A 2006 Gallup Poll found that chiropractic rated dead last among health professions with regard to ethics and honesty.1 Why? People are curious about the poor reputation of chiropractic,2 and confused about the nature of chiropractic.3 Often inspired by their own negative experiences, they ask me what I think. This article is a survey of chiropractic controversies and issues that I think patients should be aware of.
I purchase chiropractic therapy myself once in a while. I have a long-term craving for upper thoracic spine cracking. I recommend some chiropractic therapy to friends and readers. But I also respect the judgement of many expert critics who believe that, “The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.”4 This kind of criticism is often referred to as “persecution” by chiropractors; they also often call this a “hit piece,” just for reporting the existence of the issues.
This article also strongly applies to osteopathy. Despite a few key differences, most osteopaths are essentially identical to chiropractors from a patient perspective: they are all alternative medicine practitioners who believe in the therapeutic power of skilled manipulation of joints.5
Does chiropractic work?
The first thing one wants to know about any treatment — alternative or otherwise — is whether it works. Until that is decided, all talk of qualifications, regulation, and so on is just vacuous bureaucratese.
~ Dr. David Colquhoun, “Doctor Who? Deception by chiropractors”
Most people just want to know if it will help them. But “chiropractic” is many things. What kind of chiropractic treatment? Does it work for what? How much of it? For which kinds of patients? Just asking if “chiropractic works” is not specific enough to have a meaningful answer. It is not really a fair question to ask of chiropractic as a whole. But it is nevertheless the question that people actually ask, and so we have to deal with it as well as we can.
I believe it’s obvious that some chiropractic therapy does “work” in certain ways, for some people, some of the time. The most important factor in the usefulness of chiropractic therapy is not the nature of chiropractic as a profession, but the skill and good sense of the chiropractor whose hands are on your neck. Ethical, intelligent practitioners of any helping profession will always deliver better care than less competent members of their own or any other profession.
Consumers need to be aware of the issues to help them choose a good chiropractor. Or choose none, if they prefer!
Chiropractic is so controversial that this article attracts a lot of shooting-the-messenger hate mail. I am not expressing my opinions about chiropractic here: I am reporting and explaining concerns that the experts have been debating ad nauseum for decades, quoting their opinions, and citing some of the same scientific evidence that they do.
The best consumer guide to chiropractic therapy available, written by a chiropractor & America’s leading expert on pseudoscientific health care. If you want to know if chiropractic therapy “works,” stop reading my article & go get this book.
What experts? Progressive chiropractors and critics from within the profession like Dr. Samuel Homola,6 Dr. Bruce Walker,7 Dr. Donald Murphy,8 and Dr. Preston Long9; relatively progressive chiropractic regulatory agencies10; activist physicians like Dr. Stephen Barrett,11 Dr. Stephen Novella,12 or the especially credible Dr. Edzard Ernst13 (who has such great experience with both medical science and alternative therapies); and science journalists like Simon Singh,14 who was in the news because he was sued for libel by the British Chiropractic Association for comments he wrote in a column in The Guardian in 2005, in connection with his book, Trick or Treatment: The Undeniable Facts About Alternative Medicine.15 The lawsuit failed, and the misguided attempt did serious harm to the reputation of chiropractic.
The fact that patients swear by us does not mean we are actually helping them. Satisfaction is not the same thing as effectiveness.
~ Chiropractor Preston Long, author of Chiropractic Fraud and Abuse: An Insider's Lament
An introduction to chiropractic controversies
There is an undeniable history of scientific and ethical controversies swirling around the profession, from its earliest days to the present. What are those controversies? Why is chiropractic perpetually contentious?
1. The hard sell: aggressive sales and marketing
Chiropractic often involves many expensive but quick treatments,1617 and marketing and sales tactics that many people consider to be aggressive and distasteful, if not downright unethical, especially pre-paid treatment packages,18 and the hawking of many other services and products that are much more blatant quackery,19 like applied kinesiology,20 and ear infection treatment. A 2016 federal (US) audit concluded that more than 80% of Medicare payments to chiropractors were for medically unnecessary procedures, and 100% of treatments were unnecessary after the first thirty.21 In a 2018 crackdown in British Columbia, Canada (my home), many dozens of chiropractors were forced to remove unscientific claims from their websites, like anti-vaccination propaganda and claims of autism cures.22 Do chiropractors sell too hard?
An example of the diversity of conditions that chiropractors claim that they can treat, from an advertisement.
2. The big idea: “subluxation” defines chiropractic
The original “big idea” of chiropractic was that nearly any health problem can be cured by spinal manipulation.23 Today, many chiropractors still believe this,24252627 and still recommend chiropractic therapy for many problems beyond just low back pain, neck pain, and headaches. Is this reasonable? Is there any scientific evidence that chiropractic therapy can prevent, help, or cure a wide variety of diseases and ailments?28 Only if “spinal subluxation” is actually the cause of them in the first place!29 But organ health does not depend on spinal nerves.
3. The risks: what could possibly go wrong?
Adjustment of the neck might be dangerous. There are numerous class action lawsuits against chiropractors and chiropractic professional organizations for this reason.30 Is there a risk? Considering the stakes, is any risk acceptable? A large group of Canadian neurologists asks, “Is a headache worth dying for?”31 British scientists advocate abandoning it.32 The paper most cited for the defense, the Cassidy paper, does not hold up.33
4. Damned by faint praise: lukewarm evidence at best for the efficacy of back pain treatment
Spinal adjustment for acute low back pain has long been regarded as the best example of evidence-based care routinely offered by chiropractors. Nevertheless, some critics have pointed out that even this technique has been damned with overly faint praise — “positive” results so trivial that they actual prove there is no meaningful benefit. A major, credible 2012 science review supports that view with a completely negative conclusion.34 Is chiropractic actually useful for acute back pain? If there’s any real doubt about even this, what does it suggest about the rest of chiropractic care?
5. Think of the children: pediatric chiropractic is condemned even by many chiropractors
The best single example of aggressive marketing is so important that it constitutes an independent controversy: many chiropractors recommend regular treatments for children and even babies (and maybe they break their necks35). Critics say this is a worrisome extreme of dangerous conduct in chiropractic: an intervention with higher risks and even more dubious benefits. Do children really need chiropractic adjustment?
