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WillowOne's Positions

Chiropractic

My Positions

  1. The founding theory of chiropractic, that "vertebral subluxations" block the flow of nerve energy and cause disease throughout the body, is false. The subluxations do not show on any x-ray and the nerve energy does not exist.
  2. For low back pain, spinal manipulation is about as good as exercise or physiotherapy, which is to say modestly good. For everything else it has been sold for (asthma, colic, ear infections, bed-wetting, "boosting immunity") there is no evidence at all.
  3. Manipulating the neck carries a small but real risk of tearing the vertebral artery and causing a stroke, for a benefit over exercise that has never been shown. Nobody is cracking mine.
  4. Statutory regulation of chiropractors in the UK was a category error. Regulating a profession confers legitimacy, and the state should not be in the business of lending legitimacy to a theory it knows to be wrong.

Notes

  1. The origin story. Chiropractic was invented in Davenport, Iowa, in 1895 by Daniel David Palmer, a grocer and magnetic healer, who claimed to have restored the hearing of a deaf janitor by pushing a vertebra back into place. The nerve to the ear does not pass through the spine. Palmer later wrote that he had received the principles of chiropractic from the spirit of a dead physician at a séance and considered establishing it as a religion, and his son turned it into a business with a school, a radio station and a line of x-ray machines. The profession has spent a century trying to live this down, which is to its credit, but it has never quite renounced the subluxation, because the subluxation is what distinguishes a chiropractor from a physiotherapist.
  2. The evidence. Edzard Ernst's 2008 critical evaluation and the Cochrane and BMJ reviews since agree: spinal manipulation for chronic low back pain produces results similar to the other recommended conservative treatments, and no better. For neck pain the evidence is weaker. For the non-musculoskeletal conditions that chiropractors have advertised, including infant colic, asthma, otitis media and enuresis, there is no good evidence of benefit, and most of what exists was produced by chiropractors. A profession whose only supported indication is one that physiotherapists treat as well has an identity problem, and it solves it by expanding the indications rather than contracting the claims.
  3. The libel case. In April 2008 Simon Singh wrote in The Guardian that the British Chiropractic Association "happily promotes bogus treatments" for childhood conditions. The BCA sued him personally. The case took two years, cost Singh a sum he has described as the price of a house, and ended in April 2010 when the Court of Appeal ruled that his words were comment and the BCA dropped the action. The by-products were more instructive than the verdict: the sceptic community filed complaints against several hundred chiropractors for advertising the same claims, one chiropractic association told its members to take down their websites, and the case became the test case for the Defamation Act 2013. The BCA was asked, during all this, to produce its evidence for the childhood claims; the "plethora" it produced was dismantled in the BMJ in a week.
  4. The stroke risk. The vertebral arteries thread through the neck vertebrae, and a sharp rotational thrust can tear them. A 2007 review found some seven hundred serious adverse events in the literature, including 26 deaths, and a well-known case is the American model Katie May, who died in 2016 after a neck adjustment; the coroner recorded the manipulation as the cause. The profession's best defence, a 2008 Canadian study, found that stroke patients had visited chiropractors and GPs at similar rates beforehand, suggesting that some of them already had a dissection in progress and sought help for the pain. That may be partly right. It does not change the ratio: a treatment with no benefit over exercise and a non-zero risk of stroke loses the comparison even if the risk is small, and the honest answer to "how small" is that nobody has collected the data, because nobody is required to.
  5. The culture. Palmer opposed vaccination, and the profession has carried the tendency ever since; surveys repeatedly find a large anti-vaccine minority among chiropractors, and in 2019 Australia's regulator had to intervene after a Melbourne chiropractor filmed himself dangling a two-week-old baby by the ankles. The business model, which depends on x-raying everyone, finding something on every film and selling a lifetime of "maintenance adjustments", is the model of a subscription service, not a treatment. The evidence-based minority of chiropractors who treat back pain, decline to adjust infants and send the asthma to a doctor exist, and I have no quarrel with them, except that they are practising physiotherapy under a name that misleads their patients about what they do.
  6. Regulation. The General Chiropractic Council was created by statute in 1994, before the evidence above was collected, and it now polices the standards of a practice whose central theory its own members cannot agree on. I would rather the state regulated the claims than the title: let anyone manipulate a consenting adult's back, and prosecute anyone who tells a parent it will cure their child's asthma. That is what the Singh case did, by accident, and it worked better than the regulator had.

Sources

  • Ernst, E., "Chiropractic: A Critical Evaluation", Journal of Pain and Symptom Management 35 (2008)
  • Rubinstein, S. M. et al., "Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis", BMJ 364 (2019)
  • Ernst, E., "Adverse effects of spinal manipulation: a systematic review", Journal of the Royal Society of Medicine 100 (2007)
  • Cassidy, J. D. et al., "Risk of Vertebrobasilar Stroke and Chiropractic Care", Spine 33 (2008)
  • British Chiropractic Association v Singh [2010] EWCA Civ 350 — https://www.bailii.org/ew/cases/EWCA/Civ/2010/350.html
  • Singh, S., "Beware the spinal trap", The Guardian, 19 April 2008
  • Simon Singh and Edzard Ernst, Trick or Treatment? Alternative Medicine on Trial (2008), chapter 4
  • Palmer, D. D., The Chiropractor (1914), for the séance in his own words

Also see