The Chiropractic Controversies An introduction to chiropractic controversies like aggressive billing, treating kids, and neck manipulation risks SHOW SUMMARY

A 2006 Gallup Poll found that chiropractic rated dead last among health professions with regard to ethics and honesty.1 Why? People are curious about the poor reputation of chiropractic,2 and confused about the nature of chiropractic.3 Often inspired by their own negative experiences, they ask me what I think. This article is a survey of chiropractic controversies and issues that I think patients should be aware of.

I purchase chiropractic therapy myself once in a while. I have a long-term craving for upper thoracic spine cracking. I recommend some chiropractic therapy to friends and readers. But I also respect the judgement of many expert critics who believe that, “The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.”4 This kind of criticism is often referred to as “persecution” by chiropractors; they also often call this a “hit piece,” just for reporting the existence of the issues.

This article also strongly applies to osteopathy. Despite a few key differences, most osteopaths are essentially identical to chiropractors from a patient perspective: they are all alternative medicine practitioners who believe in the therapeutic power of skilled manipulation of joints.5

About footnotes. There are 50 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1 and boring reference stuff.2 Try one!

Does chiropractic work?

The first thing one wants to know about any treatment — alternative or otherwise — is whether it works. Until that is decided, all talk of qualifications, regulation, and so on is just vacuous bureaucratese. ~ Dr. David Colquhoun, “Doctor Who? Deception by chiropractors”

Most people just want to know if it will help them. But “chiropractic” is many things. What kind of chiropractic treatment? Does it work for what? How much of it? For which kinds of patients? Just asking if “chiropractic works” is not specific enough to have a meaningful answer. It is not really a fair question to ask of chiropractic as a whole. But it is nevertheless the question that people actually ask, and so we have to deal with it as well as we can.

I believe it’s obvious that some chiropractic therapy does “work” in certain ways, for some people, some of the time. The most important factor in the usefulness of chiropractic therapy is not the nature of chiropractic as a profession, but the skill and good sense of the chiropractor whose hands are on your neck. Ethical, intelligent practitioners of any helping profession will always deliver better care than less competent members of their own or any other profession.

Consumers need to be aware of the issues to help them choose a good chiropractor. Or choose none, if they prefer!

Who says?

Chiropractic is so controversial that this article attracts a lot of shooting-the-messenger hate mail. I am not expressing my opinions about chiropractic here: I am reporting and explaining concerns that the experts have been debating ad nauseum for decades, quoting their opinions, and citing some of the same scientific evidence that they do.

The best consumer guide to chiropractic therapy available, written by a chiropractor & America’s leading expert on pseudoscientific health care. If you want to know if chiropractic therapy “works,” stop reading my article & go get this book.

What experts? Progressive chiropractors and critics from within the profession like Dr. Samuel Homola,6 Dr. Bruce Walker,7 Dr. Donald Murphy,8 and Dr. Preston Long9; relatively progressive chiropractic regulatory agencies10; activist physicians like Dr. Stephen Barrett,11 Dr. Stephen Novella,12 or the especially credible Dr. Edzard Ernst13 (who has such great experience with both medical science and alternative therapies); and science journalists like Simon Singh,14 who was in the news because he was sued for libel by the British Chiropractic Association for comments he wrote in a column in The Guardian in 2005, in connection with his book, Trick or Treatment: The Undeniable Facts About Alternative Medicine .15 The lawsuit failed, and the misguided attempt did serious harm to the reputation of chiropractic.

The fact that patients swear by us does not mean we are actually helping them. Satisfaction is not the same thing as effectiveness. ~ Chiropractor Preston Long, author of Chiropractic Fraud and Abuse: An Insider's Lament

An introduction to chiropractic controversies

There is an undeniable history of scientific and ethical controversies swirling around the profession, from its earliest days to the present. What are those controversies? Why is chiropractic perpetually contentious?

1. The hard sell: aggressive sales and marketing

Chiropractic often involves many expensive but quick treatments,1617 and marketing and sales tactics that many people consider to be aggressive and distasteful, if not downright unethical, especially pre-paid treatment packages,18 and the hawking of many other services and products that are much more blatant quackery,19 like applied kinesiology,20 and ear infection treatment. A 2016 federal (US) audit concluded that more than 80% of Medicare payments to chiropractors were for medically unnecessary procedures, and 100% of treatments were unnecessary after the first thirty.21 In a 2018 crackdown in British Columbia, Canada (my home), many dozens of chiropractors were forced to remove unscientific claims from their websites, like anti-vaccination propaganda and claims of autism cures.22 Do chiropractors sell too hard?