6. Guilt by association with anti-vaxxers
Chiropractic is usually packaged with other sketchy treatment ideas and beliefs about medicine, exemplified by anti-vaccination rhetoric. You would hope that such a belief would be rare among educated professionals, but it actually permeates the profession to the point where even chiropractic regulators are anti-vaxxers — the people who should be disciplining other chiropractors for espousing the same belief. No matter what spinal manipulation does or does not do for back pain, how much can you trust a healthcare professional who has embraced one of the most extreme anti-medical beliefs possible, the medical equivalent of believing that the Earth is flat? What else do they believe?
Just asking questions
I’m not answering any of these questions posed above — I’m asking them. And I’m pointing out that they have been asked (and answered) for decades. Many credible critics rule against chiropractic on all of these issues and several others.
And while you might think that all chiropractors would defend themselves against these accusations, that’s not the case. In fact, many chiropractors are also critical of common chiropractic beliefs and practices. For instance, these controversies are only a small selection of “abberant practices” identified by progressive chiropractors themselves. Dr. Bruce Walker lists sixteen in his 2016 paper about trying to rescue chiropractic from itself.36
And so one of the most important things to understand about chiropractic is that it is a divided profession: there is significant controversy within the profession itself.
Chiropractic is a divided profession
Chiropractors themselves have many disagreements about their own profession. There is a ideological chasm between a minority of chiropractors who want to modernize the profession, and traditional chiropractors who cling to the old ways and take the founding concepts literally. Chiropractors on either side of this chasm can be amazingly different. For instance, there is a strong theme of Christian fundamentalism among old school chiropractors that blends seamlessly with the work: they talk about chiropractic like it’s a spiritual calling.37
The chiropractic profession was founded about a century ago by Daniel David Palmer. Chiropractic owes its existence to this one unusual man and his son — always referred to as “D.D.” and “B.J.” palmer — whose ideas remain the basis of the profession today. Both DD and BJ were bizarre characters, and arguably marketing geniuses. DD in particular was known for his extravagant ego. Here’s an entertaining example of his, er, rather flamboyant personal style:
I was the first to adjust the cause of disease .... The man who had the intellectual capacity to comprehend the displacement of the vertebrae; the mental ability to grasp the significance of nerve impingement; the power to conceive and discriminate between normal and abnormal positions; the foresight and wisdom to discern the outcome; the genius of originality to create such a unique science; the judgement needed for the occasion; the brain caliber of reasoning on this heretofore perplexing question — the cause of disease; the sense of touch required to discover a racked vertebra and the skill and tact to replace it, was the one destined to discover and develop the science which he named chiropractic.
~ Shall Chiropractic Survive?, by BJ Palmer
Wow! Clearly, DD’s arrogance was dialed up to 11. According to Palmer, “A subluxated vertebra … is the cause of 95 percent of all diseases.”38 Those were big words, and indeed they have been called the “big idea” in chiropractic ever since. In 1966, a group of physicians damningly wrote, “In all the years that they have been talking about them, chiropractors have never been able to furnish proof of these mysterious subluxations which they alone are able to see. They may convince their clients, but never have they provided proof of their pretensions to men of science.”39 Even 55 years ago the absence of persuasive evidence was already a concern for many experts.
Today, many chiropractors actually reject the subluxation hypothesis (although not enough of them do so publicly):
Chiropractic, which celebrated its centennial in 1995, is a curious mixture of science and pseudoscience, sense and nonsense. Much of it is based on the theory that misaligned spinal bones produce nerve interference that causes disease. Many chiropractors claim that correcting these misalignments (“subluxations”) can restore health and that regular spinal adjustments are essential to maintain it.
Neither logic nor scientific evidence supports such a belief. Although spinal manipulation can relieve certain types of back pain, neck pain, and other musculoskeletal symptoms, there is no scientific evidence that it can restore or maintain health. As a result of expressing my opinion on this subject, I have been called a chiropractic heretic.
The chiropractic profession has little tolerance for dissension. Its nonsense remains unchallenged by its leaders and has not been denounced in its journals. In fact, many chiropractic journals continue to publish articles that attempt to justify subluxation theory. Although progress has been made, the profession still has one foot lightly planted in science and the other firmly rooted in cultism. Without appropriate criticism, the good in chiropractic will never be sifted out, and competent chiropractors will not receive the recognition they deserve.
This book denounces the cultism in chiropractic but supports the appropriate use of spinal manipulation and the research efforts required to solidify its scientific basis. If you are contemplating or receiving chiropractic care, it might help protect both your pocketbook and your health.
~ Inside chiropractic, by Samuel Homola, p. vii
This controversy between chiropractors themselves is highly relevant to the consumer. The profession is divided between chiropractors who still embrace subluxation hypothesis (known as “straight” chiropractors), and those who choose to limit their expertise and therapy to musculoskeletal health, especially spinal care (known as “mixers”).40 A chiropractic college instructor writes of this “well-known division between ‘straights’ and ‘mixers’” that “we are at risk of returning to the antiscientific and dogmatic traditions that we have worked so hard to shake off during the past several decades.”41 On the other hand, if the subluxation hypothesis is rejected, then
the whole rationale for chiropractic collapses, leaving chiropractors no justifiable place in modern medical care except as competitors of physical therapists in providing treatment of certain musculoskeletal conditions.
Whatever the fate of the profession, you’d probably like to know what kind of a chiropractor is treating you today, a “straight” or a “mixer,” regardless of which you’d prefer. Unfortunately, it is nearly impossible for patients to tell which is which! And that is a serious problem for all chiropractors.
My chiropractor says this is because the top of my neck attaches to my head. Is that a common problem?
