full article 6500 words
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 patients should be aware of.
I purchase chiropractic therapy myself on occasion, primarily because I have a long-term craving for upper thoracic spine cracking. I recommend some chiropractic therapy to friends and readers. 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
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”
“Chiropractic” is many things. Does chiropractic work for what? Does what kind of chiropractic treatment work? 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 particular 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. It’s important to Choose the Therapist, Not the Therapy. Consumers need to be aware of the issues to help them choose a chiropractor.
I am not highly qualified and I am extremely biased. And so all I will do here is summarize the issues in a readable way, and quote the opinions of experts who are qualified, and cite and summarize some of the same scientific evidence that they do. I have no wish to re-invent the wheel: there are already many excellent books available on this topic. This is a quick tour, not a tour de force.
Judging the value of chiropractic therapy is best left to the experts who have already done it, to the progressive chiropractors and critics from within the profession like Dr. Samuel Homola,5 Dr. Bruce Walker,6 Dr. Donald Murphy,7 and Dr. Preston Long8; relatively progressive chiropractic regulatory agencies9; activist physicians like Dr. Stephen Barrett,10 Dr. Stephen Novella,11 or the especially credible Dr. Edzard Ernst12 (who has such great experience with both medical science and alternative therapies); and science journalists like Simon Singh,13 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.14 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
Whatever anyone thinks about chiropractic, 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? In a nutshell:
In more detail…
I’m not answering these questions here — 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 even 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.31
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.
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.32
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.”33 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.”34
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”).35 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.”36 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)
Even if the original idea significance of subluxation as a cause of disease is discarded, is there a more ordinary justification for manipulating the spine for the treatment of 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.37 Even the most promising sources of research have had serious quality control problems.38
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,39 and subsequent experiments continue to damn SMT with faint praise, showing that it works only a little at best.40 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.41
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.
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.42 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.43 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.
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 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!
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
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.
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.)
— Added a mobile-only article summary.
— Editing and reorganization of the introduction, a new summary of the main controversies, and a significant new reference about Medicare billing.
— Cited Bruce Walker’s “aberrant practices that cause significant reputational damage to the profession” (Walker).
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.BACK TO TEXT
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.BACK TO TEXT
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.BACK TO TEXT
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.BACK TO TEXT
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. BACK TO TEXT
An 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. BACK TO TEXT
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.BACK TO TEXT
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.BACK TO TEXT
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 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.BACK TO TEXT
BACK TO TEXT
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.
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.”BACK TO TEXT
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.BACK TO TEXT
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.”BACK TO TEXT
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.BACK TO TEXT