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.
Why chiropractors?
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?
Daniel Palmer, the founder of chiropractic treatment and education
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 spine. Apparently, the source of all disease. Source: OpenStax. https://openstax.org/books/anatomy-and-physiology/pages/7-3-the-vertebral-column
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.
Modern chiropractor’s don’t restrict themselves to spinal manipulation, but may provide specific advice about exercise and movement, and use a range of manual therapies as needed.
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.
Physicians can diagnose, treat, and manage a range of medical conditions. Chiropractors cannot. They have many years of specialist training to enable them to do just that. Chiropractors do not.
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.
Lots of alternative medical practices propose an innate life force of one kind or another. But we’re not aware of any genuine evidence for it yet.
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.
But an update to the Cochrane review identified that manipulations are no better than a placebo. And we even see similar results in chiropractic journals, so accusations of bias are hard to support.
Back pain is complex, and multifactorial. But research shows the benefits of spinal manipulation is limited, at best. Other approaches may be needed.
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.
Summing Up
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.
Updates
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
Your information is grossly inaccurate and skewed and if you wish to belittle a profession I suggest you actually find the truths. Palmer College if Chiropractic is in itself a 4 year degree after a 4 year university pre-requisite study and have you looked at the comparative education between an MD and a DC? A doctor of chiropractic learns much more anatomy, physiology, diagnosis (twice as much) neurology (3 times as much) etc. We do not learn pharmacology because we treat the body naturally and our diagnosis teaching includes the entire body.
Your description is not only untrue but is offensive and shows clear prejudice. if you want to compare professions at least do it honestly. I know of many places where D.C.s and P.T’s work together as a team. I’m shocked at the list of clear blatant false information in this article.
Hi Susan, your point about the comparative volume of learning chiropractors and medical doctors undergo is addressed in my linked sources. And I don’t bring up Palmer College of Chiropractic at all. But if I’ve misinterpreted the evidence I’ve cited, or made any factual errors, please let me know and I can update the article.
You literally are wrong about almost everything. Where is there a 4year degree? DC is a doctorate licsensed by state and national requirements. Dangerous? Millions get adjusted daily and chiros pay about 1000 a year in malpractice. What does an MD pay? Who does insurance think is more dangerous. This was fiction with no basis in reality. I could name a dozen other false hoods. Where did you get your degree? Online?
You do raise one valid criticism here Michael – I state chiropractic is a four-to-five year degree, but it appears that the degree programs in Australia are all 5 year programs, so I’ll make that correction to the article.
Everything else in the article is informed by research. This includes the discussion of risk that you refer to in your comment. I don’t refer to chiropractic treatment as dangerous, but I do make the point that (like in all things) we need to assess risk against benefit. Even when that risk is low.
I’m always looking to make my articles more accurate, so if you identify any other specific errors (with appropriate evidence, of course), I’d be glad to update the article.
This is a paid hack job
Fake News
Lame
Hi David, this hack job did not earn me a cent (unless you clicked on an advertisement). It’s just a hobby.
As I’ve told every other chiropractor who’s been upset by this article, if you can let me know what specific errors I’ve made I can correct them.
It’s alarming that for health professionals, none of the chiropractors that have commented here have shown any desire to engage in analytical thinking.
As a profession you can’t improve if you’re not willing to critically examine your own practices and education.
hi! what i don’t like about chiropractors, it isn’t holistic anymore specially here in philippines. they make you as their cash cows, requiring you to keep coming back and selling packages of sessions. i’ve only encountered 1 german chiro who doesn’t keep you coming back, told me if there’s no pain don’t come back…
Hi Samuel, yes, that’s a complaint I’ve heard many times before. I think generally they believe they are helping that person with those continued visits, particularly when you think about some of the misconceptions we discuss in this article.
Thank you for writing this. I am a DC as well. This is anti Chiropractic propoganda. Must have some connection to a threatened physical therapist, osteopath, orthopedist, or physiatrist. It was clear reading this that he has never really learned about the profession in any depth. I have a license in Massachusetts/US. He is also still in the land of Newtonian physics with regards to the body. Does not know Dr Candace Pert, Dr Bruce Lipton, Dr Lynn Tagert, or Dr Joe Dispenza’s scientifically based books and understanding of health.
