Listening to people talk about their aches, pains and injuries is part and parcel of working in the fitness industry. So to is hearing about what treatments those same people have received to deal with them. One common form of treatment I hear people mention a lot is chiropractic.
I was reminded of this recently when I came across an article which apparently suggested that back pain was turning gyms into no go areas for Brits. The article was from the Mail Online (don't get me started!) and the source of the information was the British Chiropractic Association. While it would be interesting to break this claim down, I thought I'd use this post to talk about chiropractic in general, as from my experience a lot of people, including most who work in health & fitness, know little if anything about the practise.
So here goes; chiropractic in a nutshell.
Before the days of evidence based medicine
Way back in the 1890s Daniel David Palmer, a magnetic healer from what is now Ontario, claimed to have cured a mans deafness by manipulating his spine. He then went on to develop the theory that misalignment of the bones in the body was the basic underlying cause of all disease and the majority of these misalignments were in the spinal column. The reason for this he claimed was that the body contained an flow of innate intelligence, a vitalistic energy or life force that represented gods presence in man. Interruption to this flow though joint misalignment would lead to disease and adjustment of the joints would restore the flow leading to a restoration of health. The majority of these misalignments were, according to Palmer, in the spine and he called them subluxations.
If you look in a medical dictionary for the word subluxation, it is defined as an incomplete or partial dislocation of a joint or organ. Simple. The chiropractic definition is somewhat different. The WHO definition of the chiropractic vertebral subluxation is:
A lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact.
If you've read my post on how to spot a snake oil salesmen you might remember me mention that they often hide the lack of substance to their claims by dressing them up in scientific sounding words or jargon! But I'm getting ahead of myself.....
Medically defined joint subluxations are by definition visible on x-ray, chiropractic ones are often not but are somehow detected by feel. None of this paints a good picture of chiropractic but to be fair the practise has changed somewhat over the years, well, at least to a certain extent.
Straights and mixers
Chiropractors can be divided into two types; those termed as straight and those termed as mixers.
Straight chiropractors are essentially traditional in their approach, that is they stick to the original principles of the practice, retaining the metaphysical and vitalistic principles that the practise was founded on. They adhere firmly to subluxation hypothesis which, as I've just outlined, suggests that the 'misalignment' of joints, especially in the spine are responsible for all disease. Straights tend not to be open to conventional medical practices which firmly places them in the Alternative Medicine bracket. To put it simply, these quacks should be avoided like the plague.
Mixers, as the term suggest, mix diagnostic and treatment methods from more mainstream medicine together with the more traditional chiropractic practices. They believe that subluxation is one of many causes of disease and today this approach is by far the most commonly practised amongst chiropractors.
Still stuck in the past
As I touched upon above, many mixers (62% according to a 2003 survey) still adhere to the belief that subluxations cause some disease, specifically for example, the heart, lungs or stomach, although a 2008 survey suggested that the majority now think they are of limited utility for addressing such disorders, favouring instead non-subluxation approaches for these types of conditions. The same survey did however suggested subluxation was the main clinical chiropractic approach for musculoskeletal issues. At this point I should remind you that in any conventional medical sense, 'chiropractic subluxations' don't exist!
So now we have a basic understanding of how chiropractors tick let's have a look at what evidence there is for the efficacy of chiropractic treatment. The title of this post is chiropractic in a nutshell and in a nutshell I can say there is no evidence what so ever for the efficacy of chiropractic in it's traditional (straight) sense. Chiropractic subluxations don't exist and the vitalistic force that heals the body after disruptions have been corrected has of course never been measured. Even when discs are herniated and severely compressing spinal nerves they do not cause disease. There is no plausible connection between structural and/or functional joint issues (imaginary or otherwise) and general health. If a chiropractor tells you differently, they are, to put it politely, being dishonest.
But what about general musculoskeletal issues?
A systematic review in 2013 found low to moderate evidence that spinal manipulation therapy (which is what chiropractic essentially is) was no more effective than inert interventions, sham manipulation or as an adjunct therapy, for acute lower back pain.
Another review of evidence in 2012 suggested spinal manipulation was not an effective intervention for pain and another from 2011 suggested there was no meaningful difference between spinal manipulation therapy and other treatments such as physical therapy and massage for reducing lower back pain or increasing function.
What about neck issues?
A review of the literature in 2010 found what it termed 'low quality evidence' that suggested manipulation of the cervical spine (neck) may offer better short term pain relief than a control for neck pain.
A 2011 review found that thoracic spinal manipulation may offer short term improvement for the treatment of acute (recently acquired if you like) and sub-acute (persistent for some time) neck pain. Note the inclusion of the qualifier 'may' in both of the above examples. The body of evidence is by all accounts weak for the chiropractic treatment of neck pain as it is for lower back issues and there is little if any evidence that it can help with other non spine related musculoskeletal problems. There is also some risk involved with neck manipulation but I'll come on to that later.
From my experience (yes i know, personal testimony, not good ;-) people think that chiropractic is a conventional treatment. By this I mean aligned somehow with conventional medicine. If you've got a musculoskeletal problem someone's far more likely to say "why don't you go and see a chiropractor" than "why don't you go and see a reiki therapist". However they are both born out of pseudoscience with little or no evidence for their efficacy. (actually no evidence for the effectiveness of reiki but that's another story!) As I've said even when you discard the pseudoscientific principles and look at chiropractic from a more conventional medical stand point, you still end up with something that seemingly offers its patients little if anything by the way of effective treatment.