~ from the “chiropractors say the darndest things” file, as reported by Dr. Grumpy (Only Outside Sleepy Hollow)
Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints
Even if the original idea of subluxation as a cause of disease is discarded, is there a more ordinary justification for manipulating the spine for the treatment of body pain? Chiropractic is the profession most obsessed with the generally shabby idea that anatomical alignment is a key factor in chronic pain problems of all kinds (not just spinal pain). “Adjusting” the spine refers to many different manual therapies that wiggle, pop and otherwise manipulate spinal joints, with the general goal of “straightening” patients or restoring normal motion. The correct umbrella term for these treatments is “spinal manipulative therapy” or SMT. Expert opinions on SMT range widely, with some prominent medical scientists expressing strong concerns, primarily because its provenance in chiropractic subluxation theory is dubious, but also because whatever benefits it has are clearly not major, and there are serious risks, even including paralysis and death in the case of SMT for the joints of the neck.
Despite all the controversy, there has been little high quality scientific research to determine whether or not SMT is safe and really works. Every published review of the literature comments on the lack of good quality evidence, making it impossible to be sure of anything.42 Even the most promising sources of research have had serious quality control problems.43
Nevertheless, if SMT works, it shouldn’t be taking over a century to prove it. Major reviews of that literature published in recent years came to underwhelming conclusions,44 and subsequent experiments continue to damn SMT with faint praise, showing that it works only a little at best.45 The biggest and best review to date (Rubinstein et al) concluded that “SMT is no more effective in participants with acute low-back pain” than shams and placebos.46
Thus, SMT fails the “impress me” test — if it’s working any miracles, they must be rare and small ones.
And yet spinal joint popping in particular is something that people crave, and most clinicians — including myself, and including skeptics like Dr. Homola — believe that some forms of SMT can be helpful to some of their patients, some of the time. There seems to be almost no doubt that there is something of therapeutic interest going on in SMT in some cases.
There is no definitive evidence that spinal manipulative therapy is more effective than other forms of treatment for patients with acute or chronic low-back pain. However, manual therapists know from experience that spinal manipulation is often more effective for providing immediate short-term relief for some types of back pain.
Scratching the itch you can’t reach: why joint popping feels good and possibly relieves pain
Occasionally, believe it or not, I recommended chiropractic therapy to my own massage therapy patients. Sometimes I believed they needed more skilful and direct stimulation of spinal joints than I could provide myself, and I believed that the scientific evidence then showed that appropriate spinal manipulation had the potential to help back pain in this way, with acceptable risks.
Many of them reported this kind of positive result from chiropractic treatment. I have experienced it myself on many occasions, and I have also observed many clients expressing relief and pleasure in response to incidental spinal “adjustments” — joint pops that occur in the course of doing massage therapy, little explosions as I slide up the spine.
Many people seem to feel that a happy spinal adjustment feels like “scratching an itch you can’t reach.” Why might that be?
Whatever you have been told before, and despite the availability of many explanations on the internet, the nature of joint popping is not well understood.47 It is firmly in that category of trivial mysteries for which there is simply no research funding, and as such it will probably remain unexplained for some time to come. We simply do not know.
Whatever a joint pop really is, it probably provides a novel sensory experience: a little blast of proprioceptive stimulation.48 Since all living systems seem to thrive on sensory input, and generally suffer without it, I speculate that a joint crack essentially feels like getting “unstuck,” and is analogous to finally getting to stretch your legs after getting off a long flight — which is not intended to trivialize it.
The strength of this idea is that it just isn’t claiming much: it both accounts for the extremely satisfying feeling that many people report, but without promising the moon. Indeed, it also seems consistent with another widely reported feature of SMT: the benefits often don’t last long! Soon the “itch” needs to be “scratched” again. It also could explain why the benefits of SMT are so variable and uncertain: it is highly dependent on many factors. For instance, whether a joint crack feels “refreshing” to you depends on how you feel about the whole idea of joint cracking.
The fear of spinal adjustment
Unfortunately, many people are not comfortable with having their spinal joints “cracked” or manipulated.
This is one of those “there are two kinds of people in the world” things: some people crave spinal joint cracking, expertly applied or otherwise, and to others it seems like fingernails on a chalkboard. My wife, for instance, wants at least one spine-cracking hug per day, and clearly becomes impatient when it has been too long since the last one! Other people would view such a hug as an alarming assault — people with such anxiety about spinal joint popping typically have never been to a chiropractor and never will, or they take a dim view of what happened to them when they reluctantly tried it.
“I will never let a chiropractor touch me again” is just as common a patient report as “I have to get adjusted at least once a month.”
Clearly, those who find joint cracking to be unpleasant are not good candidates for “scratching the itch” with a nice round of lumbar facet joint explosions! You know who you are, and you don’t really need to be reading this: chiropractic is certainly not going to work for you!
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About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter.
Related Reading about Chiropractic
This is a painstakingly prepared list. My daring plan was to make this the best such list I could find, which I assumed would be difficult or impossible. Surely there are excellent compilations of this sort already? But it’s actually pretty thin pickings: I’m surprised how little I found, and how much of what I found was rather shabby. Not that my own effort here is perfect or complete, of course, but I did really work hard on it — many, many hours. You can really sink oodles of time into wrangling not only a bunch of links, but all the reading required to describe them well. This would have been completely impossible if I hadn’t already been reading on this topic for many years.
I originally wrote it with great earnestsness for ScienceBasedMedicine.org’s Chiropractic Reference Page, in my capacity as SBM’s Assistant editor, and I’ve adapted it a little for use here — just a little lighter.
Of course, ScienceBasedMedicine.org itself is one of the premier sources of analysis and criticism of chiropractic, and their reference page also includes links to dozens of posts there, many of which have attracted hundreds of thousands of readers over the years.
- NCAMM’s summary of chiropractic is a prominent example of poor quality information about chiropractic. NCCAM is a well-funded institution with a CAM-friendly agenda,49 so it’s quite noteworthy that they offer such weak support for chiropractic treatment, confirming that most of the evidence is negative, inconclusive, or only weakly positive — despite being generally uncritical of the profession.50
- Wikipedia has a lengthy and well-written page specifically devoted to Chiropractic controversy and criticism.
- Chirobase: Your skeptical guide to chiropractic history, theories, and practices (chirobase.org). One of the first substantial chiropractic skepticism resources available on the Internet, and it remains the largest (although perhaps SBM is catching up now). Chiropractors everywhere must have strong opinions about this site. Operated by Stephen Barrett, MD, and ScienceBasedMedicine.org’s regular guest author and chiropractic insider, Samuel Homola, DC. Most articles remain relevant despite their age. The site is a bit old school, however, and its vintage is starting to show.
