A new study by Edzard Ernst and Andrew Gilbey recently appeared in the New Zealand Medical Journal surveying Internet advertising claims made by individual chiropractors and major chiropractic organizations from Canada, the U.S., New Zealand, and The U.K.
They divided the claims into those for which there is reasonable evidence of some benefit (lower back pain) and those for which no good evidence of efficacy exists (headaches, migraines, colic, asthma, ear infections, neck pain, and whiplash). What is not surprising is that chiropractors, and the professional organizations that represent the profession generally, routinely suggest or outright state that their manipulations can treat conditions which they cannot. 95% of individual chiropractic websites made at least one such claim, and all of the professional associations did as well. 38% of the chiropractors made treatment claims concerning all of the conditions in the survey which chiropractic has not been shown to actually treat.
What is a bit more surprising is that many of the sites and organizations did not promote chiropractic for lower back pain, the one condition for which the evidence of some benefit is decent. Only 28% of the individual sites and 4 out of 9 association web sites specifically mentioned lower back pain. One would think they would be most aggressively advertising their treatments for the diseases for which the best evidence exists that they actually help. But remember, chiropractic is, for the most part, really a faith-based practice founded on the non-existent subluxation and the vitalist “innate intelligence,” not an evidence-based medical specialty. It is true some individual chiropractors are exceptions to this rule and limit themselves to treating musculoskeletal pain. And there are some signs that the profession may be moving to downplay the subluxation mythology. But in general, the practice of chiropractic is still dominated by 19th century spiritualist notions and isn’t much interested in the verdict of science on its efforts.
So how do we explain the apparent de-emphasizing of the most reasonable claims chiropractic could make? I suspect that there is a deliberate effort on the part of the chiropractic profession to avoid getting limited in the public’s mind to treatment of musculoskeletal pain. Chiropractors want to be seen as an alternative choice to conventional medical providers, and they want to be involved in much more than just the treatment of musculoskeletal pain. So despite the lip service they may pay to the concept of evidence-based medicine, in reality they are convinced their treatments work for all sorts of problems regardless of the lack of evidence, and they want to protect and nurture the false impression the public may have that chiropractic is good for more than just back pain.
We have recently published a peer reviewed article reviewing some European and American courses in animal chiropractic for veterinarians and (human) chiropractors jointly. We looked at the BackBone-Academy and International Academy of Veterinary Chiropractic (IAVC), and their mother organisations Healing Oasis and Options for Animals, respectively.
It is in Swedish in the Swedish Veterinary Journal (Svensk Veterinärtidning), but with an English summary (provided below). Unfortunately, at present we have no plans of getting it published in English.
The first author is a vet, the 2nd an MD.
Ekström Kjellin, Ragnvi, and Olle Kjellin, Är djurkiropraktik lege artis för veterinärer. Svensk Veterinärtidning 2010(6):19-24
Summary
Is animal chiropractic in accordance with best practice for veterinarians?
To get an idea of the contents and scientific level of what is taught at courses in animal chiropractic, the web sites of some training organizations were scrutinized. Also, a course compendium from one of them was analysed. It was found that the scientific quality of the courses is strikingly low, as established facts are mixed with unsubstantiated claims and pseudoscientific ideas. Many methods taught are clearly outside the realm of science and best practice. In conclusion, the value of animal chiropractic to veterinary medicine is strongly questioned.
Thank you very much for pointing out this study. It would be very useful to be able to have an English language version, if that is ever possible.
We have now almost finished an updated version in English of the above-mentioned Swedish article. I wonder if I may ask you (or someone else who reads this) to have a pre-look at it and give us some comments, for contents as well as the language? And suggest which journal to submit it to?
Sorry, for the ddelayed reply. I’ve been traveling.
I’d be happy to look over the article if you like.
Thank you, that´s very kind of you. We are not ready yet but we´ll get back to you in due time.