And here in lies the problem.
From my perspective, if a practise is to be allied with conventional medicine it should at least be able to demonstrate, with the same rigour as conventional medicine has to, that what it offers is beneficial. Chiropractic it seems, has yet to meet this criteria.
You could argue that chiropractic falls well and truly into the bracket of alternative medicine which I think is a little unfair as there is at least some evidence for it's efficacy in certain areas. Fundamentally there is no such thing as alternative medicine, medicine either works or it doesn't and that which doesn't is worthless quackery. Chiropractic teeters on the edge of the alternative medical abyss and clings to the ledge by presenting the contemporary professional image of conventional medicine and not mentioning it is based, at it's core, on principles that are complete hooey.
The modern face of chiropractic (in the UK at least)
In the UK chiropractic is overseen by the General Chiropractic Council (GCC). A quick look on the GCC's website reveals a slick and modern organisation that regulates the practice for;
the benefit of practitioners and patients.
No where will you find a mention of innate intelligence, vitalism or any of the pseudoscience that the practice was founded upon. What you do get is a description of a;
"health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system and the effects of these disorders on the function of the nervous system and general health. "
It also says:
"there is an emphasis on manual treatments including spinal adjustments and other joint and soft tissue manipulation."
Chiropractors have a specialist interest in neck and back pain but take a patient's entire physical wellbeing into account. (what ever that means)
They may also offer advice about diet, exercise and lifestyle and rehabilitation programmes. Some chiropractors may also offer other treatments such as acupuncture (oh dear! but lets not go there!)
This all sounds very conventional (let's forget the acupuncture bit!) but remember, the only evidence for the efficacy of their approach (and shaky evidence at that) is for using spinal manipulation for lower back pain, neck pain and related issues such as head aches.
If modern chiropractic was concerned only with what is evidence based it would be perhaps hard for it to distinguish itself from conventional physiotherapy, so to maintain it's status as something different it clings to that for which there is little or no evidence. A 2007 study of UK chiropractors, in a chiropractic journal no less, suggested the majority of chiropractors still think that non-musculoskeletal conditions including asthma (64%,) gastrointestinal complaints (61%) and pre-menstrual syndrome (70%), could be treated using chiropractic management! Also, rather more worryingly, more than 50% of chiropractors think that infantile colic, otitis media (middle ear infection) and asthma could benefit from chiropractic!! This information is I know 10 years old but worrying none the less. As recently as 2014 the GCC itself was criticised by the Professional Standards Authority who were concerned about deficiencies found in its professional standards. These deficiencies were subsequently addressed but it doesn't shed a good light on the body that oversees the profession.
What's the harm?
The question of what are the risks associated with chiropractic treatment is hard to quantify but a risk certainly seems to exist, especially following treatment to the cervical spine. A systematic review published in the Journal of the Royal Society of Medicine (JRSM) found nearly 200 patients were considered to have been seriously harmed by spinal manipulation of the neck with the most common serious issues arising from dissection of the vertebral artery followed by stroke! According to a review of published cases in the Journal of Clinical Practise in 2010, 26 deaths had been published in the medical literature after chiropractic neck manipulation and it suggested that many more may have gone unpublished. Both papers do suggest the exact incidence of such events remain unknown but with the risks in mind you'd hope that, from an ethical perspective, all chiropractors would be rigorous in their application and adherence to informed consent. However, according to the JRSM article, in 2007, when the study was published, this was not the case. We can only hope it is different now!
To finish I'll leave you all with a quote from Edzard Ernst the former Emeritus Professor of Complimentary Medicine at Exeter University.
as long as serious doubts about the value and integrity of chiropractic exist we should remember an important foundation of health care: the precautionary principle. It compels us whenever possible to use only those therapies which demonstrably generate more good than harm. A critical analysis of the evidence shows chiropractic does not belong in this category.
Fitness Skeptic Score
Chiropractic gets an FSS of:
If you have simple lower back pain you may benefit from some spinal manipulation therapy. But remember a suitably qualified physiotherapist could do the same. If you have problems in your cervical spine (neck) I would avoid any manipulative treatment and see a physiotherapist for some alternatives. If you have musculoskeletal issues that are not back related you will definitely be better off seeing a physiotherapist and if you have any non musculoskeletal health issues, for heaven sake go and see your doctor!
"Chiropractic: a critical evaluation". Journal of Pain and Symptom Management, May 2008.
Spinal manipulation: an update of a systematic review of systematic reviews". N Z Med J. 2011
The adverse effects of spinal manipulation; a systematic review. Journal of the Royal Society of Medicine. July 2007.
The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance? Annals of Internal Medicine June 2002.
Spinal manipulative therapy for acute low back pain: an update of the cochrane review". Spine (Systematic Review) Feb 2013.
Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review". Spine (Systematic review) June 2011
"Is spinal manipulation effective for pain? An overview of systematic reviews". Pain Med. 2012.
Manipulation or mobilisation for neck pain: a Cochrane Review". Man Ther. August 2010.
Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: a systematic review". J Orthop Sports Phys Ther. September 2011.
Deaths after chiropractic: a review of published cases. International Journal of Clinical Practise July 2010.
The scope of chiropractic practise: A survey of chiropractors in the UK. Clinical Chiropractic, Sept 2007.