Chiropractic: a summary of concerns

Although obscured by controversy, there is evidence to indicate that spinal manipulation can be as effective as conventional treatment methods in relieving low-back pain.1,2,3,4This grain of truth mixed with chiropractic vertebral subluxation theory that encompasses a broad scope of ailments makes it difficult for the average person to distinguish between appropriate and inappropriate use of manipulation by chiropractors. A person who is satisfied with chiropractic manipulative treatment for back pain might be led to believe that the same treatment can be used to treat a variety of organic ailments by correcting “vertebral subluxations.” Such treatment is usually described as a “chiropractic adjustment.”

A manual chiropractic adjustment

Although chiropractic care based on subluxation theory has been rejected by the scientific community, spinal manipulation used in the treatment of mechanical-type back pain has a plausible basis that makes it acceptable in mainstream healthcare. A good back-cracking back rub provided by a chiropractor or some other manual therapist can be a pleasurable, pain-relieving experience, and this can be a preferred method of treatment for some types of back pain. But you should be well-informed enough to know where to draw the line in separating subluxation-based chiropractic adjustments from appropriate use of generic spinal manipulation if you should consider treatment by a chiropractor. Otherwise, you might become the victim of the bait-and-switch tactics of chiropractors who offer you treatment for back pain and then attempt to indoctrinate you in subluxation theory.

Much of what follows in this article has been said before in other articles of mine posted on this site. An up-to-date summary of basic concerns about chiropractic care, however, might be useful for new readers and others, including professionals, who want a brief overview for quick reference in seeking answers to questions about the problematic aspects of chiropractic use of spinal manipulation.

Subluxations do not affect general health

The vertebral subluxation theory that gave birth to the chiropractic profession proposed that 95 per cent of diseases are caused by displaced vertebrae that place pressure on spinal nerves.5 Today, chiropractic is defined as a method of adjusting a “vertebral subluxation complex,” an asymptomatic and undetectable “joint dysfunction” (involving nerves, muscles, connective tissues, blood vessels, and other factors) alleged to influence organ system function and general health.6 There is no credible evidence to support the chiropractic theory that joint dysfunction or a vertebral subluxation in any form can affect general health or cause internal organs to become diseased. Spinal nerves are commonly compressed by bony spurs and herniated discs. Even the most severe compression of a spinal nerve, which may cripple the supplied musculoskeletal structures, does not cause organic disease. In the absence of fracture or pathology such as disc herniation or osteophyte formation, vertebral misalignments rarely affect spinal nerves.

Spinal nerves supply the sensory and motor (voluntary) functions of musculoskeletal structures. Involuntary function of the body’s organs is regulated by autonomic nerve ganglia and plexuses located outside the spinal column and by autonomic cranial and sacral nerves that pass through solid bony openings. The vagus nerves are autonomic (parasympathetic) cranial nerves that originate in the brain stem, traversing openings in the base of the skull to pass down through the neck, thorax, and abdomen to supply organs along their path. Preganglionic autonomic fibres, which emerge from the spinal cord and pass through spinal segments from the first thoracic vertebra to the second lumbar vertebra, terminate in sympathetic trunk and splanchnic ganglia located outside the spinal column. The vagus nerves along with autonomic ganglia and nerve plexuses provide overlapping sympathetic and parasympathetic nerve supply from many directions and sources (in concert with chemical, hormonal, and circulatory factors) to assure continued function of the body’s organs, independent of spinal nerves.7 This is why severance of the spinal cord in the neck area, shutting off brain impulses to spinal nerves, can cause paralysis of muscles from the neck down while the body’s organs continue to function. Transplanted organs function without reconnection of severed nerves.

A serious transverse spinal cord lesion above C5 (upper neck) can cause respiratory paralysis and often death. Since the spinal cord ends at the level of the 2nd lumbar vertebra, spinal nerves pass down from the spinal cord (like the hair on a horse’s tail) to exit openings between the lumbar vertebrae and from openings in the sacrum. The spinal nerves supplying bladder and bowel sphincter muscles pass through the solid bony openings of the sacrum (a pelvic bone at the bottom of the spine) and are not subject to compression by a subluxation. But they can be compressed by protrusion of a lower lumbar disc into the spinal canal, affecting voluntary control of sphincter muscles (cauda equina syndrome).

A chiropractic vertebral subluxation or “joint dysfunction” alleged to cause disease by interfering with nerve supply to organs cannot be demonstrated and cannot be equated with a real orthopaedic subluxation, a partial dislocation that causes musculoskeletal symptoms. Spinal manipulation, massage, and other forms of manual therapy can have some temporary neurological and physiological effects that might be beneficial in relieving back pain symptoms. But there is no evidence to indicate that such effects have a significant effect on general health.

