Few health professionals divide people quite like chiropractors. You might think they are either quacks, or geniuses, and have evidence that you think supports your opinion. But what do you know about the education of chiropractors?
How good is the knowledge of graduate chiropractors? Are their beliefs based on evidence? And what are some of the misconceptions that chiropractic students and graduates possess?
We’ll start with some background.
Because their treatment is not without harm. A recent death at the hands of a chiropractor made news around the world, but it’s not an isolated incident. High speed manipulation of the cervical spine can result in, at worst, a coronary artery dissection, and stroke. Estimates of how likely this is vary from once in every 100 000 to two million adjustments, as these events don’t always occur immediately after the treatment. They result in death in 18% of cases.
Very few medical treatments are totally without risk, so this doesn’t mean we need to avoid this treatment completely. As an example, physiotherapists in New Zealand have a comprehensive code of practice that details the screening to be conducted before this treatment is used. So they make a calculated decision, assessing the risk against the benefit of the treatments. If the benefit is small, or no better than a placebo, then the risk we will accept is far less.
Origins of chiropractic education
Chiropractic has dubious origins. Daniel Palmer, a beekeeper and grocer who practiced various forms of alternative medicine on the side, is credited with creating the practice. He borrowed heavily from osteopathy (which has been developed about a decade earlier), and at one point considered establishing the practice as part of a religion.
Palmer made most of his money from chiropractic schools rather than treating patients, and many of these schools were considered diploma mills.
We’re not off to a great start, are we?
What did early chiropractors believe?
The origins of chiropractic thought come from a tradition called “vitalism”. This is the idea that living beings have a life force that makes them distinct from inanimate objects. We’ve never been able to show this exists, but it’s a common idea in alternative medicine.
Palmer proposed that misalignments in the spine disrupted the flow of this life force, and interfered with the body’s natural healing mechanisms. In chiropractic these are called “subluxations”.
Confusingly, in evidence-based practice subluxations are a dislocation of a joint, and are usually very obvious. But chiropractic subluxations have not been reliably demonstrated. They are usually assumed to be present because of the symptoms reported by the patient.
So to summarize, chiropractors used to believe in a mystical life force that allows us to heal ourselves. If we are sick, it must be because our spine is out of alignment, interfering with this life force. But we can’t observe this life force, or these subluxations.
I’m not convinced so far, but surely this is all in the past, right?
The education of chiropractors today
Fast forward to today, and what has changed? For some chiropractors, almost nothing. For others, quite a bit!
There are now two general schools of chiropractic thought. Different degree qualifications will align more with one than the other, and this will influence what your chiropractor is taught.
Traditional chiropractic education
Those with a more traditional education will be more convinced that “subluxations” are the major cause of poor health. They are more likely to use x-ray as a diagnostic tool, even though subluxations are not visible on an x-ray. They are also more likely to have negative views about vaccination, and have more positive opinions about the effectiveness of their treatments.
Practitioners educated in this traditional approach may claim they can treat, or manage, a wide range of medical conditions (which we’ll discuss more below). After all, they’re highly confident that their practices are effective.
Modern chiropractic education
One university offers a chiropractic degree where I live, and it appears to have a modern approach. Their description of the role of chiropractors focuses on assessing and treating clients with back pain. They mention the importance of immunisation in protecting patients, evidence-based practice, and scientific reasoning skills.
Some researchers from this school have even done a good job of identifying the beliefs of chiropractic students that are not based on solid evidence.
Practitioners of this modern approach may use a range of treatments more consistent with modern physiotherapy, not just spinal manipulation. They may also be more conservative about what they can claim to treat.
Chiropractors’ scope of practice
So chiropractors (in Australia at least) usually have five years of education, then may practice while claiming to treat a broad range of medical conditions. And they usually use the title of “Doctor”, which is unusual for not having completed a doctoral degree. So it’s understandable that there is some public confusion about the status of chiropractors as health professionals. But despite the title, without a lot of extra training, they do not complete anywhere near the training of a general practitioner, for example.
The scope of practice of chiropractors varies between countries, and even within countries. In the US it varies from state to state, but all include “providing care for musculoskeletal conditions using manipulation as a primary intervention“. And all states exclude the prescription of drugs, and surgery. But there is significant variation from one state to the next on other issues.
