support chiropractic as a treatment for uncomplicated lower back pain, no more nor less effective than conventional treatment. Despite the theoretical problems with chiropractic, and all the associated nonsense (colon cleansing, cold laser therapy, supplements, and so on), I’ve always accepted that at least there is some legitimate role for chiropractic treatment in the management of back pain.

However, the Cochrane reviews that Dr. Ernst reports cast some doubt on even this claim. The updated review of spinal manipulative therapy finds good quality evidence only for ” a small, statistically significant but not clinically relevant, short-term effect on pain relief.” The reviewers could not determine whether this effect is any greater than placebo because only poor quality studies with a high risk of bias investigated this question.

Chiropractors, or at least “mixers,” often claim that they do more than just manipulate the spine. A new review looked at research for this combined chiropractic interventions for low back pain. The conclusions:

while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low-back pain, there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain. Any demonstrated differences were small and were only seen in studies with a high risk of bias.

So the best we can say is that spinal manipulation alone has a small, short-term impact on back pain, probably not enough to matter to patients and certainly no better than conventional therapy. Combined or “holistic” chiropractic care does no better. So the research evidence, after more than a hundred years of study since chiropractic was invented, clearly shows no benefit for any problem other than uncomplicated lower back pain. And even for this indication, the benefit is small, possibly no greater than placebo and certainly no greater than conventional therapy. So is this benefit worth being exposed to the rampant pseudoscience promulgated by so many chiropractors, the aggressive marketing of “preventative” chiropractic treatment, and all the other nonsense that so often accompanies most chiropractic treatment?

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26 Responses to Chiropractic: The More We Look, the Less We Find

  1. Rita says:

    Chiropractic is often touted for animals, as well – including horses. I have heard it said that, in fact, no human has the strength to manipulate horse vertebrae – I’d be interested to know if this is the case. It’s got to be true that quadruped back manipulation will be very different from biped- no chance of Cochrane updating on veterinary choiropractic, I suppose?

  2. Rita says:

    oh “choiropractic” – the singing chiroprator, perhaps? 🙂

  3. art malernee dvm says:

    I have heard it said that, in fact, no human has the strength to manipulate horse vertebrae – I’d be interested to know if this is the case. >>>> Rita, havent you heard it said “when you are a stainless steel hammer everything looks like a horse subluxation”?
    art malernee dvm
    fla lic 1820

  4. Rita says:

    good one! (this would have been my comment – but the machine asked for more!)

  5. skeptvet says:

    There has been a study on horse cadavers looking at the forces needed to move vertebral joints, and my recollection is that it showed manipulation by hand could not possible “adjust” a horse’s vertebrae. I’m still looking for the study, so I’ll post it when I find it.

    I know a lot of chiropractors working on horses use devices of various kinds to bang on their backs, which supposedly generated the needed force. As usual, I don’t think there is any clinical research to validate their use.

  6. Rita says:

    “I’m still looking for the study, so I’ll post it when I find it”.
    That would be most interesting: I hope it’s not a lot of trouble. I think the various equestrian “sports” teams use some of these techniques; it would be handy to know which ones use which and how they consider the “results”……

  7. Jana Rade says:

    You know, you can knock these things all you want. Chiropractic adjustment worked for Jasmine a number of times and I know people for whom it was a life-saver. So …

    Clearly such things depend on what condition is being treated, but there is a time and place for them.

  8. Alison says:

    Rita, there seems to be more than one school of thought for equine chiropractic. Some equine chiropractors I’ve seen in action use very delicate flicks and pokes that barely move the skin, saying that all they need to do is to ‘indicate to the horse’ what needs to be done and the horse does the job with his own muscles, or ‘energy’, or something. Others use the horse’s legs and neck as levers to move the spine and pelvis. One move I saw once involved raising the horse’s hind hoof above the height of its back. Personally I think there is tremendous potential for collateral damage here – however expert the practitioner, the horse can still move at the wrong moment and twist or stretch something beyond its normal range. Doesn’t bear thinking about.

  9. Rita says:

    That’s interesting, Alison: here’s a youtube of a chiropractic session on a horse
    http://www.youtube.com/watch?v=5lizc5yUzTs
    -it’s awfully hard to imagine how this “treatment” could be doing anything; on the other hand, as you say, it has the potential to get out of hand (no pun intended, oh, all right, pun). The spiel is especially interesting, I find.
    BTW, could it have been the late, great James Rooney who said people can’t move horse skeletons about?

