Chiropractic: Does the Bad Outweigh the Good?
Samuel Homola, D.C.
Many people go to chiropractors for relief of back pain. But there is reason for caution. Much of what chiropractors do is nonsense, and they often misinform their patients.
Do you need to see a chiropractor? Many people think they do. Just about everyone thinks of a chiropractor when back pain is mentioned. There is considerable evidence that spinal manipulation can help relieve some types of neck and back pain. But neck manipulation can be dangerous. And according to a study published in the October 8, 1998, New England Journal of Medicine, spinal manipulation may be no more effective than physical therapy in the treatment of back pain and only marginally more effective than following a self-help instruction booklet. So what about chiropractic treatment?  Should you—or any member of your family—ever go to a chiropractor?
There is no doubt that dramatic relief of back pain will occasionally occur when manipulation is used to unlock a binding spinal joint. Many people with acute or chronic back pain experience relief of symptoms when the spine is loosened by manipulation performed by a chiropractor, an osteopath, a physical therapist, or an orthopedist. Manipulation is most readily available from chiropractors, however, and a report issued by the RAND Corporation stated that 94% of all such manipulation in the United States is done by chiropractors . For this reason, many people who have back pain will visit a chiropractic office where they will experience spinal manipulation for the first time.
A survey of Consumer Reports readers published in May 2000 found that 35% of 46,860 respondents had used alternative therapies for a variety of problems, 40% of whom had chiropractic treatment for back pain . The back-pain patients rated deep-tissue massage, chiropractic treatment, exercise, and physical therapy (in that order) as more effective than prescription drugs, acupuncture, over-the-counter drugs, and other forms of treatment.
Obviously, many people with back pain are going to chiropractors, and most of them are satisfied with the care they receive. But many are unaware of the controversy and the nonsense associated with some forms of chiropractic treatment and often become victims of misinformation.
The Theory of Chiropractic
It is now generally accepted that spinal manipulation can relieve some types of back pain. Most chiropractors claim to do more than just treat back pain, however. Clinging to the scientifically rejected theory that misasligned or "subluxated" vertebrae cause "nerve interference" that results in disease or ill health, many chiropractors use "spinal adjustments" to treat disease and infection as well as back pain. The Association of Chiropractic Colleges bolstered support for this theory in 1996 when the presidents of all 16 North American chiropractic colleges reached a consensus and issued a position paper stating that "Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation." .
The chiropractic profession continues to define itself as a method of correcting subluxations to restore and maintain health, despite the fact that there are no scientific studies to indicate that vertebral misalignment or any other problem in the spine is a cause of disease or infection. Basing their treatment on the vertebral subluxation theory, many chiropractors claim to be primary care physicians capable of treating and preventing a broad scope of human (and animal) ailments.
Some chiropractors advise that spinal adjustments should begin at birth to correct subluxations caused by "birth trauma." The entire family may be advised to undergo regular life-long spinal adjustments in order to maintain optimum health by "keeping the spine in line." Some chiropractors specialize in chiropractic pediatrics. According to the American Chiropractic Association, 10% of patient visits to chiropractors are made by children and adolescents who are treated for such maladies as otitis media, asthma, allergies, infantile colic, and enuresis (bedwetting).  An article in the April 2000 Archives of Pediatric and Adolescent Medicine warned that chiropractic pediatric care is often inconsistent with recommended medical guidelines.  "When I contemplate a chiropractor treating a 2-week-old neonate with a fever," said the editor in a sidebar comment, "I get a gigantic headache."
Studies conducted by chiropractors and published in "peer reviewed" chiropractic journals often recommend treatment for such conditions as infantile colic and asthma. A study published in the Journal of Manipulative and Physiological Therapeutics for example, concluded that "Spinal manipulation is effective in relieving infantile colic" —a conclusion not confirmed with reliable, unbiased research and recently refuted by a well designed study by a Norwegian research team .
When medical researchers tested chiropractic manipulation as a treatment of asthma in children, they reported that "the addition of chiropractic spinal manipulation to usual medical care provided no benefit."  Although chiropractic manipulation can be beneficial in the treatment of some types of neck and back pain, I always advise parents not to take their infants and children to a chiropractor, since the risk may outweigh any benefit.