But what other treatments or advice they can provide, and what they are qualified to provide, is far murkier…
Even chiropractors can’t agree on their scope of practice
This schism in the industry begins with education (as discussed above). Of students surveyed in the US, 67% intended to sell nutritional supplements, and 46% to sell orthotics. And alarmingly, 80% thought they were qualified to diagnose disease. In another study 50% thought adjustments strengthened the immune system, and 72% thought adjustments “help the body function at 100% of its capacity.” Whatever that means.
It doesn’t end there. An alarming number of qualified, practising chiropractors agree that they can treat asthma (64%), gastrointenstinal complaints (61%), pre-menstrual stress (70%), osteoporosis (43%), hypertension (42%), and infertility (30%). Again, how likely a chiropractor is to hold these beliefs is influenced by where they were educated.
You name it, some chiropractors think they can treat it. Not only do many of these beliefs lack evidence, they are implausible. With a decent knowledge of anatomy and physiology we can’t even come up with a decent, testable hypothesis to test how spinal adjustment could treat these issues.
And what proportion of chiropractors think they should restrict their practice to musculoskeletal issues? Alarmingly, just 6%.
This is staggering. I have never before seen an entire profession just decide to ignore the scope of their qualification. Oh, yes I have: personal trainers!
How did it get to this? Shouldn’t we know better?
You’d like to think that these sort of extravagant claims get ignored, but that’s often not the case. Chiropractors are extremely popular, as far as alternative health practices go.
It may be because people don’t really understand what chiropractic is. I’ll summarize again: a life force (that we can’t measure) keeping us healthy gets blocked by subluxations (that we can’t see) in the spine, and removing these will cure literally all disease. That’s traditional chiropractic thought in a sentence.
Our answer to a claim like this should always be “how do you know?”. If we’re relying on something we can’t see to treat something we can’t measure, we’re talking about something we can’t test. It’s literally impossible to prove that this treatment works.
Burden of proof
If you make a claim you have the burden of providing the proof for this. Would you let anyone else provide medical treatment without any proof that what they were doing was actually effective? If not, why would chiropractors get a pass?
A beautiful analogy for this was provided by Nobel Prize winner Bertrand Russell. It’s called (appropriately) “Russell’s Teapot”:
If I were to suggest that between the Earth and Mars there is a china teapot revolving about the sun in an elliptical orbit, nobody would be able to disprove my assertion provided I were careful to add that the teapot is too small to be revealed even by our most powerful telescopes.
Of course, we shouldn’t accept him at his word. He would need to prove this to us. Just like the medical treatments we consent to need to be founded on strong evidence.
Why do some chiropractors think this way?
Great question, but a difficult one to answer. How does a health professional get to the point where their beliefs are so at odds with the evidence?
The first issue is a lack of general critical thinking skills. Understanding where the burden of proof lies, and how to assess the quality of proof, is important. To the traditional chiropractor there is plenty of proof in the results their clients get – all anecdotal.
Which leads us to the second factor… bias. In any person it’s very hard to know why their pain gets better or worse, or why their symptoms change. Literally dozens of other factors influence our condition. And we usually attribute the change to whatever suits our biases. For chiropractors, that will often be their treatment, rather than the dozens of other factors we could consider.
Finally, we see a poor tolerance of uncertainty in many chiropractors. They aren’t alone here – many people find it hard to put things down to chance, and search for agency where none exists. That’s how conspiracy theories start. And why we tell ourselves that things happen “for a reason”.
This means that treatment can be uncertain, because not everything has a clear cause. In fact, back pain is a classic example of this. And sometimes in medicine a diagnosis is made only because we exclude everything else it could likely be.
This is intensely unsatisfying to some people. And often the more ignorant you are of these possibilities, the simpler the answer seems. It’s been my experience that once you appreciate the complexity of an area of knowledge you realise how hard it is to be definite. And the body is incredibly complex.
Models of healthcare
This lack of tolerance for uncertainty is made worse by the model of healthcare that persists among chiropractors, according to New Zealand physiotherapist Aaron Marshall:
Chiropractic care still lives within the biomedical paradigm. This is where a specific anatomical cause leads to specific symptoms. However, most medical and clinical professionals now appreciate the need for a biopsychosocial approach, where other factors contribute to the presence of pain or a syndrome.
We’ve discussed this before when examining the practices of physiotherapists. If your clinician is not open-minded enough to appreciate the complex, multi-faceted nature of pain, you may not be getting the most effective treatment.
Current chiropractic practice
By this point we’ve hopefully agreed that chiropractors can manage a range of musculoskeletal complaints, but should avoid more general health claims. But many don’t, because they did not learn the basics of scientific thinking in their qualifications.