  10. Alison says:

    I’ve an elderly veterinary book for horse owners in which Sue Dyson (from the Animal Health Trust in Newmarket (England)) gives it as her opinion that ‘certain methods of palpating the back can relieve muscle spasm and associated pain, thus producing clinical improvement’ but does not believe ‘that any method of manipulation can move vertebrae or move the pelvis relative to the back’.

    Possibly the claimed effects of equine chiropractic result from the massage part of the treatment. Haven’t seen any formal studies but it is plausible that for horses who enjoy it and respond by relaxing (and not all do, by any means), massage might help to reduce the perception of pain, as seems to be the case in people.

  11. John Franklin says:

    I’ve found basic chiropractic to be useful a couple of times in my life. This is anecdotal so not real proof. I certainly don’t buy into any of colon stuff or cold laser. I came out of school with a nagging back and shoulder from playing football. I was introduced to a chiropractor who pushed his services. He took xrays and showed how I had developed tweaked posture that he said caused the back pain and overall instability. It appeared to make sense. I went to him for several months and he did put my back into alignment. My shoulders were re-leveled and the pain gone. I discontinued going and had no problems going forward. Now, 20 years later, I wrenched my back working in the yard. I was in severe pain for several weeks and ongoing spot pain for several months. I don’t go to the doctors much and just assumed it would go away, eventually. Finally, I went to a chiropractor in the area. One (painful) “crack” or manipulation of the spine was all it took to remove the shooting pain I had been dealing with for months. I find it hard to believe it was placebo. Personally I think there is some benefit to simple manipulation for alignment issues.

  12. skeptvet says:

    Such anecdotes are certainly convincing, especially for the individual who experiences a benefit. The problem is that there are just as many for things that can be clearly proven never to work when compared witha placebo, so while they could be correct they could just as easily be incorrect, and there’s no real way to know without scientific studies. There’s no problem following the course such anecdotes suggest when there is a need to intervene and no better quality evidence to guide us, but as difficult as it is, when there is better evidence that contradiicts our experiences, history shows pretty clearly we’re better off if we follow the evidence rather than our feelings.

    As far as chiropractic, as I said in the post, I have generally accepted the evidence that it has some benefit for back pain, but as the studies get bigger and better, this seems to be less clear. I consider the question still open from an evidenced-based point of view, though of course no matter what the evidence says people will continue to disagree about it! 🙂

  13. Chiropractors should specialize in helping restore a person to health through the use of two
    services: vitalistic chiropractic care and Nutrition Response Testing. Their
    technique should be gentle yet specific through the use of manual, instrument or
    drop-piece adjusting to maintain a clear neurological connection between the
    brain and body to maximize overall health.

  14. skeptvet says:

    Given the overwhelming evidence that chiropractic theory is false and that in practice it does nothing for anything except back pain and only a little for that, this is a literally meaningless statement.

  15. Sarah says:

    I’ve been using chiropractic treatment on my dogs for a number of years, and have seen about 3 different practitioners. One I didn’t like much. The other 2 have both been beneficial to the dogs, and their findings have been similar. Since these are dogs, the placebo effect doesn’t really apply.

    The first dog I used chiro on was moving oddly in the knees at 5 yrs. Rimadyl suppressed it, but it came back when not using the painkillers. He had 3 or 4 adjustments, 2 weeks apart, after which he moved normally and was able to continue competition in agility & obedience. I did X-rays on him to check before getting back to competition, and he did have quite a bit of arthritis in his lower spine. He competed from 5-10 years of age like that, with adjustments every couple months, and no other treatment. A radiologist looking at X-rays I had done when the dog was 10 said that if surgery was being considered, an MRI should be done first. The dog was still actively competing. I retired him shortly after and he lived to one month shy of 14. He started dragging his feet a bit in the last couple months, so I tried starting him on Rimadyl, which unfortunately probably hastened his demise, his kidneys ultimately failed. (his bloodwork was iffy, I decided to take the risk for his comfort.)

    My 9 & 5-yr-old bitches have both had periodic adjustments since puppyhood. Usually when they start moving oddly, or popping out of weave poles on the agility course. An adjustment usually resolves the issue. The 9-yr-old recently had X-rays done for an unrelated issue, and her spine is in perfect condition.

    Actually, an even better example of chiro working on her was a few years ago, I came home, she’d been moving furniture, and was severely lame on a front leg. Off to the vet; X-rays (nothing), Rimadyl, and I scratched her from that weekend’s agility trial. Rimadyl gone, the dog lame again, I went to the chiro. He watched the dog move, said “It’s her neck”, and adjusted it. I left with a no longer lame dog, who was able to compete in the next agility trial, and has never been lame since.

