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Chiropractic

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CONTENTS

1. WHAT IS IT?

2. DOES IT WORK?

3. WHAT'S THE EVIDENCE?

4. SUMMARY OF PROPOSED USES FOR CHIROPRACTIC

5. IS IT SAFE?

6. TOO LONG; DIDN'T READ! (TLDR)

7. REFERENCES

WHAT IS IT?

Chiropractic is a system of alternative medicine that is based upon “subluxation theory”. This theory suggests that [1]:

1) Health is related to the alignment of the spine

2) Subluxations (misalignments of the vertebrae) cause poor health/disease

3) Correcting subluxations (via spinal manipulation) improves health

In this context, “poor health/disease” refers to essentially any health condition, not just those limited to the spine. In other words, chiropractic suggests that the root cause of most disease is spinal misalignment.

It should be noted: there is no credible evidence to suggest that subluxation theory is correct (for anything other than actual spine-related problems) [2]. For example, there is no reason to believe that spinal misalignment/subluxation causes asthma, menstrual pain, heart disease, or other non-musculoskeletal problems.

 
Subluxation Theory
 

The majority of modern chiropractors do not adhere strictly to the principles of subluxation theory and tend to view themselves as back pain specialists [1]. However, many chiropractors still incorporate traditional subluxation theory into their practice and believe that spinal misalignment is the cause of many diseases [1].

Many chiropractors also hold anti-vaccine viewpoints, which are in direct conflict with the scientific consensus on the importance of vaccination [3-5]. The International Chiropractors Association (ICA) and the American Chiropractic Association (ACA) [6-7] do not endorse vaccination programs. The ICA’s official policy [6] states:

“The International Chiropractors Association recognizes that the use of vaccines is not without risk and questions the wisdom of mass vaccination programs.  Chiropractic principles favor the enhancement of natural immunity over artificial immunization.”

However, many other chiropractors do support vaccination. The Canadian Chiropractic Association endorses public immunization [8].

Spinal Manipulation Therapy

Spinal manipulation therapy is the primary treatment-type used by chiropractors. However, it is also used by other health service providers, such as physical therapists and osteopaths [9].

Spinal manipulation involves the movement of the spinal joints near the end of their normal range of motion. This movement is achieved by providing a high-speed “thrust” to the joint, over a short distance (low-amplitude). Often, the manipulation is accompanied by a “cracking” sound.

Spinal manipulation therapy may be directed towards any part of the spine – cervical (neck), thoracic (mid-back), lumbar (low-back), sacral (within hips), or costovertebral/costotransverse (rib-spine joints).

DOES IT WORK?

Mostly, no.

In the case of chronic low back pain, spinal manipulation therapy appears to be as effective as other conventional treatments [9].

For neck pain, there is no difference between spinal manipulation therapy and gentler physical techniques (mobilisation). Whether or not either of these is truly effective remains unclear [10].

Little to no evidence supports the use of spinal manipulation therapy for any other health condition.

WHAT'S THE EVIDENCE?


 

Quick Definition: "Systematic Review"

A systematic review (and/or “meta-analysis”) is a scientific study that examines the agreement between many clinical trials. Instead of looking at a single study, systematic reviews attempt to analyse the totality of evidence related to a topic. By doing so, the true answer to a given question can be more accurately estimated. For example, a single study might indicate that a particular treatment is effective, leading readers to believe that this treatment works. However, what if three other studies conclude that the same treatment does not work? A systematic review might analyse the data from all four of these trials and conclude (correctly) that the totality of the evidence indicates that the treatment does not work (3 say no, only 1 says yes). The relative importance of each study is determined by things like study size (number of participants – more is better), chance for bias, consistency of measurements, and many others.

Because of their strength, systematic reviews are generally considered one of the highest standards of evidence. However, they are also not perfect, and are subject to the quality of the contributing clinical studies. Hence, if only low-quality studies are used, low-quality results will emerge (a.k.a. “garbage in, garbage out”).

 

Chronic Low Back Pain ("Chronic" = Pain Persisting Greater Than 12 Weeks)

The strongest evidence for the effectiveness of spinal manipulation therapy is for the treatment of chronic low back pain, one of the most common uses for this practice. A systematic review that examined the agreement between many clinical trials of spinal manipulation therapy for chronic low back pain demonstrated that the practice appears to be as effective as other treatments for this condition [9]. “Other treatments” included exercise therapy, physiotherapy, pain-killers, massage, standard medical care, and others. In this context, “as effective” meant “no better or worse”. In other words, spinal manipulation therapy is no better or worse than exercise therapy, physiotherapy, or standard medical care.