Limitations of Chiropractic
Since chiropractors work on the back, most people think of the chiropractor as a back specialist. But when back-pain victims visit a chiropractic office, they may be given pamphlets suggesting that chiropractic treatment is also beneficial for asthma, infantile colic, ear infection, digestive disturbances, and a host of other organic or visceral problems. There are many good chiropractors who do a good job treating back pain, but few voluntarily limit their treatment to the care of back pain. Chiropractic colleges are still teaching the theory that using spinal adjustments to correct vertebral subluxations will restore and maintain health. Unless you see a chiropractor who has been recommended by an orthopedic specialist or who works with physicians in a back-pain clinic, your chances of finding a properly limited chiropractor are slim. Poorly informed consumers may not know where to draw the line when they visit a chiropractor.
"That spinal manipulation is somewhat effective symptomatic therapy for some patients with acute low back pain is, I believe, no longer in dispute," said the editorial in the New England Journal of Medicine . But "there appears to be little evidence to support the value of spinal manipulation for non-musculoskeletal conditions. For this reason, I think it is currently inappropriate to consider chiropractic as a broad-based alternative to traditional medical care."
At least five guidelines and caveats should be observed when seeking chiropractic care for back pain.
Look for a chiropractor who openly states that his or her practice is limited to the treatment of neuromusculoskeletal problems that have a mechanical origin. You might also find a suitable one in the directory posted at Chirobase.org.
If you cannot find a chiropractor who is a neuromusculoskeletal specialist or who works in a back-pain clinic as a member of a back-care team, you have to be on guard as an informed consumer if you are to protect yourself from the nonsense associated with chiropractic treatment. There are many chiropractic procedures and techniques you should avoid—some of which are dangerous as well as a waste of time and money.
2. Seek Appropriate Manipulation
Properly performed spinal manipulation is always done by hand. Chiropractors who believe that slightly misaligned vertebrae can cause disease often use machines or small hand-held spring-loaded mallets to tap misaligned vertebrae back into place. A 1998 survey by the National Board of Chiropractic Examiners found that 62.8% of survey respondents said they used an Activator mallet to adjust subluxations . Such chiropractors might also use instruments to measure heat and electrical activity over skin surfaces in a search for subluxations. The only treatment they may offer is a spinal adjustment for whatever ails you.
A good chiropractor who specializes in the care of neuromusculoskeletal problems does not use instruments and machines to diagnose and treat subluxations. And his treatment is not limited to the spinal adjustment. Physical therapy, massage, exercise, rest, home treatment with hot or cold packs -or no treatment at all-are sometimes more appropriate than spinal manipulation.
3. Avoid Unnecessary Treatment
While an acute episode of back pain can be incapacitating and scary, remember that most back pains resolve in two to four weeks. After limiting bed rest to a couple of days, most back-pain victims can begin moving around and gradually resume normal activities over a period of a week or two. If you go to a chiropractor for relief of back pain, you should not continue with treatment
if your pain worsens during the first week or if you are not any better after two weeks. If your symptoms persist after one month, see an orthopedic specialist for a definitive diagnosis.
A chiropractor who is reasonably competent in making a diagnosis might immediately refer you to a specialist if certain red flags are present, such as: fever; a history of cancer; prolonged back pain unrelieved by rest; the possibility of a fracture resulting from advanced age, long-term use of steroids, or severe injury; and so on. In the case of a simple strain, you might be advised that rest and time are the 'best treatment. But you cannot always rely on the diagnostic ability of a chiropractor. Some chiropractors "analyze" the spine in a search for subluxations rather than make a diagnosis. They always find subluxations that require spinal adjustments. Such chiropractors are less likely to offer appropriate advice and are more likely to subject you to prolonged and unnecessary treatment.
Be wary if your chiropractor's diagnosis is "subluxated vertebrae." Be even more wary if you are given a treatment plan that recommends daily visits that are gradually reduced in frequency over a period of several months. Such plans usually lead into "maintenance care" that requires one or two treatments a month for the rest of your life!
4. Popping Normal Backs
As a general rule, chiropractic treatment, or manipulative treatment for back pain, should be discontinued when symptoms disappear and you are feeling well. It is not necessary to continue with occasional spinal adjustments unless you have a structural problem that causes chronic back pain that can be temporarily relieved with manipulation. Frequent and unnecessary manipulation may do more harm than good, causing you to seek treatment for symptoms caused by the manipulation.