- The National Council Against Health Fraud is another project of the prolific Dr. Barrett. See the NCAHF Position Paper on Chiropractic and the NCAHF Fact Sheet on Chiropractic.
- The chiropractic page on WhatsTheHarm.net lists cases of alleged harm from chiropractic treatment, with many links to more information. (Personally, I have received hundreds of anecdotes about chiropractic harm from my own readers over the years.)
- Chirotalk: The Skeptical Chiropractic Discussion Forum — probably the only such discussion forum online. (At this time, there do not appear to be any active, skeptical Facebook or Google groups on this topic.)
- The Skeptics’ Guide to the Universe 5×5 Podcast, an early spinoff project of the very popular SGU, covered chiropractic in three parts in 2010: episode 91, episode 92, episode 93.
- The Skeptic’s Dictionary has a substantial chiropractic entry.
- As important as the subject is, there are only a few books criticizing chiropractic. Chiropractic books often have poor ratings in web-based bookstores regardless of their quality. They attract outraged ratings from many chiropractors, and positive ones from a minority of sympathetic and skeptical readers. The five most notable examples:
- Chiropractic Fraud and Abuse: An Insider's Lament (book), by Preston H Long. Amazon.com ❐ SBM’s review by Dr. Hall calls A Chiropractor’s Lament a “valuable addition to the literature on chiropractic, combining Long’s personal story with everything you never wanted to know about chiropractic. It’s fun to read and packed with information. Even if you think you’ve heard it all before, there are revelations here that will be new to you, that will elicit surprise, indignation, and laughter.”
- Inside chiropractic: a patient’s guide (book), by Samuel Homola. Amazon.com ❐ Dr. Homola is a chiropractor, and the most prominent critic of his own profession. His book is an essential patient guide to a profession that is so full of controversy that consumers need a guide before going to a chiropractic office. If you like getting your spine cracked, or you think you need to be “adjusted,” read this book before making your next chiropractic appointment!
- Spin doctors: the chiropractic industry under examination (book), by Paul Benedetti and Wayne MacPhail. Amazon.com ❐ I include this selection as much for its Canadian content as because it is a good book. Canadians visit chiropractors about thirty million times a year, and surveys show that patients are generally satisfied with their treatment. But studies also show that as many as two hundred Canadians a year may suffer strokes brought on by neck manipulation. Spin Doctors takes a hard, dramatic, and spine-chilling look into the world of chiropractic medicine. You will be surprised to learn what chiropractors treat and why — and how much it costs you as a taxpayer. Most important, you'll learn how to protect yourself and your family from dangerous adjustments, practice-building tactics, bogus treatments, and misleading information. Paul Benedetti is an award-winning journalist who, for more than a decade, has written investigative stories about alternative medicine and health fraud. Wayne MacPhail is a journalist who has written about AIDS, alternative medicine and other health, science, and social issues for twenty-five years.
- Trick or Treatment: The Undeniable Facts About Alternative Medicine (book), by Simon Singh and Edzard Ernst. Amazon.com ❐ A thorough examination and judgement of more than thirty of the most popular “alternative” treatments, such as acupuncture, homeopathy, aromatherapy, reflexology, chiropractic and herbal medicine. The ultimate verdict on alternative medicine is delivered for the first time with clarity, rigour and authority. A thorough examination and judgement of more than thirty of the most popular “alternative” treatments. Although this book covers much more subject matter than chiropractic, it’s historically significant to chiropractic because of its role in Simon Singh’s famous conflict with the British Chiropractic Association. See SBM’s review.
- Chiropractic:The Victim’s Perspective, by George Magner (1995).
- British science writer Simon Singh was sued in 2008 by the British Chiropractic Association for criticizing spinal adjustment for children with conditions like asthma and ear infections, calling it “bogus” and pointing out the lack of evidence. The BCA withdrew its lawsuit two years later, having suffered a public relations disaster. See my summary of the Singh case.
- The other famous chiropractic legal case is Wilks vs. American Medical Association (AMA), fought from 1976 to 1987. Previously, AMA rules made it officially unethical for medical doctors to associate or refer patients to chiropractors. A federal antitrust suit was brought against the American Medical Association (AMA) and 10 other institutional co-defendants by chiropractor Chester A. Wilk, DC, and four co-plaintiffs. After many years of appeals, the case ultimately concluded with a ruling against the AMA, specifically finding them guilty of prevent physicians from referring patients to chiropractors (violating Section 1, but not Section 2, of the Sherman Antitrust Act). The judge expressed faith in the AMA’s goodwill and “subjective belief that chiropractic was not in the best interests of patients,” but still judged that their “concern for scientific method in patient care could have been adequately satisfied in a manner less restrictive of competition.” The AMA nows permits medical doctors to refer patients to chiropractors. “Chiropractors crowed about their victory,” writes Dr. Harriet Hall, “but it actually did little to change ‘discriminatory’ practices or to enhance the reputation of chiropractic.”
- “Can Chiropractors and Evidence-Based Manual Therapists Work Together?,” Samuel Homola, Journal of Manual & Manipulative Therapy, 2006. Dr. Sam Homola covers the topics of subluxation theory and spinal manipulative therapy in this 2006 article, managing to be precise and thorough without losing his amiable tone (exactly what I aim for on PainScience.com). It’s still a bit heavy going for patients, but it’s worthwhile for anyone who’s really keen to understand the subject matter, and it’s still completely relevant more than a decade later.
- Vertebral Subluxation on Wikipedia.com. An emotionally neutral evaluation of the chiropractic idea of intervertebral subluxation. I can save you some reading time: the bottom line of the article is that a century of debate has failed to produce any clear answers. Subluxations remain elusive.
- “Subluxation: Chiropractic's Elusive Buzzword,” Stephen Barrett, ChiroBase.org. Dr. Stephen Barrett’s take on chiropractic subluxation theory. This is one of the most prominent anti-chiropractic articles available on the internet.