“One of the key ‘selling points’ for chiropractic care is the anatomically impossible premise that your spinal nerve roots are important to your general health.”8 An excellent, reader-friendly discussion of this subject can be found on PainScience.com via the reference for this quotation.

Despite the implausibility of chiropractic subluxation theory, which is more a belief than a theory, state laws and chiropractic publications in the United States continue to define chiropractic as a method of correcting vertebral subluxations to restore and maintain health.9

Alternative chiropractic care

Although the public generally thinks of chiropractors as back specialists, few chiropractors limit their care to treatment of back pain. The vague and all-inclusive chiropractic subluxation theory generates a hodgepodge of entrepreneurial techniques and treatment methods for a variety of ailments. Treatment methods vary from one chiropractor to another, and are often incompatible with interchange in mainstream health care. According to the Association of Chiropractic Colleges, chiropractic is associated with the field of complementary and alternative medicine as a method of improving and preserving health.10 The profession has chosen not to seek development as a scientifically acceptable musculoskeletal specialty, despite the fact that back pain and musculoskeletal conditions are the No. 1 and No. 2 causes of disability worldwide.11 Some chiropractic colleges offer decent instruction in the care of musculoskeletal problems but are tainted by subluxation theory that encompasses a broad scope of ailments. Physicians who refer patients to chiropractors for spinal manipulative therapy must be cautious in selection of a chiropractor, and they must take responsibility for the diagnosis, lest inappropriate treatment makes them vulnerable to liability for damages. Care must also be taken to make it clear that referral to a selected chiropractor who uses manipulation appropriately is not an endorsement of subluxation-based chiropractic.

Subluxation theory perpetuated as a belief system

There are no indications that subluxation theory, the foundation of chiropractic, will ever be discarded by all chiropractors. With no plausible or scientific rationale to support it, subluxation theory will be perpetuated as a belief system. Putative chiropractic subluxations that are not detectable by conventional methods are allegedly being located by such dubious procedures as thermography, applied kinesiology, and leg-length checks. Dozens of different techniques are used to correct such subluxations. Some chiropractors use a spring-loaded stylus in an attempt to tap vertebrae into alignment in order to “restore the integrity of the nervous system.” Upper cervical chiropractors believe that aligning the atlas (the vertebra at the top of the spine) will “influence the central nervous system and brain stem function” as well as realign vertebrae from the neck down.12

While there are some good chiropractors who offer a service of value in the care of back pain, combining appropriate use of spinal manipulation with other physical treatment methods, it would certainly seem advisable to avoid the services of any chiropractor who proposes to treat a health problem by adjusting vertebral subluxations. Physical therapists who use mobilization or generic spinal manipulation to relieve pain and restore mobility in an injured area of the spine are more likely to use manipulation appropriately than a chiropractor who adjusts every patient to remove “nerve interference” caused by an asymptomatic “vertebral subluxation complex.” A subluxation-based chiropractor may even manipulate the neck as a treatment for low-back pain.12 Since upper cervical manipulation has been associated with stroke caused by injury to vertebral arteries, neck manipulation should be reserved for a carefully selected, albeit rare, neck problem for which there is no other viable treatment option. Manipulative techniques that involve rotating the head to force rotation of upper cervical structures should not be used. Risk certainly outweighs benefit when neck manipulation is used routinely to correct chiropractic subluxations.13

Note: Mobilization moves joints through normal ranges of movement. Manipulation forces movement of a joint beyond a normal range, often into a paraphysiologic space where there may be slight separation of joint surfaces (cavitation) to produce a popping sound. Manipulation can produce popping sounds in normal joints. Such popping is not considered to be significant, but it can have a powerful placebo effect among those who believe that the popping sound signals correction of a disease-causing subluxation. Unfortunately, some chiropractors allow their patients to believe that a popping sound means that vertebral subluxations are present, producing a nocebo effect that lures chiropractic patients into a program of regular spinal adjustments in an attempt to maintain health by keeping their vertebrae aligned.