    As long as the chiropractic treatments keep my dogs sound and happy, I don’t really care what a study says, I can see for myself that it’s working. I don’t expect it to treat conditions other than musculoskeletal, and the chiropractors I use don’t suggest it for anything else. The primary one I use right now is also a DVM.

  16. skeptvet says:

    Stories like these are compelling, but ufortunately they don’t reallly represent the truth reliably. I’ve written before about all the reasons things seem to respond to a treatment which is actually ineffective, and about the much misunderstood placebo effect and in humans. And others have written very well about how easily we can be fooled into thinking an intervention like chiropractic is working when its not. The reality is thatt science has improved our lives and health more in a couple of centuries than we managed to do in all the thousands of years before it because it accounts for how easily misled we are by what seems obvious.

    Of course, this fact, clear as it is, rarely changes anyone’s mind because beliefs in therapies like this are as much or more a matter of faith as fact, and faith is by definition a commitment to a belief regardless of evidence. But stories like these can be, and have been, told to “prove” the effectiveness of faith healing, bloodletting, animal sacrifice, UFO abduction, and almost any other claim anyone can make. So either everything someone has “seen with their own eyes” is equally likley to be true, or we can’t always believe what we see.

  17. speakmatt says:

    Bravo again. I really get tired of hearing people complain about western medicine and praising this “holistic/chiropractic” crap, recommending people stop taking medications and stop vaccinating kids, etc. It boggles my mind. Humans are living longer and healthier than we have at any other time in history and many diseases that had at one time wiped through humanity have been all but eradicated…thanks mostly to western medicine.

  18. skeptvet says:

    Thanks! It is frustrating and perplexing how most people view conventional medicine and the alternatives in ways inconsistent with reality. Hopefully, the information I provide here may help just a tiny bit.

  19. skeptvet says:

    Posted by SkeptVet on behalf of a reader who couldn’t get the post past the spam filter:

    I found this blog and its arguments after beginning a Google search with ‘why isn’t chiropract…’ and then accepting one of Goggle’s prefilled search suggestions that closely matched my query. I finished up with ‘why isn’t chiropractic taken seriously?’

    Who am I to comment? I am English (for reference). I am a clear, scientific thinker. My evidence for this claim is that I was by a large margin the brightest scientific mind in my school. I am now an engineer in industry and I’m continually astonished by how utterly incapable of clear scientific thought many of my peers with engineering degrees truly are. In light of this I thought back to my school days and realised that the people we in society place on pedestals as scientists and indeed doctors and veterinarians were drawn from a population who’s capability for scientific thought is at best, comparable to my own. I accept that their subsequent training has given them a different knowledge set from the one I’ve acquired and I can only guess at the tiniest fraction of what they know about their chosen specialism. However their capacity to use this knowledge in clear, free original thought is as questionable as that of my peers in engineering and I feel this gives me the right to comment from a scientific viewpoint.

    I was surprised to learn that the chiropractic profession is accused of making sweeping unsubstantiated claims about the efficacy of its practices for a wide variety of illnesses. I had thought that chiropractic was entirely about the treatment of spinal problems. I went to a chiropractor about 8 years ago as my preferred treatment for back pain. Certainly the chiropractor I went to was proud of his extensive knowledge of the spine and the correction of problems associated with it. Indeed, he gave me the impression that his entire training was based on the spine. It is also true that the chiropractor I’m about to see because my back problem has returned, makes his major claims based on the relief of back pain and realignment of the spine. There are other claims on the web site which include neck pain, sciatica, headaches, numbness or tingling in the arms or legs, joint pain and muscle pain. Certainly, and entirely based on accepted principles upheld by mainstream medical practitioners, all these can indeed be caused by spinal problems and therefore relieved by their correction. The web site states that this list is the named few and in this we may suggest that there might be some unsubstantiated claim to further benefits but since they aren’t listed it would be difficult to take a strong accusatory stance against this claim.

    The reason I originally went to a chiropractor for my back problem was that I had met or heard of many people who’d spent years on painkillers and undergone painful manipulations at the hands of mainstream physiotherapists but who continued to suffer from uncorrected back problems for years. I’d also heard anecdotes of people who’d been ‘cured’ by chiropractic. This was my experience. I make no claims on the scientific value of a sample of 1, but my back problem was fixed by the chiropractor in just a few treatments and I’ve been entirely pain free for many years until the last couple of weeks. I’m confident that I will be fixed again and won’t have to take painkillers and suffer forever like the unfortunate people who aren’t given the option of this ‘cure’ by the proponents of mainstream medicine.