- “Undercover Investigations of Chiropractors,” Stephen Barrett, QuackWatch.org. In a series of informal but devious and persuasive tests, physician Stephen Barrett contrived to challenge the diagnostic skills of a number of chiropractors. The results were inconsistent, and make for some fascinating and disturbing reading.
What’s new in this article?
Five updates have been logged for this article since publication (2006). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.
I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.
See the What’s New? page for updates to all recent site updates.
This is one of my oldest articles, with origins in the early 2000s and revised and updated many times since, but without logging the changes. (Update logging was erratic on PainScience.com for a long time: I did it religiously for some, neglected it for others. I started logging all updates consistently in 2016.)
Aug 22, 2020 — Added a little information about osteopathy and its similarities to chiropractic to the introduction.
2019 — Added a couple sources regarding the prevalance and persistence of subluxation-based chiropractic, most notably Mirtz et al.
2016 — Added a mobile-only article summary.
2016 — Editing and reorganization of the introduction, a new summary of the main controversies, and a significant new reference about Medicare billing.
2016 — Cited Bruce Walker’s “aberrant practices that cause significant reputational damage to the profession” (Walker).
2006 — Publication.
- ChiroWeb.com [Internet]. Gallup poll: Americans have low opinion of chiropractors' honesty and ethics; 2006 Mar 25 [cited 12 Mar 9].
- When I was a Registered Massage Therapist (2000-2009), my clients asked me about it frequently. That was the original inspiration for this article — I wrote it for my clients, like many of the older articles on PainScience.com.
- Homola S. Finding a Good Chiropractor. Archives of Family Medicine. 1998;7(1):20–23. PainSci #56032 ❐ Chiropractic is a puzzling profession because, according to Sam Homola, a chiropractor himself, it “is one of the most controversial and poorly defined healthcare professions with recognition and licensure … it has the confusing image of a back specialty capable of treating a broad scope of health problems.”
- Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage. 2008 May;35(5):544–62. PubMed #18280103 ❐
- Both professions have extremely similar pre-scientific origin stories in the late 1800s. The major difference today is that osteopathy has a somewhat broader scope, and a much stronger progressive faction. In the United Stated particularly, many osteopathic colleges "levelled up" became mainstream, granting genuine medical degrees. However, the majority of osteopaths around the world are still not physicians, and for all intents and purposes work just like chiropractors do, and share many beliefs with them. For more information, see Reviews of Pain Professions.
Samuel Homola, Doctor of Chiropractic, is a second-generation chiropractor who has dedicated himself to defining the proper limits on chiropractic and to educating consumers and professionals about the field. He is hardly the only critic of his own profession, but he is probably the most famous and widely read. His 1963 book, Bonesetting, Chiropractic, and Cultism, supported the appropriate use of spinal manipulation to treat some spinal pain but renounced the common chiropractic dogma that spinal adjustment is a panacea. I strongly recommend his 1999 book Inside Chiropractic: A patient’s guide. It provides an incisive look at chiropractic’s history, benefits, and shortcomings.
- Dr. Bruce Walker is Editor-in-Chief of the journal Chiropractic & Manual Therapies. In his 2015 keynote speech in Melbourne, Australia, at the Chiropractic & Osteopathic College of Australasia and Chiropractic Australia national conference, he condemned many pseudoscientific practices in chiropratic and presented “a ten point plan for a new chiropractic that will achieve full acceptance for this troubled profession.” His article based on the speech is cited below.
- Chirobase.org [Internet]. Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF. How Can Chiropractic Become a Respected Mainstream Profession? The Example of Podiatry; 2008 Aug 29 [cited 12 Mar 9]. Dr. Murphy is one of five research-oriented chiropractors that have bared their profession’s shortcomings in a 2008 article that calls for “dramatic changes” and states that chiropractic “finds itself in a situation in which it is rated dead last amongst healthcare professions with regard to ethics and honesty.” This readable document is an excellent survey of the problems with the chiropractic profession.
- Dr. Long is the author of a 2013 book, Chiropractic Fraud and Abuse. You can read an excerpt of it — “Twenty Things Most Chiropractors Won’t Tell You” — which is in the same spirit as this article … but much harsher.
- For instance, in 2008, the Chiropractors Registration Board of Victoria in Australia (now defunct, replaced by a national organization), proposed new standards that attack common chiropractic beliefs and practices, particularly in the case of treating children. Although perhaps not obviously “fightin’ words” to the general public, within the world of therapy the CRBV’s proposal is a strong attack on the philosophical foundations of subluxation-based chiropractic: “There is currently an overwhelming lack of good quality scientific evidence to support the use of spinal manipulation in the treatment of [disease]. Non-indicated, unreliable and invalid diagnostic tools, instruments or methods and unnecessary diagnostic imaging procedures are to be avoided.” The draft document goes on to condemn unnecessary X-ray examination, especially for children, and the use of surface electromyography (SEMG) or thermography for diagnosis. These common diagnostic methods are described as “inappropriate.” I think that such opinions are both credible, given the source, and of great concern. And this CRBV is hardly the only chiropractic regulator responding to a need to clamp down on such practices — it is just a good recent example.
Dr. Stephen Barrett, a retired psychiatrist, is America’s most prominent scientific medicine activist. (I am pleased to know Dr. Barrett a little bit myself, having exchanged several notes with him over the years, and spoken with him at some length on the phone on one occasion.) In addition to founding the prominent websites QuackWatch and Chirobase, Dr. Barrett operates 23 websites in all; edits Consumer Health Digest (a weekly electronic newsletter); is medical editor of Prometheus Books; and has been a peer-review panelist for several top medical journals. He has written more than 2,000 articles and delivered more than 300 talks at colleges, universities, medical schools, and professional meetings. His dozens of books include The Health Robbers: A close look at quackery in america and seven editions of the college textbook Consumer Health: A guide to intelligent decisions.
Note that nearly everything Dr. Barrett’s critics say about it him is malicious fiction. In particular, it is not true that he lost his medical license.
Dr. Steve Novella is an academic neurologist on full-time faculty at Yale University School of Medicine. That in itself would be career enough for me, but Dr. Novella is almost frighteningly productive above and beyond his professional duties at Yale. He is the co-founder and President of the New England Skeptical Society, Associate Editor of The Scientific Review of Alternative Medicine, a contributing editor of QuackWatch, author and contributor to numerous columns, blogs and podcasts, most notably the popular podcast Skeptic’s Guide to the Universe, which has many tens of thousands of listeners and is my own favourite podcast.