Hi Kate, thanks for reading.
You should note that I have also been critical of physical therapists on this site, though I’ve worked closely with many in the past. I’m also highly critical of fitness professionals where needed. After all, if we aren’t critical of our professional practices, how can we improve them? So your accusation of propaganda rings a little hollow. You shouldn’t be threatened by criticism, you should welcome it, and make sure your professional practices are sound enough to stand up to scrutiny.
You have minimal knowledge of our profession
We have staff privileges at many hospitals…ignorance and bias .
Shame you belong about 2o years ago..
If I’ve made any errors in the article, please let me know, I always strive to produce accurate work. But you’ve instead chosen to accuse me of being ignorant, biased, and out of date. What do you think a casual reader would think of a professional that chooses to make these accusations, rather than engage in a discussion of research and evidence?
I totally agree. This article is skewed and grossly misrepresents chiropracty. While I agree that all chiropractors are not of like ability, this is the same in the medical profession or any other profession for that matter. I have certainly been helped by chiropracty for pains in my neck, back and shoulder. This is both a preventitive therapy and one that responds to acute events. Some chiropractors also study nutrition, as some medical doctors have a sub-specialty. Nutrition has been abandoned by the medical profession. This adoption of a competitive stance between medical doctors and chiropractors is stupid. It is no secret that the medical profession has abandoned preventative health and is now acting in general as purveyors of drugs to treat symptoms rather than root causes. When Medicine is treated like a business it views every other form of treatment as a competitor instead of another weapon against ill health and harm is done to the patient as a result. The Hippocratic Oath says “do no harm.” Stop the hypocrisy and practice real medicine. Chiropracty is a useful tool and works within its scope.
Hi Diana, as I offer to anyone criticizing this article, I will gladly update it if you identify any specific errors. But most of your comments aren’t related to the topic of the article, so you’ll excuse me for not making any changes just yet.
You state that “Chiropractors are extremely popular, as far as alternative health practices go.” And then claim that this may be because people don’t understand what chiropractic is. Isn’t this just ignoring the obvious? Do you really think that millions of people are so stupid that they would routinely visit chiropractors and recommend chiropractic to their friends and families if they weren’t getting results? They are getting the results they are looking for. I’ve worked in a chiropractic office and been a chiropractic patient for over 30 years. In that time I’ve avoided seeing any medical doctors, avoided taking harmful drugs and being cut open. And yes, I do believe that keeping the nervous system free of interference allows the body to function at a higher level. That’s what people are looking for, and that is why chiropractic is so extremely popular.
Thanks for commenting Lynn. It’s great that you’ve had a good personal experience with chiropractors, and have been healthy and injury free for such a long time.
But the popularity of a treatment does not indicate that the treatment works. This is an example of an argument from popularity, and there are many others we could make too. Millions of people think 9/11 was an inside job, Barack Obama is a Muslim, or that COVID-19 is a hoax promoted by the New World Order.
Regardless, in this article when commenting on the effectiveness of chiropractic treatment, I’m referring to research to inform my conclusions. This type of evidence is more reliable than personal anecdotes. While this isn’t the focus of the piece, I’ll gladly update this section of the article if more research comes to my attention.
18 % death rate??? What are you talking about? More allopathic fiction. This type of professional discrimination was tried in the US years ago resulting in a victorious landmark lawsuit against virtually every professional medical association in the US. Upheld by the supreme court in 1991. Also review the study done in New Zealand years ago. Patients who get regular Chiropractic care have less strokes than those who are never adjusted. You very long article is profoundly disappointing
I’ve provided references for the figures I cite, but if you have more information feel free to point me in the right direction, and I can update the article accordingly.
This is an extremely biased article for anyone who has knowledge of Chiropractic. I’d say everything was presented in a poor and discrediting way. Chiropractic PHYSICIANS in the US go to school for about 8 years and they receive a Doctorate degree. Also the statistics used to estimate artery dissection rates are completely false.Most reputable sources agree this closer to 1 in every 2 million. Some even higher. In these cases it has not always been clear if to be considered a causation but rather an association. Blaming a Chiropractor for a patient with stroke 2 weeks after his visit is just unfair. There are too many factors to really pin down the source of his stroke. Also it is believed that some people may have genetic predisposition on the lining of their vessels. There is so much wrong with this article I could go on and on. Almost every point is wrong or twisted truth at best.