Sounds like the same old rhetoric to me, pity that none of these “experts” has dual qualifications, in both professions….too much heat and not enough light if you ask me. But people, and now pets, horses, and their owners must be voting with their feet, if these sceptics are so concerned. Perhaps it is time, the “scientists” did some real investigation, and not just rumour mongering. By the way…I like the concept of Innate Intelligence…some internal order, which controls the body, its functions, repair mechanisms..and so. Don’t think it all happens by chance…do you?
Dr. Bridson,
Since chiropractic is, apart from a few solidly science-based exceptions, mostly a faith-based belief system in vitalism and in effects validated only by anecdote and not research evidence, to claim that only people qualified as chiropractors should be taken seriously is like saying only astrologers or psychics should be taken seriously when evaluating those belief systems. It is precisely the point that if something is true, objective, skeptical outsiders should be able to replicate its effects and prove it true just as easily as true believers.
As for people voting with their feet, sceintific reality is not decided on the basis of popular opinion, so this is certainly not an argument in favor of chiropractic. It is, unfortunately, a sad example of how easily people can be misled, intentionally or not.
What would you consider “real investigation” as opposed to “rumour mongering?” Seems to me there is an enormous scientific literature on the subject of chiropractic, and conclusions based on this are hardly “rumours.” This particular study demonstrated in a fairly objective way that what chiropractors claim in their advertisements is not the same as what they can legitimately demonstrate through scientific means to be true. This seems a legitimate ethical problem.
“I like the concept of Innate Intelligence…some internal order, which controls the body, its functions, repair mechanisms..and so. Don’t think it all happens by chance…do you?”
You may like the idea, and it may comfort you, but that is not evidence it is true. This is why chiropractic is, like so many alternative therapies, a form of faith healing rather than scientific medicine. We are all entitled to our metaphysical beleifs and the comfort they provide, but when we use them as the basis for deciding how to treat diseases, we get bloodletting, excorcism, and all manner of ineffective or dangerous nonsense. I prefer to base the therapies I provide for my patients on science rather than metaphysical, mystical forces.
mmmmm..funny you should mention ‘bloodletting’ because this was an accepted medical practise, for centuries…and it caused many deaths, and infections…leeches became the prereferred option later, because the ‘side effects’ of treatment, did not prove so hazardous. Other historical dangerous nonsense, in medicine…included the failure to learn about infection control from the midwives, in the 18th century…risky use of xray, for all kinds of diseases in the early 20th century…thalidomide prescribed for morning sickness, and the resultant deformations, in the 60’s and 70’s, not to mention the wholesale removal of tonsils, and adenoids, and other proceedures which are now largely abandoned too.
Do you really know the number of medical treatments which are proven ‘scientifically..and how many drugs that were generally recognised as safe, which are removed from the safe list every single year.??
It makes interesting reading.
You are completely missing the point. Bloodletting was justified for all that time by the same poor epistemology, namely tradition, anecdote, and personal experience, as is currently used to justify alternative medicine. It was only recognized as ineffective when more reliable standards of evidence were adopted. Likewise, all the harmful practices you cite were recognized as harmful and abandoned because people examined their effects scientifically. In contrast, alternative medical practices are claimed to be safe and effective because they are traditional or because people have used them and have the impression they work. Proponents if these approaches refuse to abandon then no matter how much scientific evidence accumulates against them.
So you have scientific medicine, which is imperfect but does alter it’s practices in light of new evidence, and you have alternative medicine which view opinion and the longevity of a practice as sufficient reason to continue that practice regardless if how demonstrably unsafe and ineffective it may be (just think glucosAmine, ear candling, energy medicine, faith healing, homeopathy, and many many others). So your tu quoque fallacy argument fails.