Dr. Edzard Ernst possesses a rare mixture of significant expertise and experience with both scientific and so-called “alternative” medicine, and consequently has become one of the most interesting and credible experts on the subject. He qualified as a physician in Germany in 1978 where he also completed his MD and PhD theses, but has also received training in acupuncture, homeopathy, massage therapy and spinal manipulation. His experience and research have made him one the most credible and interesting critics of alternative medicine in general, and chiropractic in particular, along with science journalist co-author Simon Singh (see below). His 2008 interview in New Scientist is an interesting introduction (see Interview). Dr. Ernst has published more than 40 books — including the current book Trick or Treatment, and last year (right up my alley) Complementary Therapies for Pain Management — and in excess of 1000 articles in the peer-reviewed medical literature and has been given visiting professorships in Canada and the US. His work has been awarded with 13 scientific prizes.
- Simon Lehna Singh, MBE, is an Indian-British author of Punjabi background, who has specialised in writing about mathematical and scientific topics in an accessible manner. Most recently and relevant to this article and this website, Mr. Singh wrote Trick or Treatment with prominent scientist co-author Dr. Edzard Ernst (just mentioned above). Mr. Singh’s written works also include Fermat's Last Theorem (about one of the most difficult problems in mathematics), The Code Book (about cryptography and its history) and Big Bang (about the Big Bang theory and the origins of the universe). He has also produced documentaries and works for television to accompany his books, is a trustee of NESTA, the National Museum of Science and Industry.
- Simon Singh’s legal battle with the British Chiropractic Association is a good example of why I increasingly avoid criticizing chiropractors directly myself. Instead I simply refer PainScience.com readers to more prominent critics who are backed by organizations and lots of academic credibility. Mr. Singh, however, is “just” a science writer fighting for the right to free speech and scientific analysis, and can use all the public support he can get: please see the Sense About Science campaign page “Sign up now to keep the libel laws out of science!” and join the Facebook group For Simon Singh and Free Speech — Against the BCA Libel Claim
- ChiroBase.org [Internet]. Barrett S. Don't Pay or Contract in Advance for Chiropractic Visits at a "Discount" Price; 2009 Mar 9 [cited 12 Mar 9].
In this short article, Dr. Barrett describes a range of chiropractic over-prescription practices. The bottom line is that, “Even if chiropractic treatment can legitimately help a problem, it is not possible to know in advance that a large specified number of visits will be needed.”See the next note for an example of chiropractic over-prescription. I have encountered substantial chiropractic over-prescription and “contracts” for excessive chiropractic therapy repeatedly in my own career.
- For example, consider the case of Gertrude West, a retired attorney, who sought help for knee pain from chiropractor Donald Harte in Marin County, California. Harte advised West to have intensive care for “subluxation degeneration” of her spine, and West signed 100 visits with a discount for advance payment but severe penalties for discontinuing. After 49 visits over a 4-month period, she concluded that she was not being helped and asked that payment for the unused visits be refunded. When Harte refused, she sued him. A trial judge ruled that West had been misled and the penalty clause was “unconscionable,” and this was upheld by a small claims appeals court in the spring of 2009.
- ScienceBasedMedicine.org [Internet]. Homola S. Chiropractic gimmickry; 2012 Oct 2 [cited 12 Oct 4].
A good overview of dubious practices in chiropractic care other the standard chiropractic treatment.Sam Homola offers a disturbing overview of pre-paid treatments: “One of the most disturbing complaints I hear comes from chiropractic patients who have paid thousands of dollars in advance for a course of treatment lasting several months─after succumbing to a high-pressure sales pitch involving scare tactics. These patients have usually opted to discontinue treatment because symptoms have either worsened or disappeared. Most have signed a contract, however, that does not allow a refund, even if the treatment regimen was not completed. Some have used a chiropractic “health care credit card” to borrow the advance payment from a loan company, leaving the patient legally bound to repay the loan.” See his article for more.
- The (American) National Board of Chiropractic Examiners occasionally publishes a Job Analysis of Chiropractic. Dr. Stephen Barrett: “The reports are interesting because they provide a basis to assess the minimum extent of irrational practices among chiropractors.” For instance, the 2003 survey found that 37.6% used applied kinesiology muscle testing and 25.7% used Palmer upper cervical. And the 2009 survey found that 38.6% prescribe homeopathic remedies, and a whopping 94.4% offer “nutritional/dietary recommendations” — hardly what most people think of when they make an appointment with a chiropractor, but the selling of nutrititional supplements is clearly a lucrative part of many chiropractic offices. The value of all of these services is much more in question than “standard” chiropractic spinal adjustment.
- Applied kinesiology muscle testing is a bizarre alternative medicine method of diagnosis and prescription. (It has nothing to do with actual kinesiology, the study of human movement.) It’s based on the idea that fluctuations in muscle strength reveal patient sensitivities and needs, reacting to probing questions or substances placed within the body’s energy field. AK is too ridiculous to have ever been studied scientifically, and has been properly debunked: it’s based on well-documented illusions and psychology, particularly the ideomotor effect. See Applied Kinesiology is Bunk: The skeptical position on applied kinesiology, a bizarre alternative medicine method of diagnosis.
- Department of Health and Human Services, Office of Inspector General. Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply With Medicare Requirements. oig.hss.gov. 2016. PainSci #53330 ❐
- Lindsay, Bethany. Chiropractor crackdown: College gives ultimatum on misleading health claims. CBC.ca. Oct 15, 2018.
- Always a bit murky, the definition of the chiropractic subluxation and its correction has broadened over the years to the point of absurdity, and now includes any harmful “imbalance or distortion” anywhere in the body (see The Role of Subluxation in Chiropractic). Subluxation has effectively come to simply mean “something wrong that chiropractors fix.”