Chiropractic is safe. Chiropractic malpractice insurance is a fraction of that of a general medical practitioner. The insurance companies know the statistics so they charge very little in comparison.
There are multiple forms of Doctors. There are Doctors of Dentistry, Veterinarians, Doctors of Medicine and even Doctors of Chiropractic. When I visit my dentist, I call him Doctor. This is a simple concept, I’m not sure why some people refuse to get it. When I visit my Chiropractor, I call him Doctor as well. For anyone reading this make sure you get informed from a reputable sources. Maybe look into length of studies and curriculum in a Doctor of Chiropractic school to get an idea.
As a matter of fact Chiropractic students go through more anatomy than general practitioner medical doctors. They do NOT do pharmacology which is why they don’t prescribe you medications.
Hi Omar, thanks for reading. If you have some more up-to-date, evidence-based sources of information to correct any of the statements I’ve made, please let me know and I can update the article.
It’s all in the manner of just going to the curriculum of studies. Go-to Logan College of chiropractic or Canadian Memorial College of Chiropractic websites. Here you will see that the training is at least equal to or greater than medical training, especially when you are looking at the original Hippocratic Oath.
Dennis Pick, D.C.
Hi Dennis, I have linked to a source that compares medical and chiropractic training in the article, if you wanted to read more. It’s not really a focus of this article, so I touch on it only very briefly.
I refer back to my original complaint regarding the education of a chiropractor. However, here is another chiropractic college that reveals the superior training of Chiropractic physicians: Canadian Memorial College of Chiropractic.
After reading the curriculum, I rest my case.
You mentioned that one already Dennis, but again, that’s not really the focus of the article. The point is, despite how good you think the quality of chiropractic education is, significant misconceptions survive this education. We should strive to be better than this in all fields of learning.
Where to even start…your last comment, ” have linked to a source that compares medical and chiropractic training in the article, if you wanted to read more. It’s not really a focus of this article, so I touch on it only very briefly.” Well, the title of your very biased and factually erroneous article is “The education of chiropractors is not all it’s cracked up to be.” So, from the title it seems like that SHOULD be the focus of the article.
I’m not sure why there is a need to constantly compare DCs to MDs but get your facts straight if you insist on doing so. Looking at the education of chiropractors vs medical doctors education in hours:
Anatomy-physiology: DC 540, MD 508
Microbiology: DC 120, MD 114
Diagnosis and derm: DC 630, MD 324
Neurology: DC 320, MD 112
Orthopedics: DC 210, MD 156
(Source: https://www.google.com/url?sa=t&source=web&rct=j&url=https://biology.uni.edu/sites/default/files/chiropractic_education_vs_medical_education.pdf&ved=2ahUKEwieovHE6OvtAhVLuVkKHYqzCC0QFjABegQIHxAF&usg=AOvVaw2f3dRYIhoP60I-eIuDbc7d. OR https://pubmed.ncbi.nlm.nih.gov/9737032/
Moving on to the next topic. You seem to only want to accept double-blind placebo co trolled clinical trials as evidence that something works. Do you know in the medical industry they use something called “off label” prescriptions…? Meaning they are using a medication for something that wasn’t part of the trials for the drug. Do you know they also do exploratory surgery? No double-blind studies on that either.
As surgeon and health care researcher Atul Gawande observes, “Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.”
I will agree that those DCs that continue to follow DD Palmer and his “vitalism” approach may not have much evidence to back their claims but there is plenty of research available that chiropractic is helpful in treating many conditions. In fact, some insurance companies (who don’t really care about the health of their policyholders beyond premium payments) are requiring either a trial of chiropractic or PT before injections or surgery.
Also, let’s look at what evidence-based practice means…it is a conscientious, problem-solving approach to clinical practice that incorporates the best evidence from well-designed studies, patient values and preferences, and a clinician’s expertise in making decisions about a patient’s care. So, the “evidence” that you seek to prove/disprove chiropractic is viable is only one of three aspects of EBP. So, to your previous response to the comment above, “But the popularity of a treatment does not indicate that the treatment works.” except it does in a way as EBP includes clinician expertise and patient values and preferences.