An example of the diversity of conditions that chiropractors claim that they can treat, from an advertisement.

2. The big idea: “subluxation” defines chiropractic

The original “big idea” of chiropractic was that nearly any health problem can be cured by spinal manipulation.23 Today, many chiropractors still believe this,24252627 and still recommend chiropractic therapy for many problems beyond just low back pain, neck pain, and headaches. Is this reasonable? Is there any scientific evidence that chiropractic therapy can prevent, help, or cure a wide variety of diseases and ailments?28 Only if “spinal subluxation” is actually the cause of them in the first place!29 But organ health does not depend on spinal nerves.

3. The risks: what could possibly go wrong?

Adjustment of the neck might be dangerous. There are numerous class action lawsuits against chiropractors and chiropractic professional organizations for this reason.30 Is there a risk? Considering the stakes, is any risk acceptable? A large group of Canadian neurologists asks, “Is a headache worth dying for?”31 British scientists advocate abandoning it.32 The paper most cited for the defense, the Cassidy paper, does not hold up.33

4. Damned by faint praise: lukewarm evidence at best for the efficacy of back pain treatment

Spinal adjustment for acute low back pain has long been regarded as the best example of evidence-based care routinely offered by chiropractors. Nevertheless, some critics have pointed out that even this technique has been damned with overly faint praise — “positive” results so trivial that they actual prove there is no meaningful benefit. A major, credible 2012 science review supports that view with a completely negative conclusion.34 Is chiropractic actually useful for acute back pain? If there’s any real doubt about even this, what does it suggest about the rest of chiropractic care?

5. Think of the children: pediatric chiropractic is condemned even by many chiropractors

The best single example of aggressive marketing is so important that it constitutes an independent controversy: many chiropractors recommend regular treatments for children and even babies (and maybe they break their necks35). Critics say this is a worrisome extreme of dangerous conduct in chiropractic: an intervention with higher risks and even more dubious benefits. Do children really need chiropractic adjustment?

6. Guilt by association with anti-vaxxers

Chiropractic is usually packaged with other sketchy treatment ideas and beliefs about medicine, exemplified by anti-vaccination rhetoric. You would hope that such a belief would be rare among educated professionals, but it actually permeates the profession to the point where even chiropractic regulators are anti-vaxxers — the people who should be disciplining other chiropractors for espousing the same belief. No matter what spinal manipulation does or does not do for back pain, how much can you trust a healthcare professional who has embraced one of the most extreme anti-medical beliefs possible, the medical equivalent of believing that the Earth is flat? What else do they believe?

Just asking questions

I’m not answering any of these questions posed above — I’m asking them. And I’m pointing out that they have been asked (and answered) for decades. Many credible critics rule against chiropractic on all of these issues and several others.

And while you might think that all chiropractors would defend themselves against these accusations, that’s not the case. In fact, many chiropractors are also critical of common chiropractic beliefs and practices. For instance, these controversies are only a small selection of “abberant practices” identified by progressive chiropractors themselves. Dr. Bruce Walker lists sixteen in his 2016 paper about trying to rescue chiropractic from itself.36

And so one of the most important things to understand about chiropractic is that it is a divided profession: there is significant controversy within the profession itself.

Chiropractic is a divided profession

Chiropractors themselves have many disagreements about their own profession. There is a ideological chasm between a minority of chiropractors who want to modernize the profession, and traditional chiropractors who cling to the old ways and take the founding concepts literally. Chiropractors on either side of this chasm can be amazingly different. For instance, there is a strong theme of Christian fundamentalism among old school chiropractors that blends seamlessly with the work: they talk about chiropractic like it’s a spiritual calling.37

The chiropractic profession was founded about a century ago by Daniel David Palmer. Chiropractic owes its existence to this one unusual man and his son — always referred to as “D.D.” and “B.J.” palmer — whose ideas remain the basis of the profession today. Both DD and BJ were bizarre characters, and arguably marketing geniuses. DD in particular was known for his extravagant ego. Here’s an entertaining example of his, er, rather flamboyant personal style:

I was the first to adjust the cause of disease .... The man who had the intellectual capacity to comprehend the displacement of the vertebrae; the mental ability to grasp the significance of nerve impingement; the power to conceive and discriminate between normal and abnormal positions; the foresight and wisdom to discern the outcome; the genius of originality to create such a unique science; the judgement needed for the occasion; the brain caliber of reasoning on this heretofore perplexing question — the cause of disease; the sense of touch required to discover a racked vertebra and the skill and tact to replace it, was the one destined to discover and develop the science which he named chiropractic. ~ Shall Chiropractic Survive?, by BJ Palmer

Wow! Clearly, DD’s arrogance was dialed up to 11. According to Palmer, “A subluxated vertebra … is the cause of 95 percent of all diseases.”38 Those were big words, and indeed they have been called the “big idea” in chiropractic ever since. In 1966, a group of physicians damningly wrote, “In all the years that they have been talking about them, chiropractors have never been able to furnish proof of these mysterious subluxations which they alone are able to see. They may convince their clients, but never have they provided proof of their pretensions to men of science.”39 Even 54 years ago the absence of persuasive evidence was already a concern for many experts.