- Funk MF, Frisina-Deyo AJ, Mirtz TA, Perle SM. The prevalence of the term subluxation in chiropractic degree program curricula throughout the world. Chiropr Man Therap. 2018;26:24. PubMed #29988608 ❐ PainSci #53049 ❐
“Despite the controversies and paucity of evidence the term subluxation is still found often within the chiropractic curricula of most North American chiropractic programs.”
- Gliedt JA, Hawk C, Anderson M, et al. Chiropractic identity, role and future: a survey of North American chiropractic students. Chiropr Man Therap. 2015;23(1):4. PubMed #25646145 ❐ PainSci #54179 ❐
This survey of more than 7000 chiropractic students showed that traditional chiropractic subluxation theory is alive and well. 61% agreed that the “emphasis of chiropractic intervention is to eliminate vertebral subluxations/vertebral subluxation complexes … while a larger percent found it is important to learn about evidence-based practice. These two key points may seem contradictory, suggesting cognitive dissonance.”
Or perhaps it just suggests a woeful ignorance of what evidence-based medicine actually is. A lot of CAM practitioners happily pay lip service to EBM. It’s easy to sound science-y while cherry-picking junk science that confirms biases.
- Sciencebasedmedicine.org [Internet]. Homola S. Opposing Chiropractic: Persecution or Justified Criticism? – Science-Based Medicine; 2015 Feb 1 [cited 19 Oct 24].
Clinging to the theory that gave it birth and independence, the chiropractic profession continues to define chiropractic as method of removing nerve interference or correcting vertebral subluxations to restore and maintain health. State laws using vertebral subluxation theory to define and license chiropractors remain unchallenged. According to the National Board of Chiropractic Examiners in the United States:
The specific focus of chiropractic practice is known as the chiropractic subluxation or joint dysfunction. A subluxation is a health concern that manifests in the skeletal joints, and through complex anatomical and physiological relationships, affects the nervous system and may lead to reduced function, disability, or illness. (Christensen MG, et al. Practice Analysis of Chiropractic. National Board of Chiropractic Examiners. Greeley, Colorado. May 2010.)
- Mirtz TA, Morgan L, Wyatt LH, Greene L. An epidemiological examination of the subluxation construct using Hill's criteria of causation. Chiropractic & Osteopathy. 2009 Dec;17(1):13. PubMed #19954544 ❐ PainSci #55783 ❐ “Despite the controversies and paucity of evidence the term subluxation is still found often within the chiropractic curricula of most North American chiropractic programs.”
- Most scientific evidence about chiropractic therapy is of poor quality, plagued by common methodology errors, like abuses of statistics that tend to make chiropractic study results seem more “significant” than they are. For instance, chiropractors routinely claim that the benefits of spinal adjustment are “proven,” but Williams found that clinical trials have “shown an effect size for manipulation that is less than the threshold for what is clinically worthwhile.” In other words, spinal adjustment might be proven to do something … just not much. For much more information about these kinds of errors, see Statistical Significance Abuse: A lot of research makes scientific evidence seem more “significant” than it is.
- Mirtz TA, Morgan L, Wyatt LH, Greene L. An epidemiological examination of the subluxation construct using Hill's criteria of causation. Chiropractic & Osteopathy. 2009 Dec;17(1):13. PubMed #19954544 ❐ PainSci #55783 ❐
This landmark paper penned by four chiropractors is a strong indictment of a philosophical pillar of their own profession. Although a bit of a moving target over the years, subluxation theory generally refers to idea that spinal joint dysfunctions have broad health significance, which has been a major component of chiropractic thought since the founding of the profession. The authors analyze and condemn it:
No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal this leaves the subluxation construct in the realm of unsupported speculation.
And yet it’s been there for more than a century, I’d like to add.
- Do a Google search for “class action lawsuit chiropractic.” It’s remarkable.
- Neck911.com [Internet]. Statement of Concern to the Canadian Public from Canadian Neurologists Regarding the Debilitating and Fatal Damage Manipulation of the Neck May Cause to the Nervous System; 2009 [cited 09 Jul 19].
- Wand BM, Heine PJ, O’Connell NE. Should we abandon cervical spine manipulation for mechanical neck pain? Yes. BMJ. 2012;344:e3679. PubMed #22677796 ❐
- Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008 Feb;33(4 Suppl):S176–83. PubMed #18204390 ❐
Since its publication, “the Cassidy paper” has been the defensive citation used by chiropractors to respond to accusations that neck adjustments involve a risk of stroke, and therefore should not be conducted without proven benefit and informed consent. The abstract seems to strongly exonerate chiropractors: “We found no evidence of excess risk of VBA stroke associated with chiropractic care compared to primary care.”
“But abstracts are like movie trailers,” as Dr. Mark Crislip wrote. “They give a flavor of the movie, but often leave out many important plot devices and characters. … If you were to read this article in its entirety, you would not be so sanguine about the safety of chiropractic.” He goes on to explain exactly why in one of the earliest popular posts on ScienceBasedMedicine.org, Chiropractic and Stroke: Evaluation of One Paper.
- Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for acute low-back pain. Cochrane Database Syst Rev. 2012;9:CD008880. PubMed #22972127 ❐ PainSci #54694 ❐ More about this paper when I discuss SMT in more detail below.
- Sep 28, 2013, an Australian scandal started with this: Call for age limit after chiropractor breaks baby’s neck. The original report read: “A baby’s neck has been broken by a chiropractor in an incident doctors say shows the profession should stop treating children.” It may or may not have actually happened. The allegation was denied by the Chiropractors’ Association of Australia with an equally predictably disingenuous mixture of spin, assertion and avoidance of the real issues. What is clear is that “the response of the chiropractic profession to these cases is unsatisfactory, to say the least,” writes Dr. Novella. For a complete summary of the incident, see The chiropractic war with reality rages on …. See
- Walker BF. The new chiropractic. Chiropr Man Therap. 2016;24:26. PubMed #27366317 ❐ PainSci #53460 ❐ Dr. Walker’s sixteen “aberrant practices that cause significant reputational damage to the profession”:
- Adherence to a flawed chiropractic ideology centring on innate intelligence and vitalism
- I overheard a fine example: a chiropractor speaking to a patient about an upper cervical treatment said, “Your neck is now in God’s alignment.” It wasn’t just an adjustment, it was holy! Many religious chiropractors make a strong connection between spinal adjustment and getting right with God. I have seen chiropractic offices festooned with religious imagery. Any health care professional can be religious, but it’s a pretty safe bet that chiropractic has a higher percentage of Christian fundamentalists than any profession other than clerics.