Now, let’s look at some more evidence that chiropractic is effective for treating some conditions:
“Spinal manipulation is an effective option for migraine and cervicogenic headaches.” Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3716373/#:~:text=Spinal%20manipulation%20is%20an%20effective%20option%20for%20migraine%20and%20cervicogenic,inconclusive%20for%20tension-type%20headaches.&text=There%20is%20little%20information%20available,Bronfort%20et%20al%20is%20notable.
Clinical Outcomes
LOW BACK PAIN
• The Agency for Healthcare Research and Quality reviewed the current evidence on nonpharmacological LBP treatments and found that spinal manipulative therapy (SMT) is an
effective intervention for chronic LBP.
• A systematic review published in the Journal of the American Medical Association (AMA) studying the effectiveness of SMT for the treatment of acute LBP found that “SMT was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms.”
• Research suggests that SMT plus home exercise with advice is more effective than receiving only home exercise with advice for patients with subacute and chronic back-related leg pain.
• Results of a 2013 randomized controlled trial suggests that 12 sessions of SMT for chronic LBP offer the best “dose.”
NECK PAIN
• In 2016, the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders found
that mobilization, manipulation, and clinical massage are all effective interventions to manage
whiplash-associated disorders or neck pain and associated disorders. Electroacupuncture, strain-
counterstrain, relaxation massage, and some passive physical modalities were not found to be
effective.6
HEADACHE
• Manual therapy consisting of SMT, mobilization, soft-tissue therapy, or exercise is more
effective than medication in the short term and as effective as medication long-term for muscle
tension-type headaches.
7
• Cervicogenic headaches, which may include muscle tension type headaches, can be effectively
treated with SMT, mobilization, and exercise by reducing headache intensity and frequency.
8,9
• SMT may be as effective for Migraine headache treatment as prophylactic medication use.
10
GUIDELINES
• A guideline from the American College of Physicians recommends nondrug treatment including
SMT for acute or subacute LBP. For chronic LBP, nondrug treatment should also initially be
selected including interventions such as exercise, acupuncture, mindfulness-based stress
reduction, yoga, low-level laser therapy, cognitive behavioral therapy, and SMT.11
• A guideline for chiropractic care for LBP recommends a treatment schedule of 2-3x/week for 2-4
weeks for acute or subacute pain. For recurrent or flare-up episodes, 1-3x/week for 1-2 weeks.
For chronic pain, 1-3x/week for 2-4 weeks. Reevaluations should occur between 1-4 weeks,
depending on the stage of pain.12
• In a guideline for chiropractic care for neck pain, SMT is recommended in combination with
conservative treatments such as mobilization and exercise in both the short and long-term for
the acute stage. For chronic, SMT is recommended as a sole treatment option as well as in
combination with other conservative treatments in the short and long-term.13
• SMT is recommended for treating patients with cervicogenic and migraine headaches, according
to a guideline for chiropractic care for headache.14
Risks
• Most of the adverse events reported in studies of SMT include mild and transient symptoms
such as aggravation of complaints, radiating pain, stiffness, muscle spasm, and fatigue.3,15,16
• A 2016 systematic review of the literature on cervical artery dissection following SMT found no
causal link.17 These findings are consistent with previous studies which have concluded that
increased risks of VBA stroke associated with both chiropractic and primary care are likely due
to patients seeking care because they are experiencing symptoms of headache and neck pain
due to ongoing VBA dissection.18,19
• A review studying serious adverse events related to SMT in the low back concluded that any
recorded events are anecdotal in nature and causality has not been established
REFERENCES
1. Sackett DL. Evidence-based medicine. Spine (Phila Pa 1976). 1998;23:1085-1086.
2. Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al. Nonpharmacologic Therapies
for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice
Guideline. Ann Intern Med. 2017;166:493-505.
3. Paige NM, Miake-Lye IM, Booth MS, Beroes JM, Mardian AS, Dougherty P, et al. Association of
Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic
Review and Meta-analysis. JAMA. 2017;317:1451-1460.