Today, many chiropractors actually reject the subluxation hypothesis (although not enough of them do so publicly):

Chiropractic, which celebrated its centennial in 1995, is a curious mixture of science and pseudoscience, sense and nonsense. Much of it is based on the theory that misaligned spinal bones produce nerve interference that causes disease. Many chiropractors claim that correcting these misalignments (“subluxations”) can restore health and that regular spinal adjustments are essential to maintain it. Neither logic nor scientific evidence supports such a belief. Although spinal manipulation can relieve certain types of back pain, neck pain, and other musculoskeletal symptoms, there is no scientific evidence that it can restore or maintain health. As a result of expressing my opinion on this subject, I have been called a chiropractic heretic. The chiropractic profession has little tolerance for dissension. Its nonsense remains unchallenged by its leaders and has not been denounced in its journals. In fact, many chiropractic journals continue to publish articles that attempt to justify subluxation theory. Although progress has been made, the profession still has one foot lightly planted in science and the other firmly rooted in cultism. Without appropriate criticism, the good in chiropractic will never be sifted out, and competent chiropractors will not receive the recognition they deserve. This book denounces the cultism in chiropractic but supports the appropriate use of spinal manipulation and the research efforts required to solidify its scientific basis. If you are contemplating or receiving chiropractic care, it might help protect both your pocketbook and your health. ~ Inside chiropractic, by Samuel Homola, p. vii

This controversy between chiropractors themselves is highly relevant to the consumer. The profession is divided between chiropractors who still embrace subluxation hypothesis (known as “straight” chiropractors), and those who choose to limit their expertise and therapy to musculoskeletal health, especially spinal care (known as “mixers”).40 A chiropractic college instructor writes of this “well-known division between ‘straights’ and ‘mixers’” that “we are at risk of returning to the antiscientific and dogmatic traditions that we have worked so hard to shake off during the past several decades.”41 On the other hand, if the subluxation hypothesis is rejected, then

the whole rationale for chiropractic collapses, leaving chiropractors no justifiable place in modern medical care except as competitors of physical therapists in providing treatment of certain musculoskeletal conditions. Dr. Harriet Hall, regarding Mirtz et al in The End of Chiropractic

Whatever the fate of the profession, you’d probably like to know what kind of a chiropractor is treating you today, a “straight” or a “mixer,” regardless of which you’d prefer. Unfortunately, it is nearly impossible for patients to tell which is which! And that is a serious problem for all chiropractors.

My chiropractor says this is because the top of my neck attaches to my head. Is that a common problem? ~ from the “chiropractors say the darndest things” file, as reported by Dr. Grumpy (Only Outside Sleepy Hollow)

Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints

Even if the original idea of subluxation as a cause of disease is discarded, is there a more ordinary justification for manipulating the spine for the treatment of body pain? Chiropractic is the profession most obsessed with the generally shabby idea that anatomical alignment is a key factor in chronic pain problems of all kinds (not just spinal pain). “Adjusting” the spine refers to many different manual therapies that wiggle, pop and otherwise manipulate spinal joints, with the general goal of “straightening” patients or restoring normal motion. The correct umbrella term for these treatments is “spinal manipulative therapy” or SMT. Expert opinions on SMT range widely, with some prominent medical scientists expressing strong concerns, primarily because its provenance in chiropractic subluxation theory is dubious, but also because whatever benefits it has are clearly not major, and there are serious risks, even including paralysis and death in the case of SMT for the joints of the neck.

For more information about the risks of treating the neck, see What Happened To My Barber?

Despite all the controversy, there has been little high quality scientific research to determine whether or not SMT is safe and really works. Every published review of the literature comments on the lack of good quality evidence, making it impossible to be sure of anything.42 Even the most promising sources of research have had serious quality control problems.43

Nevertheless, if SMT works, it shouldn’t be taking over a century to prove it. Major reviews of that literature published in recent years came to underwhelming conclusions,44 and subsequent experiments continue to damn SMT with faint praise, showing that it works only a little at best.45 The biggest and best review to date (Rubinstein et al) concluded that “SMT is no more effective in participants with acute low-back pain” than shams and placebos.46

Thus, SMT fails the “impress me” test — if it’s working any miracles, they must be rare and small ones.