The bottom line

There is no credible evidence to support use of spinal manipulation for anything other than uncomplicated mechanical-type back pain and related neuromusculoskeletal problems. There is no evidence at all to support chiropractic subluxation theory. It has never been demonstrated that a real orthopaedic subluxation or a pinched spinal nerve can affect general health or that an undetectable “vertebral subluxation complex” can cause organic problems.14 If you are looking for a chiropractor who offers spinal manipulation as an option in the treatment of back pain, look for one who does not subscribe to subluxation theory ─ one who is willing to exchange office notes with your family physician. Remember that most of the time, acute low-back pain is a self-limiting condition that will resolve in four to six weeks, with or without treatment. Appropriate treatment can, however, relieve symptoms and speed recovery. When back pain grows progressively worse, persists unrelieved for longer than a week, or is worsened by rest, there may be cause for alarm. Chiropractic care should not be continued for longer than two to four weeks if there is no measured improvement. A correct diagnosis is essential when considering treatment options. Treatment based on correction of an alleged chiropractic vertebral subluxation complex may result in unnecessary chiropractic adjustments for nonexistent or unrelated problems, delaying appropriate treatment based on a correct diagnosis. I don’t know of any reason to manipulate the immature, cartilaginous spine of a neonate or an infant as some paediatric chiropractors are doing.15

References

1. Rubinstein, Sidney M., Marienke van Middelkoop, Willem J.J. Assendelft, et al. 2011. Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine. 36(13):E825-46. http://www.ncbi.nlm.nih.gov/pubmed/21593658Accessed February 17, 2014.
2. Rubinstein, Sidney M., Caroline B. Terwee, Willem J.J. Assendelft, et al. 2013. Spinal manipulative therapy for acute low-back pain: an update of the Cochrane review.Spine. 38(3):E158-77. http://www.ncbi.nlm.nih.gov/pubmed/23169072 Accessed February 17, 2014.
3. National Center for Complementary and Alternative Medicine. 2012. Spinal manipulation for low-back pain: What the science says. NCCAM Clinical Digest. May.http://nccam.nih.gov/health/providers/digest/chronic-low-back-pain-scienceAccessed February 6, 2014.
4. Agency for Healthcare Research and Quality. 2010. Complementary and Alternative Therapies for Back Pain. http://www.ahrq.gov/research/findings/evidence-based-reports/backcam2tp.html Accessed February 6, 2014.
5. Palmer, Daniel David. 1910. The Chiropractor’s Adjuster: A Textbook of the Science, Art, and Philosophy of Chiropractic for Students and Practitioners. Portland, Oregon. Portland Printing House.
6. Association of Chiropractic Colleges. Chiropractic Paradigm.http://www.chirocolleges.org/paradigm_scope_practice.html Accessed February 6, 2014.
7. Homola, Samuel. 2006. Chiropractic: History and Overview of Theories and Methods. Clinical Orthopaedics and Related Research. 444:236-242.http://www.ncbi.nlm.nih.gov/pubmed/16446588 Accessed April 2, 2014.
8. Ingraham, Paul. 2014. Spinal Nerve Roots Do Not Hook Up to Organs!https://www.painscience.com/articles/spinal-nerves-and-organs.php Accessed November 26, 2014.
9. Bellamy, J.J. 2010. Legislative alchemy: The U.S. state chiropractic practice acts.Focus on Complementary and Alternative Therapies. 15(3):214-222.http://onlinelibrary.wiley.com/doi/10.1111/j.2042-7166.2010.01032.x/abstractAccessed April 2, 2014.
10. CCE. An open letter to the profession from the Council on Chiropractic Education. November 22, 2011. http://www.acatoday.org/pdf/CCE_Letter.pdf Accessed February 6, 2014.
11. Vos, Theo, Abraham D. Flaxman, Mohsen Naghavi, et al. 2012. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis of the Global Burden of Disease Study 2010. The Lancet. 380(9859):2163-2196. http://www.ncbi.nlm.nih.gov/pubmed/23245607 Accessed April 2, 2014.
12. Homola, Samuel. 2009. The problem with chiropractic NUCCA. Science-Based Medicine. August 7. https://www.sciencebasedmedicine.org/index.php/the-problem-with-chiropractic-nucca/ Accessed February 6, 2014.
13. Homola, Samuel. 2009. Neck Manipulation: Risk vs. Benefit. Science-Based Medicine. August 27. https://www.sciencebasedmedicine.org/neck-manipulation-risk-vs-benefit/ Accessed February 6, 2014.
14. Mirtz, Timothy A., Lon Morgan, Lawrence H. Wyatt, et al. 2009. An epidemiological examination of the subluxation construct using Hill’s criteria of causation.Chiropractic and Manual Therapies. 17:13.http://www.ncbi.nlm.nih.gov/pubmed/19954544 Accessed April 2, 2014.
15. Homola, Samuel. 2010. Pediatric Chiropractic Care: Scientifically Indefensible? Science-Based Medicine. https://www.sciencebasedmedicine.org/pediatric-chiropractic-care-scientifically-indefensible/ Accessed February 6, 2014.