Some modern chiropractors may not look that different from physiotherapists in their advice around exercise and load management, maybe with some manual therapy thrown in.
But we may see more high speed spinal manipulation, often for the management of back and neck pain. There is little evidence for the use of these manipulations for any other issue, but even with back pain, research is conflicted.
The gold standard of evidence – a Cochrane review – in 2011 found a mild, short-term benefit, that was about as effective as other treatments at the time. A more recent review in the British Medical Journal reached similar conclusions.
Chiropractors are more likely to treat when it’s not needed
For other health professionals, providing unneeded treatment is unethical. After all, some treatments come with a level of risk – and we’ve already identified there’s a risk from spinal manipulation. And all treatments cost money. So if there’s no benefit to the patient, we don’t provide the treatment.
In my professional experience, clients appreciate your honesty if you tell them they don’t need to see you. Or if you direct them to someone who could provide a more useful service. This is part of good professional practice. Clients like that you save them time and money, and may refer their friends to you. And other professionals appreciate the referrals, and may refer other people to you. Everyone wins – clients and practitioners.
Traditional chiropractors have a different approach. If your belief is that spinal manipulation can treat almost any condition, you will think everyone will benefit from seeing you at the slightest ache, pain, or runny nose. And given so many chiropractors see treatment as helping “the body function at 100% of its capacity”, they may see it as kind of like a tune up. Not compulsory, but certainly recommended. For the rest of your life!
So many are prepared to treat you, even if there is no obvious need. Physiotherapist Aaron Marshall thinks that “given the limited financial resources of most people, charging for a treatment that is not needed is something most clinicians should baulk at.”
Public perception of chiropractors
Despite flawed educations, claims that cannot be proven, a lack of scientific thinking, and unnecessary treatment being rife in the profession, chiropractors are generally viewed positively by the public. They also get generally positive discussion on social media.
And students obviously have a positive view of chiropractic treatment before they start studying. So they are exposed to public positive messages, and receive an education that fits their beliefs and values, which they choose because they want to help people. Their profession quickly becomes part of their identity.
And that’s ok, most of the time. But how would you react to evidence that your treatments are no better than a placebo, as we discussed earlier? Do you shrug, and get another job? Or do you double down, and look for weaker, confirming evidence you trust more?
To make change in the profession, maybe we need to change what we accept as members of the public, or part of a community of allied health professionals. If the shortcomings of traditional chiropractic care were better known, their public reputation may be different. And we would expect better from them, like we do from other health professionals.
Why do you hate chiropractors so much?
I don’t. I’ve met some wonderful, caring, friendly chiropractors. I’ve even received chiropractic treatment myself for relief of neck pain caused by a couple of decades of contact sport. But I didn’t notice any significant, lasting improvement.
Like all health professionals, chiropractors mean well, want the best for you, and genuinely want to help. But they need to have an awareness, like every other profession, of what they can do, and what others can do better. And they need to have an awareness of when to change. Aaron Marshall thinks this is confronting for any health professional:
The truth is, the first time you tell a patient that what you were doing is no longer supported by research, it is terrifying. You feel like your reputation is lost and your career over. But really, people appreciate your honesty and your drive to do better for them. While it is hard to let go of your biases, when you do this, and put the patient front and centre in your practice, your effectiveness and reputation will improve.
I’m not criticising people here – I’m criticising their ideas. If your idea about is too precious or fragile to be criticised, it probably isn’t a good idea, especially when our health is at stake.
Chiropractors have a huge disadvantage when misconceptions not only survive, but thrive, in their education. The most damning comment comes from a paper by Innes and colleagues, when they identified just how many unscientific beliefs their own students possessed. Their findings were “at odds with a curriculum which is intended to prepare them to be lifelong learners, and hence capable of delivering evidence-informed care.”
Do better chiropractors.
13/10/2020: we originally wrote that chiropractic degrees in Australia were either four or five years. On further investigation is seems the degree programs in Australia are all three year undergraduate degrees, followed by two year masters degrees.
3/1/2021: a new systematic review (looking at the use of chiropractic treatment in back pain) was brought to our attention, so we’ve updated the article and linked to this review. It was consistent with the previous research we discussed, so our conclusions did not change.
20/2/2021: we originally relied on a high estimate, when talking about how often adverse events occurred after chiropractic adjustments. We’ve adjusted this to represent the full range of estimates