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It has been said that the purpose of an education is to replace an empty mind with an “open” one…. and until we can grasp this concept, little discovery occurs because we hold tightly to certain beliefs, even “scientific ones” like the flat earth theory, it was good for 5000 yrs, or so. Try to remember how much we all used gravity…before Newton “discovered” it…for example. It may well be that much is yet to be revealed, in science, and to act as though, it cannot be used, or trusted, until fully explained…is a little limiting. Psychiatry, remains unexplained..scientifically, as does the power of the mind in healing… think of grief, and loneliness, fear, and pain….these elements are quite hard to evaluated “scientifically”… so perhaps we can grow in a philosophical sense, more if we cooperate, and learn together, rather than take this hard line …black and white position…
I wonder if you have met and talked to many Chiropractors, and also Vet/Chiropractors..to see what things they may be able to share with you, to increase your understanding, and knowledge. It may lead to the capacity for greater service to the community, which is the real goal of everyone. An open mind, surely is a gateway to learning, understanding, and greater contribution.
Science is a methodology by which we separate fact from fiction. It is not a belief system.
It’s interesting that the author of this blog, who apparently thinks that chiropractic shouldn’t be taken seriously, nevertheless works for an animal hospital that features a link to the services of a chiropractor.
I have edited your comment to remove my name and practice since, as I explain in my FAQ, I want the focus of discussion here to be about ideas, not about me.
That said, the general point you make is perfectly legitimate. I work at a large practice (21 vets), and I am not an owner or manager. Some of my colleagues share my skepticism about chiropractic and others do not. I personally explain to interested clients the limitations of the available evidence and my concerns about the underlying theory and the safety of chiropractic, and I do not recommend it for my patients, nor do I supervise chiropractic treatment. Just as I am free to do this, my colleagues are free to educate their clients and recommend those treatments they prefer as they please. There are differences in opinion on many subjects in our profession, and contrary to some of the accusations made against me, I am in no position to dictate that my colleagues practice according to my opinions. All I can do is educate and inform as much as possible, which oviously I am doing here and which I also do on a daily basis in my practice.
I wonder are the posts by Dr David Bridson actually by Doctor of Chiropractic David Bridson? Because, given the topic, I think it would be good to know.
Certainly seems likely given the content of his comments.
Hey Skeptvet,
I truly appreciate your skepticism and that of the entire network of skeptics who are anti anything non-traditional or alternative medicine. When I was studying for my PhD in human biology genetics, about 20 years ago, I too was a skeptic. However, as luck may have it I suffered a significant disc injury while teaching an undergraduate class – I bent to pick up a pencil and couldn’t get up. I was scheduled for a discectomy, which I really didn’t want as I knew the outcomes for discectomies in that era were not great. My mother-in-law who was a “true believer” in Chiropractic tried to convince me to go and see her Chiropractor. I flat refused as everything that I had heard about Chiropractic was not good to say the least but she was very persistent and on the eve of my surgery she convinced me to go with her to watch her get “adjusted” and to just talk with her Chiropractor. Suffice it to say that although I was not convinced I did get an “adjustment” and avoided having the discectomy.
The reason I was passionate and skeptical about studying human biology and specifically genetics is that when I was 18 I was diagnosed with a genetic condition and told that I would be in a wheel chair before I turned 40. So, I wanted answers and because some of my toughest professors were very much “skeptics” I became skeptical about anything which didn’t have solid science supporting it. Of course, this lead to significant frustration for me when it came to Chiropractic because you are absolutely right that there is very little or very low quality evidence to support it for treating anything but low back pain. However, in my own case my “genetic condition” caused aggressive arthritic degeneration of my knees and severe chronic pain (3 arthroscopies and several biopsies concluded nothing), migraines and chronic headaches, sinus allergies, asthma, stomach ulcers, and IBS. I was on 9 different medications for the above conditions when I injured my lower back and all of these conditions spontaneously went into remission following my chiropractic treatment.
Having experienced this phenomenon and not being willing to accept the chiropractors explanation for how this happened is what eventually lead to my going to chiropractic college. I must say that by comparison studying for a masters degree and studying for a chiropractic degree there is a much higher level of emphasis on research in a masters program but quite frankly this makes perfect sense as the same thing is true in medicine, dentistry and veterinary science. There are scientists in each profession and then there are the professionals that go out and practice. Those who go out and practice depend on the scientists to provide them with quality data by which they can make clinical decisions.