    At this point I want to think about the holistic side of the chiropractic approach and consider the less direct claims that some chiropractors may have made. It is certain that when the body has to deal with pain, whether as a direct result of the stress of continual pain, or as a less direct function of the muscular effort continually required to carry the body in ways that avoid the worst of the pain, it causes stresses on the system which inevitably affect it in other ways. Certainly people having to deal with continual pain are generally fatigued by it on a daily basis. It also seems likely that the continual long term throughput of painkillers is going to have a detrimental effect on the system. We are constantly reminded of the long term effects of alcohol on the system. It is clear that in the short term the liver and kidneys can metabolize and extract the alcohol and its by-products without apparent immediate damage. We do know though that in the long term this is damaging. If we think about paracetamol we know that only a small overdose can cause irreparable and fatal liver damage. I am sure paracetamol is safe to use and I do so on a regular basis but I would be concerned about taking it daily for long periods. However, despite all the medical trials in the world the sample size for the study of the long term effects of alcohol is many orders of magnitude greater. I therefore wonder if the ‘safe’ drinking limits would be the same if the sample size was many orders of magnitude smaller. Would it be large enough to show the long term detrimental effects that we know exist in the much larger study group. Perhaps someone with access to the appropriate data could enlighten us. I am therefore suggesting that it is likely that there should be some holistic benefit from the drug free pain relief provided by chiropractic treatment. However, this would only be realized in cases where the patient has pain for which the treatment is effective and would conversely be of no benefit to other patients.

    There are many references on the internet both from outside and within the mainstream medical community accepting the benefits of chiropractic in the treatment of musculoskeletal problems rooted in the spine. In fact there seems to be little debate against the efficacy of this element of chiropractic treatment. It therefore seems to me that we are in danger of throwing out the baby with the bathwater. Clearly some in the medical mainstream are seizing upon the less firmly grounded claims of chiropractors in order to dismiss the entire practice as quackery. At the same time there are those on the other side who make their arguments with such ineptitude and fake scientific rhetoric that it is no wonder that they aren’t taken seriously. This seems to me to be a shame. If the medical mainstream were supplying chiropractors with a steady stream of patients requiring effective treatment for the ailments they are best able to treat then perhaps they would have less need to boost their coffers by trying to attract patients by making more tenuous claims.

    Richard Smith

    Leyland Trucks Ltd, Croston Road, Leyland, Lancashire; PR26 6LZ

    Tel: 01772 642736

    Fax: 01772 625770

    Email: A-Richard.Smith@leyland-trucks.co.uk

  20. skeptvet says:

    There are a number of misconceptions in your comment. While there is reasonable evidence that chiropractic has benefit, as measured by subjective assessment, for lower back pain, this effect is no greater than that provided by conventional therapy, and there is no good evidence to support any other benefit. And contrary to your assertion, even this limited benefit is not a validation of the theoretical principles the majority of chirpractors believe in, such as the “subluxation.” This concept is a complete myth.

    While a small number of chiropractors are trying to transform their profession into a legitimate elemnt of the physical therapy field, the vast majority still bellieve in the subluxation and make completely invalid claims about the potential uses of chiropractic for a wide variety of medical problems. this is not a problem with critics of chiropractic, it is a problem with the chiropractic profession. And while critics generally accept the limited benefits that decades of extensive research have validated, there is much more bathwater than baby. And the bathwater is sometimes quite dangerous, especiallly when chiropractors argue against vaccination, manipulate the neck, treat small children, prescribe herbs and colonics, and so on. None of the regulator or professional bodies in the profession have attempted to stop these things, so the argument that there is a tiny kernal of real benefit amidst the other stuff isn’t a very compelling argument for the overall benefit of chiropractic to society.

    As for the digression ont he dangers of chronic alcohol use, I’m not sure what the point is. If you’re trying to say that medications have side effects, that is ovious. However, the idea that chiropractic is a useful alternative that in the long run is safer isn’t supported by the evidence.