Normal spinal joints often make popping sounds when the joint surfaces are forcefully separated by manipulation.
Chiropractic patients often interpret these sounds as movement of vertebrae that are out of place. Some chiropractors use the popping sound to encourage patients to return for regular spinal adjustments in order to "maintain vertebral alignment." While such treatment has a strong placebo effect, it is misleading and tends to perpetuate illness or fear of illness.
5. "Neck Specialists"
Some subluxation-based chiropractors believe that most ailments, including low-back pain, are related to misaligned vertebrae in the neck. These "upper cervical specialists" always adjust the neck, usually the top two vertebrae at the base of the skull. This can be dangerous, since excessive rotation of the head and upper cervical spine places a strain on the vertebral arteries and can result in vascular injury or stroke.
There are special cases in which cervical manipulation can be beneficial when vascular problems have been ruled out and head rotation during manipulation does not exceed 50 degrees. But cervical manipulation should never be done routinely, especially as a preventive-maintenance measure. Most of us will never need cervical manipulation. Upper cervical chiropractors who manipulate the neck of every patient they see should be avoided. Elderly persons, especially those who have vascular disease or who might be taking blood thinners, should not submit to neck manipulation of any kind.
The Dangers of Neck Manipulation
A 1996 RAND report on The Appropriateness of Manipulation and Mobilization of the Cervical Spine estimated that stroke and other injuries resulting from cervical spine manipulation occurred about 1.46 times per 1,000,000 manipulations . It also concluded that only 11.1% of reported indications for cervical manipulation could be labeled appropriate. A patient who receives regular, frequent, and totally unnecessary neck manipulation is subjected to greater risk. Since many cases of stroke caused by cervical manipulation have not been recognized as such, studies are being done to determine how many stroke victims had neck manipulation prior to their stroke. The incidence of stroke from cervical manipulation might be much higher than indicated in past studies. A study by the Canadian Stroke Consortium, published in the July 18, 2000, Canadian Medical Association Journal, for example, reported that stroke resulting from neck manipulation occurred in 28% of 74 cases studied . Other causes were sudden neck movement of various types. The most common finding was vertebral artery dissection (splitting or tearing of arterial walls with clot formation and embolism) caused by sudden movement or rotation of the top two cervical vertebrae.
Chiropractors commonly manipulate the upper cervical spine as a treatment for head and neck pain. But since such pain in itself can be a symptom of vertebral or carotid artery dissection, especially following injury, it may be wise to forego neck manipulation for sudden onset of head or neck pain until risk factors can be better identified. Informed consent should always be obtained from patients about to undergo cervical manipulation. In many cases, massage, traction, and other forms of therapy can be substituted for prescribed cervical manipulation. Tension headache, for example, is commonly treated with chiropractic neck manipulation. A study published in the Journal of the American Medical Association found that spinal manipulation was no more effective than massage in relieving episodic or recurring tension headache . So be cautious. Until studies on cervical manipulation have been completed, don't submit to neck manipulation unless you have a problem that cannot be treated any other way. A chronic "cervicogenic" head pain, for example, in which pain is transferred from joints in the cervical spine, can often be relieved with appropriate cervical manipulation. But such manipulation should be done only after a correct diagnosis has been made and other forms of treatment have failed.
The Bottom Line
A good chiropractor can do a lot to help you when you have mechanical-type back pain and other musculoskeletal problems. But until the chiropractic profession cleans up its act, and its colleges uniformly graduate properly limited chiropractors who specialize in neuromusculoskeletal problems, you'll have to exercise caution and informed judgment when seeking chiropractic care.
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- Coulter IE and others. The Appropriateness of Manipulation and Mobilization of the Cervical Spine. Santa Monica, Calif: RAND, 1996, pp 18-43.
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Samuel Homola, D.C. practiced chiropractic for 43 years. He is the author of twelve books, including Bonesetting, Chiropractic, and Cultism ; Backache: Home Treatment and Prevention; and Muscle Training for Athletes. His book Inside Chiropractic: A Patient's Guide was published by Prometheus Books in 1999. He is now retired and lives in Panama City, Florida, with his wife, Martha. This article is reprinted (with slight modification) with permission from the January/February 2001 issue of Skeptical Inquirer, the magazine of the Committee for the Scientific Investigation of the Paranormal (CSICOP).