Going through Chiropractic college as a skeptic is quite tough and yes you are asked to accept many things at face value without any significant evidence to support it. So much so that as a student I often wondered if I would ever be able to have enough confidence to put my hands on a patient – I knew that I could physically make the actions required for an adjustment but in my mind I would always be questioning the efficacy of the treatment especially if the patient had a condition that I knew there was no quality evidence to support the treatment. I guess you might call it my moral compass – even though I had a personal experience that significantly helped me this doesn’t mean that the same treatment would be effective for another person even if they suffered with a similar set of symptoms. Fortunately for me my very first “real” patient while working as a student intern changed that for me.
My first patient presented with chronic neck pain of 6 months duration that did not respond to other treatments (anti-inflamatories, pain killers, muscle relaxants, as well as physical therapy). She was chaperoned by her boy friend who was a pre-med student at the time and did not reveal much in her personal history as her focus was on the neck pain. She denied any history of significant traumas or car accidents and reported that the pain onset when she started university because of a reading device that she used to zoom in the text on the chalkboard and for text books. She had been legally blind for 4 years. No other health history was revealed although I did full systems review. We did an x-ray of her cervical spine and it revealed a degenerative pattern and sclerotic plaquing of the vertebral arteries that would be consistent with a history of whiplash. On questioning her about this finding she admitted to having been in a car accident 6 years prior but did feel that it related to her condition as she never experienced neck pain following the accident. However, on further consultation about her visual problem she revealed that her vision began to decline 6 months after her car accident and continued to steadily decline until it’s current state. We began a treatment for her neck pain using a very low force adjusting method as it was important to me to avoid any possible complications with the vertebral arteries. She responded extremely well. Not only did her neck pain improve but several health conditions that she didn’t previously report improved quite dramatically in her first month of treatment. Specifically dysmenorrhea (which she was on disability for as she required 200mg of morphine daily during her menses), chronic urinary tract infections, chronic yeast infections, IBS, and yes her vision improved too. On six month follow up all of her conditions continued to be in spontaneous remission and her vision had improved from 20:2000 when we initially examined her to 20:50 without corrective lenses and 20:20 with corrective lenses. Yes, her case was extremely well documented, as my supervising clinician took special interest in her case, but what I find my interesting about her case was that I didn’t even know about the majority of the health conditions that she had and I definitely was not applying a treatment for her loss of vision. The treatment I applied was designed to help her with the neck pain and although the evidence for chiropractic and neck pain is rather thin there is still enough to suggest that it can be beneficial. So, I felt OK in treating her for neck pain but the result was that the treatment for neck pain caused a spontaneous remission of several other apparently unrelated health conditions.
The scientist in me was more frustrated than ever. If chiropractic can help these conditions why is their no quality evidence/studies to show that it is effective for these conditions? Well the scientist in me continues to win in my practice because I don’t ever what to give someone false expectations of what I do. I know the conditions that I can treat based on quality evidence and what types of results I can provide my patients and for the moment I just let the spontaneous remissions be just that spontaneous remissions.
I have pondered many possibilities including placebo and suggestion, which both may in fact be involved but the regularity with which we see patients going into spontaneous remission from conditions that we are not treating for them tends to make me think there is more to it. So, I have stayed a student of the science of health and continue to expand my knowledge regularly, which brings me to my question for you.