4. Bronfort G, Hondras MA, Schulz CA, Evans RL, Long CR, Grimm R. Spinal manipulation and home
exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive
allocation. Ann Intern Med. 2014;161:381-391.
5. Haas M, Vavrek D, Peterson D, Polissar N, Neradilek MB. Dose-response and efficacy of spinal
manipulation for care of chronic low back pain: a randomized controlled trial. Spine J. 2013.
6. Wong JJ, Shearer HM, Mior S, Jacobs C, Cote P, Randhawa K, et al. Are manual therapies, passive
physical modalities, or acupuncture effective for the management of patients with whiplash-
associated disorders or neck pain and associated disorders? An update of the Bone and Joint
Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa collaboration. Spine
J. 2016;16:1598-1630.
7. Mesa-Jimenez JA, Lozano-Lopez C, Angulo-Diaz-Parreno S, Rodriguez-Fernandez AL, De-la-Hoz-
Aizpurua JL, Fernandez-de-Las-Penas C. Multimodal manual therapy vs. pharmacological care for
management of tension type headache: A meta-analysis of randomized trials. Cephalalgia.
2015;35:1323-1332.
8. Chaibi A, Russell MB. Manual therapies for cervicogenic headache: a systematic review. J
Headache Pain. 2012;13:351-359.
9. Racicki S, Gerwin S, Diclaudio S, Reinmann S, Donaldson M. Conservative physical therapy
management for the treatment of cervicogenic headache: a systematic review. J Man Manip Ther.
2013;21:113-124.
10. Chaibi A, Tuchin PJ, Russell MB. Manual therapies for migraine: a systematic review. J Headache
Pain. 2011;12:127-133.
Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and
Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann
Intern Med. 2017;166:514-530.
12. Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, Whalen WM, et al. Clinical Practice Guideline:
Chiropractic Care for Low Back Pain. J Manipulative Physiol Ther. 2016;39:1-22.
13. Bryans R, Decina P, Descarreaux M, Duranleau M, Marcoux H, Potter B. Evidence-based guidelines
for the chiropractic treatment of adults with neck pain. J Manipulative Physiol Ther. 2014;37.
14. Bryans R, Descarreaux M, Duranleau M, Marcoux H, Potter B, Ruegg R, et al. Evidence-based
guidelines for the chiropractic treatment of adults with headache. J Manipulative Physiol Ther.
2011;34:274-289.
15. Rubinstein SM. Adverse events following chiropractic care for subjects with neck or low-back pain:
do the benefits outweigh the risks? J Manipulative Physiol Ther. 2008;31:461-464.
16. Walker BF, Hebert JJ, Stomski NJ, Clarke BR, Bowden RS, Losco B. Outcomes of usual chiropractic.
The OUCH randomized controlled trial of adverse events. Spine (Phila Pa 1976). 2013;38.
17. Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Meta-
analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus.
2016;8:e498.
18. Kosloff TM, Elton D, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke:
results of a case-control study in U.S. commercial and Medicare Advantage populations. Chiropr
Man Therap. 2015;23:19.
19. Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke
and chiropractic care: results of a population-based case-control and case-crossover study. Spine.
2008;33:S176-S183.
20. Hebert JJ, Stomski NJ, French SD, Rubinstein SM. Serious Adverse Events and Spinal Manipulative
Therapy of the Low Back Region: A Systematic Review of Cases. J Manipulative Physiol Ther.
2015;38:677-691.
21. Dagenais S, Brady O, Haldeman S, Manga P. A systematic review comparing the costs of
chiropractic care to other interventions for spine pain in the United States. BMC Health Serv Res.
2015;15:474.
22. Goertz CM, Long CR, Hondras MA, Petri R, Delgado R, Lawrence DJ, et al. Adding chiropractic
manipulative therapy to standard medical care for patients with acute low back pain: results of a
pragmatic randomized comparative effectiveness study. Spine (Phila Pa 1976). 2013;38:627-634.
23. Hertzman-Miller RP, Morgenstern H, Hurwitz EL, Yu F, Adams AH, Harber P, et al. Comparing the
satisfaction of low back pain patients randomized to receive medical or chiropractic care: results
from the UCLA low-back pain study. Am J Public Health. 2002;92:1628-1633.
24. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. The outcomes and costs of care
for acute low back pain among patients seen by primary care practitioners, chiropractors, and
orthopedic surgeons. The North Carolina Back Pain Project. N Engl J Med. 1995;333:913-917.
25. Kane RL, Olsen D, Leymaster C, Woolley FR, Fisher FD. Manipulating the patient. A comparison of
the effectiveness of physician and chiropractor care. Lancet. 1974;1:1333-1336.
26. Hurwitz EL. The relative impact of chiropractic vs. medical management of low back pain on health
status in a multispecialty group practice. J Manipulative Physiol Ther. 1994;17:74-82.
Thanks for such a detailed reply Diane.
To me it looks like we agree on quite a bit. We both agree that traditional chiropractic treatment is lacking in evidence. We both prefer conservative, lifestyle approaches to medication and surgery where possible. And we both refer to high quality evidence to support our arguments. This is very encouraging!
We both agree that spinal manipulation may be appropriate for neck and back pain. I’ll have a look through the relevant references you’ve provided, and will update my comments about this if warranted. As this isn’t my area of expertise, I will be guided by the consensus of systematic reviews.
Again though, I don’t make a direct comparison of the education of medical doctors and chiropractors. My interest is in the biases, and errors in knowledge, of chiropractic students and graduates. And regardless of how many hours someone has spent in training, if their knowledge is flawed, we need to question the quality of this training.
This is an excellent article. I worked in P.T. As an assistant for many years and saw many patients with really bad injuries from their Chiropractor. Glad you wrote this article. People are often trusting without examining the consequences of seeing someone who is not a medical doctor. I am retired and notice that people are very defensive when you care enough to give an educated opinion. Thanks for your work. Take care, Hillary Wolf
Thank you for commenting Hillary! Yes, the response to criticism has been a little surprising. In academia we see thoughtful, informed criticism as an opportunity to improve.
“Johns Hopkins study suggests medical errors are third-leading cause of death in U.S.”
https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/
Allopathic medicine, in general, is from being without risks.
And, anecdotally, as a chiropractor of 10 years, I’ve treated many people injured by their PT and injured by other DCs so I’m not sure what your point is. Any and all intervention is not without risks.
I’ve also treated people injured while lifting their children, while driving their car, while walking or running, from sleeping, from bending, from sneezing…and a whole host of other mechanisms of injuries.
I feel I must defend my chiropractor. After a car accident, I became unable to turn my head to the left for perhaps 2 years. After my first visit, my neck fully released and I had full range of motion.
My husband saw the same doctor for acute lower back pain that was level 10 for a few days and the pain could not be controlled w/ heavy medication. (PCP had said well if he’s not better in a week I’ll order an MRI and that was all he could do!). After the first
visit to the aforementioned chiropractor his pain was immediately reduced to a 3.
I’m glad you and your husband had good experiences Theresa. As I mention in the article, there are some great chiropractors out there, doing wonderful jobs within their scope of practice!
I’ve been licensed practicing chiropractor for 33 years here in PA. Grew a family, put the children through college, paid all my bills and have had a wonderful life. Great rewarding profession. I’ve seen quite a bit of health care providers who can’t say the same and are actually in jail for fraud. What qualifications and experience do you exactly have.
Thanks for commenting Mark. As I mention in the article there are many great chiropractors out there, of which I’m sure you are one. But that is a different issue to the problems with traditional chiropractic practice and education, which was the main point of the article.
As a chiropractor who is leaving the profession in a couple of months, I agree with the majority of what is being said here. I did want to point out a statistic in the “Why Chiropractors” section of your that is being skewed.
In regards to CAD/stroke, you state that “Estimates of how likely this is vary, as these events don’t always occur immediately after the treatment. But we think they occur about once in every 100 000 adjustments…” The study you link states the occurrence of CAD/stroke is between 100,000 – 2,000,000. This paints a very different picture than just using 100,000. It would be a more accurate representation of the data if you used the range.
Thanks for reading Cory, and you’ve made a fair criticism. I’ll check for more recent literature, and then update this sentence.