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Chiropractic therapy: placebo or panacea?

Most people see chiropractors for spine pain or other musculoskeletal conditions. Michael Dorausch

PANACEA OR PLACEBO – A weekly series assessing the evidence behind complementary and alternative medicines.

Chiropractors use manual therapy to address musculoskeletal-related conditions (joints, ligaments, muscles and nerves of the body). In recent times the chiropractic profession has attracted criticism about its effectiveness and safety, outdated theories, and the promotion of anti-vaccination views.

There are approximately 4,200 registered chiropractors in Australia. The general public can access a chiropractor without referral from another health-care practitioner. A 2004-5 survey indicated that 2% of the Australian population consulted a chiropractor in the two weeks prior to the survey.

Chiropractic training in Australia is taught at Macquarie University, Murdoch University, RMIT University and Central Queensland University. A chiropractic degree takes five years to complete.

Chiropractors are trained to provide mainly hands-on care, combined with physical therapy modalities (such as ultrasound), exercise, nutritional advice and lifestyle modification. The profession is regulated by the Chiropractic Board of Australia, which is part of the Australian Health Practitioner Regulation Agency.

History of chiropractic

Chiropractic was founded in the United States in the 1890s by a magnetic healer David Daniel (DD) Palmer. He reportedly cured deafness in his janitor through the application of a chiropractic adjustment (a type of spinal manipulation) to a “chiropractic subluxation”.

Palmer hypothesised that spinal subluxations, or misalignments, compromised health by interfering with nerve flow and innate intelligence, and that subluxations could be related to almost all health conditions.

Much animosity towards chiropractic, and an area of controversy within the profession, is based on these historical origins. There is vigorous debate within the chiropractic profession about subluxations and scope of practice, and commentators have divided the profession into two broad groups.

For one group, the fundamental approach to chiropractic practice is in finding and correcting chiropractic subluxations. The other group wish the profession adopt a more contemporary, evidence-based approach, and restrict chiropractic care to musculoskeletal conditions (see here, here and here).

Some chiropractors, and some professional chiropractic organisations, promote the use of the term subluxation and its effects on human health as proposed by Palmer. Other chiropractic organisations have adopted the UK General Chiropractic Council statement that chiropractic vertebral subluxation complex is an historical concept and is not supported by clinical research linking it to the cause of disease.

Clinical studies have not demonstrated the existence of chiropractic subluxations, and many studies show that chiropractors cannot agree on where these spinal lesions are located. Surveys conducted in North America suggest that more than three quarters of chiropractors consider the presence of subluxations in their clinical decision making. Similar data for Australian chiropractors are not currently available.

Missing evidence

Little is known about why people seek chiropractic care and what chiropractors do in practice. From available data it seems most people who present to chiropractors have spine pain (low back or neck pain), or other musculoskeletal conditions (such as sports injuries, neck-related headaches and sciatica).

For common back and neck pain there’s no single, optimally effective therapy. Most therapies examined in high quality systematic reviews demonstrate only low to moderate effects and few therapies are better when compared to other therapies.

Chiropractors use a range of therapies and many have not been subjected to rigorous scientific scrutiny. A 2010 review provided the most comprehensive examination of the evidence for commonly used chiropractic manual therapy techniques (spinal manipulation, mobilisation and massage).

This review, alongside high quality Cochrane systematic reviews summarising the best available evidence, support chiropractic care for the symptomatic relief of back and neck pain. But the effects are typically small.

Treatments used by chiropractors are equally effective as other common therapies for the management of low back and neck pain. Although chiropractic treatment has a low risk of serious adverse events.

Some chiropractors claim to provide relief for non-musculoskeletal conditions, such as infantile colic, bed wetting, asthma, period pain, ear infections and high blood pressure. There’s no evidence to support the use of chiropractic treatment for these conditions and indeed, we have some evidence against its use.

Attending a chiropractor for musculoskeletal conditions, such as back and neck pain, is as reasonable as seeing any other healthcare practitioner. But traditional chiropractic practice based on finding and “correcting” subluxations is being challenged from within, and outside, the profession.

Much more research is needed to inform chiropractic practice and to optimise the health of Australians who seek chiropractic care.

Read the other instalments of panacea or placebo:

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