I have very little if any knowledge of veterinary science aside from the possible carry over knowledge from my human studies. However, this last year I had my first chiropractic veterinary experience as one of my patients asked if I would adjust their dog. A chiropractor friend of mine that is passionate about dogs and horses regularly treats them and in fact many competitive horse owners pay to have her attend races with them and treat their horses. So, when my patient asked me to adjust their dog I first gave my friend a call in hopes that she could give me some guidance. She said, “Don’t try to be a veterinarian just be a chiropractor. Watch the dog walk and see where his spine isn’t moving and adjust it, then just see what happens. Remember how many humans fail to tell you exactly what is going on with their health and you can still help them – it is just the same with dogs.” I can promise you that what she thought was a pep talk did nothing for my confidence. I was hoping she could get me some anatomy info or something (I did find plenty of that on Google) but it was the last thing she said that really convinced me to try to adjust this dog. She said, “I have never worked on a dog that didn’t respond within a couple treatments and the vast majority of the time it only took one treatment to see marked improvement.”
So, I explained to my patient that I have absolutely no experience working with dogs and no traditional training about how to work on dogs but that I would be willing to try to adapt my knowledge of working on humans to try to help her dog. My patient responded that her veterinarian has suggested putting the dog down as he doesn’t think that he will ever recover from the injury so at this point there is really nothing to lose. Her dog is a 12yo German Mastif and absolutely massive. She has 3 other large dogs and says that they all play pretty rough in the garden. Six months ago she reported that the Mastif in the morning was very playful but after being outside to play with the other dogs he returned with his head down and limping off of the right front leg. His temperament changed from playful and loving to growling and angry. She took him to the vet and they tried anti-inflammatories for several weeks with no improvement. Then they tried cortico-steroids and again no improvement. After six months of continual treatment there had been no improvement in his condition and he was now starting to refuse eating, which is the reason the vet has suggested putting him out of his pain. When she brought her dog to my office he had no interest in seeing me – in fact he immediately began to growl at me. I asked her to walk across my office leading the dog so that I could watch him walk. I noticed three areas in his spine that did not appear to be moving harmoniously with the other areas of the spine. Specifically at the very base of the spine (near what would be L4-L5 in a human) in the transition between the lumbar spine and dorsal spine (near T12-L1 in a human) and just above the front shoulders at the base of the neck (near C5-C6 in a human). I palpated each of these areas and on palpation it elicited an angry bark from the lower regions and he snapped at me on palpating the neck. I asked the owner to muzzle the dog for my protection and then proceeded to use a hand held adjusting instrument to apply forces to the mentioned areas. Following the treatment I asked my patient to lead her dog around the office so that I could watch the dog walk again and to my amazement the dogs head came up and it’s tail began to wag. He walked with much greater symmetry and then proceeded to smother me in saliva. She brought her dog back the following week for a follow up and no more than the elevator door opened than the dog ran down the hallway and straight up to jump and my a lick my face. I was a bit overwhelmed but I appreciated his gratitude. My patient reported that immediately after the first treatment that her dogs behavior returned to normal and he was back out in the garden playing with his friends and eating as normal. This week she brought me another thank you note as it has now been a year since I adjusted her dog and he is still going great with no relapses.
So, my question is, “How could you possibly design a study for this?”
20 years ago when I began studying chiropractic critically I kept asking, “where are the studies? where is the evidence?” Now having practiced chiropractic for 15 years I am asking, “how do you design a study for this?” I am very familiar with the scientific method and study design as it was a huge part of my masters degree and my PhD and where it comes to treating specific health conditions I don’t think that any of the design models will ever work to demonstrate chiropractic effectiveness and the reason why is actually quite simple.
In my clinical experience the vast majority of health concerns where a patient experiences a spontaneous remission following chiropractic care had you attempted to apply a treatment specifically for that health condition they most likely would not have experienced the spontaneous remission. Why? Because the area of the spine which is causing the specific health concern is functioning normally but is in a pattern of compensation for another area of the spine where a problem actually exists. For example, I have had many patients that suffer from headaches, which is classically thought to come from a problem in the upper cervical spine but on assessing them the upper cervical spine appeared to be able to move as expected but another area of the spine was not moving as expected. Upon treating the area of the spine that was not moving as expected and resolving the movement issue the headaches also resolve. Likewise I have had many patients with chronic low back pain that the lower back appears to be functioning as expected but another area of the spine is not. On addressing the area with abnormal movement the lower back pain improves or resolves. Similarly, with many other health conditions: allergies, asthma, digestive problems, musclo-skeletal problems, and other organic health concerns. That is not to say that all health concerns are caused by abnormal movement patterns in the spine but I would suggest that abnormal movement patterns in the spine are abnormal and can lead to other health concerns with or without spinal related pains.