A more recent clinical trial also demonstrated that spinal manipulation therapy, when added to home exercise advice, provides additional short-term (but not long-term) pain relief [11]. That is, if patients are told to perform pain-relieving exercises at home, the addition of spinal manipulation therapy appears to provide extra pain relief [11]. However, another recent study revealed that spinal manipulation therapy is not clinically different from “sham” spinal manipulation (i.e. “fake” or “control” therapy) [12]. In this study, half of the patients were given usual chiropractic care (including spinal manipulation), while the other half received “sham” therapy that consisted of inactive interventions (e.g. pressing on the patient’s back with little to no force) that are not believed to have any clinical effects. When the two groups (usual chiropractic care vs sham therapy) were compared, there was no clinically relevant difference in their pain or physical function. In other words, the effects of adding spinal manipulation to home exercise advice are probably not specific to spinal manipulation per se – adding any other comparable treatment (or perhaps even “sham” therapy) would likely have the same effect.

Overall: spinal manipulation therapy appears to be no better or worse than other treatments for chronic low back pain. Hence, if other options are more accessible or more affordable, they may be preferable.

Acute Low Back Pain ("Acute" = Pain For Less Than 6 Weeks)

A systematic review that examined the agreement between many clinical trials of spinal manipulation therapy for acute (short-term) low back pain concluded that no reliable evidence exists to suggest that spinal manipulation should be recommended for this use [13]. In this context, spinal manipulation was no better than sham (fake) spinal manipulation, inactive therapies, or other treatments. Therefore, when it comes to treating short-term low back pain, spinal manipulation therapy probably does not work.

 
Chiropractic Back Pain
 

Neck Pain

Chiropractic therapy is commonly promoted for the treatment of neck pain. However, there is an important distinction between two methods of neck-related treatment: spinal manipulation and mobilisation.

Spinal manipulation (as described above) involves “a localized force of high velocity and low amplitude directed at specific spinal segments”, usually moving a joint near the end of its clinical range of motion [10]. Mobilisation, on the other hand, “use[s] low-grade/velocity, small- or large-amplitude passive movement techniques or neuromuscular techniques within the patient’s range of motion and within the patient’s control” [10]. Simply put, mobilisation is gentler than manipulation and it avoids the high-speed neck movements that are characteristic of manipulation.

In another systematic review, the results of many clinical trials were analysed to assess the effectiveness of manipulation and mobilisation for the treatment of neck pain [10]. This study concluded:

1) There is no difference between manipulation and mobilisation.

2) No high-quality evidence was found to suggest that manipulation or mobilisation is effective at treating neck pain.

In other words, since both manipulation and mobilisation produce the same effects, the gentler approach (mobilisation) is probably preferable if patients decide to pursue chiropractic treatment for neck pain. However, whether or not either of these options even works at all remains unclear.

 
Manipulation and Mobilisation
 

Other Conditions

Little to no evidence supports the use of spinal manipulation therapy for any other health condition [14] [see table below]. This includes asthma, menstrual pain, infantile colic, bedwetting in children, carpal tunnel syndrome, fibromyalgia, gastrointestinal problems, and others [2, 15-23]. Given that chiropractic treatment typically only involves manipulation of the spine (and no other organ systems/physiological process), this is perhaps unsurprising.

SUMMARY OF PROPOSED USES FOR CHIROPRACTIC

 
Summary Chiropractic
 

IS IT SAFE?

Generally speaking, chiropractic spinal manipulation appears to be relatively safe, and serious adverse events (side effects) are rare [10, 24-27]. However, such events do occur.

Serious adverse effects of spinal manipulation may include:

  • Stroke (particularly with neck manipulation)
  • Disk herniation
  • Cauda equina syndrome (a serious neurologic condition affecting the lower spinal cord)

It should also be noted that indirect harm can come from chiropractic treatment if it serves to delay or replace necessary evidence-based treatments. This is true of all forms of natural health practices.

TOO LONG; DIDN'T READ!

With respect to spinal manipulation therapy:

For chronic low back pain: spinal manipulation therapy appears to be as effective as other conventional treatments.

For neck pain: gentler techniques (i.e. mobilisation) work the same.

For everything else: there is little to no evidence to support the use of spinal manipulation therapy.

REFERENCES

1)  Ernst E. Chiropractic: A critical evaluation. Journal of Pain and Symptom Management. 2008;35(5):544–562. doi:10.1016/j.jpainsymman.2007.07.004.

2)  Mirtz TA, Morgan L, Wyatt LH, Greene L. An epidemiological examination of the subluxation construct using hill’s criteria of causation. Chiropractic & Osteopathy. 2009;17(1):13. doi:10.1186/1746-1340-17-13.

3)  Russell ML, Injeyan HS, Verhoef MJ, Eliasziw M. Beliefs and behaviours: Understanding chiropractors and immunization. Vaccine. 2004;23(3):372–379. doi:10.1016/j.vaccine.2004.05.027.