And yet spinal joint popping in particular is something that people crave, and most clinicians — including myself, and including skeptics like Dr. Homola — believe that some forms of SMT can be helpful to some of their patients, some of the time. There seems to be almost no doubt that there is something of therapeutic interest going on in SMT in some cases.

There is no definitive evidence that spinal manipulative therapy is more effective than other forms of treatment for patients with acute or chronic low-back pain. However, manual therapists know from experience that spinal manipulation is often more effective for providing immediate short-term relief for some types of back pain. “Can Chiropractors and Evidence-Based Manual Therapists Work Together?”

Scratching the itch you can’t reach: why joint popping feels good and possibly relieves pain

Occasionally, believe it or not, I recommended chiropractic therapy to my own massage therapy patients. Sometimes I believed they needed more skilful and direct stimulation of spinal joints than I could provide myself, and I believed that the scientific evidence then showed that appropriate spinal manipulation had the potential to help back pain in this way, with acceptable risks.

Many of them reported this kind of positive result from chiropractic treatment. I have experienced it myself on many occasions, and I have also observed many clients expressing relief and pleasure in response to incidental spinal “adjustments” — joint pops that occur in the course of doing massage therapy, little explosions as I slide up the spine.

Many people seem to feel that a happy spinal adjustment feels like “scratching an itch you can’t reach.” Why might that be?

Whatever you have been told before, and despite the availability of many explanations on the internet, the nature of joint popping is not well understood.47 It is firmly in that category of trivial mysteries for which there is simply no research funding, and as such it will probably remain unexplained for some time to come. We simply do not know.

Whatever a joint pop really is, it probably provides a novel sensory experience: a little blast of proprioceptive stimulation.48 Since all living systems seem to thrive on sensory input, and generally suffer without it, I speculate that a joint crack essentially feels like getting “unstuck,” and is analogous to finally getting to stretch your legs after getting off a long flight — which is not intended to trivialize it.

The strength of this idea is that it just isn’t claiming much: it both accounts for the extremely satisfying feeling that many people report, but without promising the moon. Indeed, it also seems consistent with another widely reported feature of SMT: the benefits often don’t last long! Soon the “itch” needs to be “scratched” again. It also could explain why the benefits of SMT are so variable and uncertain: it is highly dependent on many factors. For instance, whether a joint crack feels “refreshing” to you depends on how you feel about the whole idea of joint cracking.

The fear of spinal adjustment

Unfortunately, many people are not comfortable with having their spinal joints “cracked” or manipulated.

This is one of those “there are two kinds of people in the world” things: some people crave spinal joint cracking, expertly applied or otherwise, and to others it seems like fingernails on a chalkboard. My wife, for instance, wants at least one spine-cracking hug per day, and clearly becomes impatient when it has been too long since the last one! Other people would view such a hug as an alarming assault — people with such anxiety about spinal joint popping typically have never been to a chiropractor and never will, or they take a dim view of what happened to them when they reluctantly tried it.

“I will never let a chiropractor touch me again” is just as common a patient report as “I have to get adjusted at least once a month.”

Clearly, those who find joint cracking to be unpleasant are not good candidates for “scratching the itch” with a nice round of lumbar facet joint explosions! You know who you are, and you don’t really need to be reading this: chiropractic is certainly not going to work for you!

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About Paul Ingraham I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter.

Related Reading about Chiropractic

This is a painstakingly prepared list. My daring plan was to make this the best such list I could find, which I assumed would be difficult or impossible. Surely there are excellent compilations of this sort already? But it’s actually pretty thin pickings: I’m surprised how little I found, and how much of what I found was rather shabby. Not that my own effort here is perfect or complete, of course, but I did really work hard on it — many, many hours. You can really sink oodles of time into wrangling not only a bunch of links, but all the reading required to describe them well. This would have been completely impossible if I hadn’t already been reading on this topic for many years.

I originally wrote it with great earnestsness for ScienceBasedMedicine.org’s Chiropractic Reference Page, in my capacity as SBM’s Assistant editor, and I’ve adapted it a little for use here — just a little lighter.

Of course, ScienceBasedMedicine.org itself is one of the premier sources of analysis and criticism of chiropractic, and their reference page also includes links to dozens of posts there, many of which have attracted hundreds of thousands of readers over the years.

Notes