That being said there are many studies that demonstrate how posture can affect ones health as well as studies that show how abnormal movement in the spine can negatively affect ones posture. There are also plenty of studies that show how chiropractic can help to improve posture.
My personal opinion is that chiropractic should avoid trying to prove that they can treat specific health conditions such as asthma and allergies etc. and focus on what we can easily demonstrate, which is our ability to identify abnormal movement and/or positions of the spine and and our ability to correct these. Then simply list the “side affects” of such treatment via the various spontaneous remissions that occur during the studies related to postural correction and use a similar dialog as various medications use: Side affects may include….
Of course it is also important to remember that what chiropractors do as a treatment is much more similar to a surgeon as compared to a medical doctor because we are not utilizing a “pill” which can be exactly duplicated by every other chiropractor. With surgeons there is always the element of surgical skill and experience that can determine outcomes and the same thing is true with chiropractors. Would you like to have spinal surgery done by a surgeon fresh out of medical school or would you prefer to have the surgeon that has successfully performed hundreds of surgeries? Because it is impossible to remove the practitioner from the equation it is virtually impossible to perform clinically controlled double blinded randomized studies on surgical procedures in much the same way that it is impossible to do the same for chiropractic treatment.
However, if you can think of a better study design that will improve our knowledge on what chiropractic is good for and what it is not good for I am open to listening to your ideas.
So we must forever rely on anecdote and uncontrolled personal observation? That is a cop-out. If it cannot be studied scientifically, it has to be taken on faith. The historical track record of medical therapies taken on faith is pretty terrible, so it doesn’t seem in the interests of patients to go back to that way of thinking.
Except you can’t demonstrate this. A century of effort has failed to find any objective or repeatable measure of the vertebral subluxation complex. When different chiros exam a single patient, or when one examines the same patient repeatedly in controlled studies, they cannot consistently identify a lesion. And they cannot demonstrate in any objective way such a lesion exists. And the enormous clinical trial literature shows only modest benefit for idiopathic back pain. So again, the science can and has been done, and the results are inconsistent with your personal experience. So you have to decide which to trust.
Ultimately, your conversion experience has created a faith in chiropractic that no longer requires scientific evidence to support your belief. Understandable and your right, of course, but this is not a compelling argument for anyone else. Thousands of people will tell you the same story only substituting some other miraculous intervention for chiropractic, from Lourdes water to homeopathy to Reiki. All of them did something, felt better, and credit the intervention with the cure, thus no longer requiring any other evidence. Either everything is true, or such experiences cannot be relied on to tell true from false.
Some very interesting arguments in the comments. Hopefully soon we’ll have a way of measuring whether chiropractic helps!
Don’t we already? Clinical trials in chiropractic have, like any other clinical trial, specific measures for outcome. Some of these are dubious or subjective, but others can be quite rigorous. There’s nothing about chrio that makes it especially hard to study (unlike, for example, acupuncture).
Thanks for this, Skeptvet. I like the title. Was the aforementioned article ever released in English?
It never appeared in journal form but did get printed as a guest post on the Science-Based Medicine Blog.
thought for sure a vet was going to author this one.https://sciencebasedmedicine.org/science-based-satire-more-chiropractors-are-using-subluxation-sniffing-dogs/?utm_source=rss&utm_medium=rss&utm_campaign=science-based-satire-more-chiropractors-are-using-subluxation-sniffing-dogs&fbclid=IwAR1OXRFnmipMB1GKuZSMcOXnAB4HcwbvRbJFXQTc-E-VJaxFfwPSYOkG-3U