- Palmer DD. The science, art and philosophy of chiropractic. Portland Printing House Company; 1910.
- College of Physicians and Surgeons of the Province of Quebec. The scientific brief against chiropractic. The New Physician, Sept 1966. Yes, this an old source! However, “men of science” (and women) remain unconvinced. The spirit of this statement is just as valid as it was more than forty years ago.
- Biggs L, Hay D, Mierau D. Canadian chiropractors’ attitudes towards chiropractic philosophy and scope of practice: implications for the implementation of clinical practice guidelines. J Can Chiropr Assoc. 1997;41(3):145–154. PainSci #57174 ❐ Less than 19 percent of Canadian chiropractors “reject traditional chiropractic philosophy as espoused by D.D. and B.J. Palmer and emphasize the scientific validation of chiropractic concepts and methods.”
- Keating JC. The Specter of Dogma. J Can Chiropr Assoc. 2001;45(2). PainSci #56491 ❐
Despite all of these genuinely progressive steps, the chiropractic profession here in North America may be slipping backwards. I perceive that we are at risk of returning to the antiscientific and dogmatic traditions that we have worked so hard to shake off during the past several decades. This apparently unrecognized reversion to the uncritical and unskeptical tendencies of early day chiropractic has everything to do with politics and economics and nothing to do with science. For more than a century chiropractors have fended off the efforts of organized, political medicine to ‘contain and eliminate’ this profession. In the process, deep rifts have formed among chiropractors. I’m not speaking here merely of the well-known division between ‘straights’ and ‘mixers,’ but more importantly about the chasm between those who would see chiropractic progress as a scientific healing art and those who are committed to old-time biotheology and ‘phoooolosophy.’ Today, chiropractors are hungry, one might even say desperate, for unity. It is this deeply felt yearning for unity, I believe, which places the scientific integrity of the profession at risk. We are at risk of accepting dogma and pseudoscience and ambiguous platitudes in order to come together.
- Fernández-de-Las-Peñas writes “There are few published randomized controlled trials analyzing the effectiveness of spinal manipulation and/or mobilization … in the last decade.” Bronfort: “There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up.” The 2006 Cochrane review of SMT found only 39 experiments to analyze, and most of those had small sample sizes.
- Ernst E, Posadzki P. An independent review of NCCAM-funded studies of chiropractic. Clin Rheumatol. 2011 Jan. PubMed #21207089 ❐
Dr. Edzard Ernst is a highly qualified critic of sloppy researchers in alternative medicine. In this review of The National Center for Complementary and Alternative Medicine (NCCAM) studies of chiropractic therapy, he finds that “their quality was frequently questionable. Several randomized controlled trials failed to report adverse effects and the majority was not described in sufficient detail to allow replication.” But if NCCAM cannot produce the best quality studies of alternative medicine, who can? No organization has ever been better funded (or motivated) to validate alternative therapies.
Ernst concludes: “It seems questionable whether such research is worthwhile.”
- Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine. 2004;4(3):335–356.
This large and complex review comes to no firm, simple conclusions. It presents tentative evidence that some kinds of SMT are probably effective under some conditions.
- Jüni P, Battaglia M, Nüesch E, et al. A randomised controlled trial of spinal manipulative therapy in acute low back pain. Ann Rheum Dis. 2009 Sep;68(9):1420–7. PubMed #18775942 ❐
In this good test of SMT, researchers took a hundred patients with nasty, fresh cases of low back pain, and delivered half of them into the care of chiropractors, and the other half into “standard care” — advice and ordinary pain medications, namely. Note that it has often been argued that SMT is best for acute low back pain, not chronic, so this is right in chiropractic’s strike zone: if there is anything remotely impressive about SMT, it should have done well in this contest. It should have pulled out a can of whupass on “advice and meds.” It did not.
SMT and standard care did equally well — or equally poorly, if you prefer. All the patients had the same experience that pretty much everyone with chronic back pain has. The researchers found that “SMT is unlikely to result in relevant early pain reduction in patients with acute low back pain.”
- Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for acute low-back pain. Cochrane Database Syst Rev. 2012;9:CD008880. PubMed #22972127 ❐ PainSci #54694 ❐ Despite this, the rest of their conclusions seem crafted to prolong the controversy. They explain to clinicians why they should still refer patients for SMT (“preferences” and “costs”); they say that more research is needed to “examine specific subgroups.” (This is based on the faint hope that SMT might work well for an unknown subcategory of patients that they can pull up the average, but see Saragiotto 2016, Saragiotto 2017.) And they say there’s a need for “an economic evaluation,” but if a treatment is not effective, it can’t be “cost effective.” If it were possible to report good news on this topic, these authors would probably do so. But they have not.
- For many years now I have been looking forward to getting around to writing an article all about this. Unfortunately, I have not yet made the time. Meanwhile, suffice it to say that the dominant theory of joint popping depends on the concept of “cavitation” — the rapid formation and explosive collapse of bubbles in a liquid due to pressure changes. The theory is full of holes and doesn’t begin to explain many features of joint popping, in particular the “recharge” phenomenon, wherein joints that supposedly cavitated nicely just a moment ago need to be left alone for seconds, minutes or hours before they can cavitate again. Also, the cavitation hypothesis does not explain why there is such significant variation between individuals and between joints. It is, in short, almost certainly wrong or incomplete.
- Proprioception is the sense of position and movement. See Proprioception, the True Sixth Sense.
- The National Center for Complementary and Alternative Medicine (https://nccih.nih.gov)
NCCAM, the biggest pro-alternative-medicine institution in history, publishes this page to summarize homeopathic issues and science, but admits that “there is little evidence to support homeopathy,” despite their extremely well-funded mandate to produce that evidence over many years.
- This seems to be NCCAM’s modus operandi, of course: they can’t say anything positive about the evidence supporting most alternative treatments … so they just don’t say anything negative. Allow me …