4)  Campbell JB, Busse JW, Injeyan HS. Chiropractors and vaccination: A historical perspective. PEDIATRICS. 2000;105(4):e43–e43. doi:10.1542/peds.105.4.e43.

5)  Busse JW, Morgan L, Campbell JB. Chiropractic Antivaccination arguments. Journal of Manipulative and Physiological Therapeutics. 2005;28(5):367–373. doi:10.1016/j.jmpt.2005.04.011.

6)  International Chiropractors Association (ICA). http://www.chiropractic.org/vaccination-mandates.

7)  American Chiropractic Association (ACA). Public Policies: Vaccination. http://www.acatoday.org/About/Public-Policies.

8)  Canadian Chiropractic Association (CCA). Code of Ethics: Vaccination and Immunization. http://www.chiropractic.ca/about-cca/code-of-ethics/vaccination-immunization/.

9)  Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database of Systematic Reviews. February 2011. doi:10.1002/14651858.cd008112.pub2.

10)  Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database of Systematic Reviews. September 2015. doi:10.1002/14651858.cd004249.pub4.

11)  Bronfort G, Hondras MA, Schulz CA, Evans RL, Long CR, Grimm R. Spinal manipulation and home exercise with advice for Subacute and chronic back-related leg pain. Annals of Internal Medicine. 2014;161(6):381. doi:10.7326/m14-0006.

12)  Walker BF, Hebert JJ, Stomski NJ, Losco B, French SD. Short-term usual Chiropractic care for spinal pain. Spine. 2013;38(24):2071–2078. doi:10.1097/01.brs.0000435032.73187.c7.

13)  Rubinstein SM, Terwee CB, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for acute low back pain. Spine. 2013;38(3):E158–E177. doi:10.1097/brs.0b013e31827dd89d.

14)  Ernst E, Canter P. A systematic review of systematic reviews of spinal manipulation. Journal of the Royal Society of Medicine. 2006;99(4):192–196. doi:10.1258/jrsm.99.4.192.

15)  Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database of Systematic Reviews. April 2005. doi:10.1002/14651858.cd001002.pub2.

16)  Proctor M, Hing W, Johnson TC, Murphy PA, Brown J. Spinal manipulation for dysmenorrhoea. Cochrane Database of Systematic Reviews. July 2006. doi:10.1002/14651858.cd002119.pub3.

17)  Dobson D, Lucassen PL, Miller JJ, Vlieger AM, Prescott P, Lewith G. Manipulative therapies for infantile colic. Cochrane Database of Systematic Reviews. December 2012. doi:10.1002/14651858.cd004796.pub2.

18)  Huang T, Shu X, Huang YS, Cheuk DK. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews. December 2011. doi:10.1002/14651858.cd005230.pub2.

19)  O’Connor D, Marshall SC, Massy-Westropp N, Pitt V. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database of Systematic Reviews. January 2003. doi:10.1002/14651858.cd003219.

20)  Ernst E. Chiropractic treatment for fibromyalgia: A systematic review. Clinical Rheumatology. 2009;28(10):1175–1178. doi:10.1007/s10067-009-1217-9.

21)  Schneider M, Vernon H, Ko G, Lawson G, Perera J. Chiropractic management of Fibromyalgia syndrome: A systematic review of the literature. Journal of Manipulative and Physiological Therapeutics. 2009;32(1):25–40. doi:10.1016/j.jmpt.2008.08.012.

22)  Ernst E. Chiropractic treatment for gastrointestinal problems: A systematic review of clinical trials. Canadian Journal of Gastroenterology. 2011;25(1):39–40. doi:10.1155/2011/910469.

23)  Ernst E. Spinal manipulation for asthma: A systematic review of randomised clinical trials. Respiratory Medicine. 2009;103(12):1791–1795. doi:10.1016/j.rmed.2009.06.017.

24)  Stevinson C, Ernst E. Risks associated with spinal manipulation. The American Journal of Medicine. 2002;112(7):566–571. doi:10.1016/s0002-9343(02)01068-9.

25)  Gouveia LO, Castanho P, Ferreira JJ. Safety of Chiropractic interventions. Spine. 2009;34(11):E405–E413. doi:10.1097/brs.0b013e3181a16d63.

26)  Carlesso LC, Gross AR, Santaguida PL, Burnie S, Voth S, Sadi J. Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: A systematic review. Manual Therapy. 2010;15(5):434–444. doi:10.1016/j.math.2010.02.006.

27)  Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ. Assessing the risk of stroke from neck manipulation: A systematic review. International Journal of Clinical Practice. 2012;66(10):940–947. doi:10.1111/j.1742-1241.2012.03004.x.