  21. megan Smith says:

    I have at times been helped by chiropractic but I would really watch out for any chiropractor who wants you to come in 3x a week for the rest of your life. My judge of a “good” chiropractor is that the longer you see them, the less often they tell you to come in. I stopped going because the chiropractor I was seeing because he repeatedly tried to dictate how often I came in. It go so bad that he told me that if I went more than a month w/o coming in that he would insist I go through the “new patient” procedure which involved an hour long session with a $95 price tag. So basically he was going to punish me financially unless I came in 2x a week as he deemed essential. Also he repeatedly told me, rather forcefully, to go off my medications being prescribed by an MD because all medications are evil. I must admit I got annoyed enough that part of me wanted to go off them and then sue him when I crashed and burned. I can’t believe he would open himself up to potential legal liability by giving me medical advice he was not qualified to give. (I am assuming everyone reading this knows that unless they also have a medical degree, chiropractors are not licensed to prescribe medication.)

  22. Jim McKiernan says:

    Interesting yet sick people, people in pain continue to seek chiropractic as an alternative source of relief. Why is it because they are stupid? these are not animals, they have the ability to choose the care they desire. Maybe they are interested in results compared to the possibility of addictive medicine or a surgery that most likely will be problem in their future. There is pseudo science in both fields and each form of healing is a form of promotion, look at the drug companies. Any person is free to try chiropractic without having to put up with the kind of degradation offered here. There is plenty of imbalance in medical health care and plenty of good. The same can be said for chiropractic.

  23. skeptvet says:

    Or maybe people are imperfect and susceptible to placebo effects and other errors that make them believe the treatment is working when it isn’t? No, that would be inconceivable.

    “Degradation?” Seriously?! So as a believer in chiro you are free to say whatever you like, but if someone is critical of it they are “degrading” you? Ridiculous.

  24. Vasilis Karpouzis says:

    Having done equine dissection I can guarantee you no human hand can manipulate/sublax (or whatever they want to call it) a horse’s spine. Just the supraspinous ligament and longissimus dorsi alone would make that impossible.

  25. Mary Feuer says:

    Coming into this conversation quite late, I’m not going to argue my anecdotal experience with a form of chiropractic that involves no “cracking” of anything called Network Chiropractic. Doubtless anything I say will be dismissed out of hand as the product of gullibility and placebo effect. To that, I pretty much say, “So what?” The placebo effect is a wonderful thing that fares well in pretty much every study, though it rarely tops the substance being tested (not surprising considering who’s paying for the study). It has no side effects other than a sense of well being, and a sense of well being usually equals well being (unless of course you’re about to succumb to carbon monoxide poisoning, in which case a sense of well being is a sign of impending doom). When you say there’s no proof chiropractic helps any more than conventional care, and the conventional care prescribed to me is nothing but Advil and rest, personally, I’m heading to the chiropractor. My kidney doctor neighbor agrees, having seen the effects of chronic Advil use a little too up close in her practice.

    A friend of mine was dog sitting my arthritic old dog once. He was about 13 at the time and I was beginning to think about quality of life issues, feeling it was getting close to goodbye time for us. When I picked him up from my friend’s house, though, he jumped into the car. He was bouncy. This is a dog who had not bounced in years. I took him home, where he raced around like a puppy, wanted to play, wagged his tail like a windshield wiper. I called my friend to ask her what she’d done to my dog and she laughed as she told me he’d been in the room while she’d had a Reiki session. Now, if you think chiropractic is based on unsound theory, try Reiki. It’s basically the laying on of hands. But something had happened, and neither the dog nor I even knew the “healing” had occurred, so there’s no way to pin it on expectation, or placebo, or anything. Did it make me a believer? Not really. But it did make me less determined to shoot things down that work for others.

    The dog I have now gets laser treatments on his spine at the vet. They put little sunglasses on him and a red light goes up and down his back. Seems like mumbo jumbo to me, but this is accepted veterinary medicine. apparently. I don’t know. Whatever works, works. And hooray for placebos! No side effects!

  26. skeptvet says:

    Actually, the problem with placebos is much more real than you appear to believe. A treatment which makes you feel as if your condition is better when it actually isn’t can lead to great harm. One study, for example, found that people taking a fake inhaler during an asthma attack felt they could breathe better much of the time (though not as often as with a real inhaler). however, the objective lung function tests showed the real inhaler actually improved their lung function while the placebo did not. If they had just continued using the placebo, they would have had a false sense of improvement along with unnecessary ongoing lung injury and eventually ended up with much worse lung function down the road.

    There is also a study showing that nearly half of people report their dogs are improved when on placebos. Of course, the dogs don’t have a direct placebo effect themselves, so what is happening here is that the owner thinks the dog is better when really there is no change. This leaves our veterinary patients living with unnecessary pain because their human caregivers have been fooled by a placebo effect. Whether a treatment really works or just looks like it works does actually make a real difference in the well-being of patients, human and non-human.

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