Focus on Alternative and Complementary Therapies
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Focus Alternat Complement Ther©2005 Pharmaceutical Press
Focus Altern Complement Ther 2005; 10: 87–8
Chiropractic and osteopathy are the only two CAM professions that are regulated by statute in the UK. In other countries, chiropractic belongs to the most popular forms of CAM. Hundreds of thousands of citizens consult chiropractors each year. Therefore the question of the therapeutic value of chiropractic spinal manipulation is important for public health and we should evaluate it in more detail.
In order to do this properly, we must, of course, employ the best available evidence. It is counter-productive to simply use those bits of evidence that suit our argument and forget about others that don’t. Virtually all experts agree that the best available evidence in any area of health care is that provided by Cochrane reviews. The Cochrane Collaboration is a worldwide network of independent scientists dedicated to systematically summarising the totality of the evidence related to specific medical subjects in a rigorous and transparently impartial fashion. Four Cochrane reviews of spinal manipulation are available today.
Back pain is by far the condition most frequently treated by chiropractors. The Cochrane review of spinal manipulation for back pain summarised 39 clinical trials.1 The authors’ conclusions were very clear: ‘There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.’
A Cochrane review of spinal manipulation and mobilisation for mechanical neck disorders evaluated 33 clinical trials.2 The authors found that, combined with exercise, these approaches were promising, but ‘the evidence did not favour manipulation and/or mobilisation done alone or in combination with various other physical medicine agents; when compared to one another, neither was superior.’2
Another Cochrane review summarised the available trials of chiropractic treatment for asthma.3 The authors found only two such studies and ‘neither trial found significant differences between chiropractic spinal manipulation and a sham manoeuvre on any of the outcomes measured.’ Finally, a Cochrane review assessed five trials of spinal manipulation for dysmenorrhoea.4 The authors concluded that ‘there is no evidence to suggest that spinal manipulation is effective in the treatment’ of this condition.
Any discussion of therapeutic value would be incomplete if it excluded adverse effects. Most chiropractors recognise that manipulation of the upper spine may lead to a stroke, which can be fatal. However, they are adamant that such dramatic complications are extremely rare. In its current promotional literature, the UK General Chiropractic Council does not mention serious risks at all and only states that ‘it is normal to experience some reaction to treatment, including temporary increase in discomfort, stiffness or tiredness for a day or so.’5 On the other hand, the same brochure also informs us that before treatment starts chiropractors should explain clearly to patients ‘the probability of risks associated with your condition and proposed treatment.’5
No Cochrane review is available specifically on the safety of spinal manipulation. An authoritative (non-Cochrane) systematic review of this area included 295 complications after spinal manipulation.6 The authors concluded that ‘referral for spinal manipulative therapy should not be made to practitioners applying rotary cervical manipulation.’6 Based on these findings and more recent data as well, a US forensic examiner advised that ‘the public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45.’7
Having been repeatedly accused of bias by chiropractic organisations, e.g 8,9 it is pertinent to stress that none of the above-cited articles was published by me or a member of my team. I am also not calling for a ban – only for reliable evidence to ensure we are not putting patients at risk.
And what about national guidelines? Chiropractors argue that their approach must be safe and effective, not least because the official guidelines on the treatment of back pain recommend using chiropractic. However, this is true only for some, but by no means all, countries. Secondly, guidelines are well known to be influenced by the people who serve on the panel that develops them. Cochrane reviews, on the other hand, are generally considered to be objective and rigorous. Writing about the importance of systematic reviews for health care in the Lancet, Sir Ian Chalmers stated, ‘I challenge decision makers within those spheres who continue to frustrate efforts to promote this form of research to come out from behind their closed doors and defend their attitudes and policies in public. There is now plenty of evidence to show how patients are suffering unnecessarily as a result of their persuasive influence.’10
I fear that chiropractors’ views on their very own treatment might not be entirely free of conflicts of interest. Independent research, such as that conducted by the Cochrane Collaboration, is designed to be transparent, reproducible, fair and of the highest possible standard. In the interests of public health, let’s make sure that we are guided by such evidence at all times.
