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PERSPECTIVE
Focus on Alternative and
Complementary Therapies
Volume 18(2) June 2013 89–94
© 2013 Royal Pharmaceutical Society
DOI 10.1111/fct.12016
ISSN 1465-3753

Pseudoscience in the use of manipulation by chiropractors

Samuel Homola

Abstract
While spinal manipulation is an acceptable modality in the treatment of back pain, it is used inappropriately by some
chiropractors who use manipulation as a treatment for disease by ‘adjusting vertebral subluxations.’ Defined by the
subluxation theory that gave it birth, the core of the chiropractic profession continues to cling to a modified version of the
theory, despite rejection by the scientific community. Philosophical differences between the various factions in chiropractic,
ranging from some who have renounced subluxation theory to those who are subluxation-based, keep the profession divided
and marginal.

Keywords
Alternative medicine • chiropractic • physical therapy • spinal manipulation • subluxation

Implausible subluxation theory nerves that pass through solid bony openings.
The vagus nerves are autonomic (parasympathetic)
Many people visit chiropractic offices seeking relief cranial nerves that originate in the brain stem, tra-
from back pain, assuming that chiropractors are back versing openings in the base of the skull to pass down
specialists since they work on the spine. A good back- through the neck, thorax and abdomen to supply
cracking back rub can be a pleasurable pain-relieving organs along their path. Pre-ganglionic autonomic
experience. Unfortunately, chiropractic is commonly fibres, which emerge from the spinal cord and pass
promoted as a method of restoring and maintaining through spinal segments from the first thoracic ver-
health by adjusting vertebral subluxations (mis- tebra to the second lumbar vertebra, terminate in
aligned vertebrae) to remove pressure on spinal sympathetic trunk and splanchnic ganglia located
nerves or to restore normal nerve function. outside the spinal column. The vagus nerves, along
There is no credible evidence to support the with autonomic ganglia and nerve plexuses, provide
theory that nerve interference caused by a vertebral overlapping sympathetic and parasympathetic nerve
subluxation can affect general health or cause supply from many directions and sources (in concert
organic disease. Spinal nerves are commonly com- with chemical, hormonal and circulatory factors) to
pressed by bony spurs and herniated discs. Even the assure continued function of the body’s organs, inde-
most severe compression of a spinal nerve, which pendent of spinal nerves.1 This is why severance of
may cripple the supplied musculoskeletal structures, the spinal cord in the neck area, shutting off brain
does not cause organic disease. In the absence impulses to spinal nerves, can cause paralysis of mus-
of fracture or pathology, such as disc herniation culoskeletal structures from the neck down while the
or osteophyte formation, vertebral misalignments body’s organs continue to function. [A serious trans-
rarely affect spinal nerves. verse spinal cord lesion above C5 can cause respira-
Spinal nerves supply musculoskeletal structures. tory paralysis and often death. A lower lumbar disc
The body’s organs are supplied primarily by auto- protrusion into the spinal canal can affect bladder
nomic nerve ganglia and plexuses located outside the and bowel control (cauda equina syndrome) by com-
spinal column and by autonomic cranial and sacral pressing spinal nerves that pass down from the spinal

89
90 Focus on Alternative and Complementary Therapies June 2013 18(2)

cord, which ends at the level of the first lumbar Standards for chiropractic colleges, reference to the
vertebra.] word subluxation was omitted. The American Chiro-
A chiropractic vertebral subluxation or ‘joint dys- practic Association (ACA) responded, in part, arguing
function’ alleged to cause disease by interfering with that:
the nerve supply to organs has never been proven to
exist. An asymptomatic and undetectable chiroprac- ‘The elimination of any reference to this term [sub-
tic subluxation (often referred to as a ‘vertebral luxation] in the proposed standards will be viewed by
subluxation complex’) cannot be equated with a many within the profession as a counter productive
real orthopaedic subluxation – a partial dislocation action that will, in the long-term, likely weaken
that causes musculoskeletal symptoms. While spinal the profession’s collaborative strength and historical
manipulation can have some temporary neurological identity. We would propose placing the ‘subluxation
and physiological effects, so can a cold shower or a theory’ back into Section 2, H. Educational Programs
slap on the back. There is no evidence to indicate for the Doctor of Chiropractic degree and Vertebral
that such effects have a significant effect on general Subluxation Complex into Section 3 Initial assess-
health. ment and diagnosis as a required component.’7
A recent study by academic chiropractors con-
cluded that ‘no supportive evidence is found for the Responding to widespread objection to omission
chiropractic subluxation being associated with any of the word subluxation, the CCE compromised
disease process or of creating suboptimal health con- by using the nebulous phrase, subluxation/neuro-
ditions requiring intervention.’2 Another independ- biomechanical dysfunction, in the final 2012
ent study by academic chiropractors revealed that Standards in an attempt to satisfy advocates of the
‘despite the controversies and paucity of evidence the vertebral subluxation theory.8 Subluxation-based
term subluxation is still found often within the chi- chiropractors joined forces, however, to oppose the
ropractic curricula of most North American chiro- CCE’s ambiguous position on subluxation theory:
practic programs.’3
‘Speaking in opposition to the CCE’s new standards
Defining chiropractic were the International Chiropractors Association,
the International Federation of Chiropractors and
In the USA, state laws and chiropractic publications Organizations (IFCO), the Movement for Chiroprac-
continue to define chiropractic as a method of cor- tic Quality and Integrity, the Georgia Council of
recting vertebral subluxations to restore and main- Chiropractic, and the Foundation for Vertebral Sub-
tain health.4 A 2010 publication of the National luxation, among others.’9
Board of Chiropractic Examiners (NBCE), Practice
Analysis of Chiropractic, states that:
Obviously, the chiropractic profession in the USA has
not discarded subluxation theory.
‘The specific focus of chiropractic practice is known
In an effort to separate themselves from the stigma
as the chiropractic subluxation or joint dysfunction.
associated with chiropractic subluxation theory,
A subluxation is a health concern that manifests in
some chiropractors no longer use the term subluxa-
the skeletal joints, and, through complex anatomical
tion, instead substituting some other vague descrip-
and physiologic relationships, affects the nervous
tion of a spinal lesion, such as joint dysfunction,
system and may lead to reduced function, disability,
vertebral subluxation complex or subluxation/neuro-
or illness.’5
biomechanical dysfunction; all alleged to have a del-
eterious effect on the nervous system and general
This definition of chiropractic is in keeping with a
health. This veneer of definition, however, does not
paradigm formulated by the Association of Chiro-
conceal the fact that a chiropractic subluxation under
practic Colleges (ACC) in 1996, signed by 16 North
any other name is still a chiropractic subluxation.
American chiropractic college presidents:

‘Chiropractic is concerned with the preservation and

Manipulation without subluxation theory
restoration of health, and focuses particular attention
on the subluxation . . . a complex of functional In 1994, the US Department of Health and Human
and/or structural and/or pathological articular Services, a division of the Agency for Health Care
changes that compromise neural integrity and Policy and Research (AHCPR), published a Clinical
may influence organ system function and general Practice Guideline titled Acute Low Back Problems in
health.’6 Adults, which suggested that spinal manipulation can
be helpful in the treatment of acute low-back prob-
When the Council on Chiropractic Education lems without radiculopathy when used within the
(CCE) published its proposed 2012 Accreditation first month of symptoms.10 Chiropractic was not
 Perspective 91

mentioned. Since then, many articles, pro and con, chiropractic profession severely criticised for its use
dealing with the use of manipulation in the treat- of spinal adjustments in the treatment of a broad
ment of acute, sub-acute and chronic back pain scope of human ailments, chiropractic as a method
have been published. Most have supported the use of of ‘restoring and maintaining health’ has found
manipulation for short-term symptomatic relief of support in the camp of CAM. Some chiropractic col-
uncomplicated back pain, but no credible studies leges now offer training in acupuncture, naturopa-
have offered support for chiropractic adjustment of thy and other forms of alternative medicine. The
the spine to restore and maintain health. National University of Health Sciences (NUHS), for
A 2011 Cochrane review of spinal manipulative example, often referred to as the foremost American
therapy for chronic low-back pain reported that chiropractic college, offers Doctor of Chiropractic,
‘high-quality evidence suggests that there is no Doctor of Naturopathic Medicine, Master of Science
clinically relevant difference between SMT [spinal in Acupuncture and Master of Science in Oriental
manipulative therapy] and other interventions for Medicine degrees. The NUHS recently announced
reducing pain and improving function in patients a new cooperative arrangement with the Graduate
with chronic back pain.’11 A 2012 Cochrane review of Program in Complementary and Alternative Medi-
spinal manipulative therapy for acute low-back pain cine at Georgetown University Medical Center in
concluded that ‘SMT . . . appears to be no more effec- Washington, District of Columbia. Faculty at the
tive than other recommended therapies.’12 A 2012 two schools will work together to help students
National Center for Complementary and Alternative seeking advanced degrees in health care by advising
Medicine review of back-pain studies reported that: students of the benefits of each other’s programmes
and providing preferential seating and advanced
‘Overall, studies have shown that spinal manipula- standing in each other’s programmes when
tion is one of several options – including exercise, appropriate.14
massage, and physical therapy – that can provide Confirming chiropractic’s association with alter-
mild-to-moderate relief from low-back pain. Spinal native medicine, the website of the Association
manipulation also appears to work as well as conven- of Chiropractic Colleges (ACC), in its ‘What Is Chi-
tional treatments such as applying heat, using a firm ropractic?’ section, states: ‘Because of the emphasis
mattress, and taking pain-relieving medications.’13 on holistic health care, chiropractic is associated
with the field of complementary and alternative
medicine.’15 Many healthcare professionals consider
While spinal manipulation used to improve health
alternative medicine to be a haven for unproven
by correcting chiropractic subluxations is classified
and implausible treatment methods, sustained
as a form of unproven alternative medicine, spinal
largely by anecdotal case studies and placebo
manipulation used in the treatment of back pain has
effects.
a plausible basis that makes it acceptable in main-
Few consumers are aware of the great diversity
stream health care.
in chiropractic, and few know what questions to
Although manipulation may not be any more
ask when looking for a science-based chiropractor.
effective than other treatment methods in improving
Treatment methods vary from one chiropractor to
recovery from back pain, it has been the author’s
another, often incompatible with interchange in
experience as a practising chiropractor that use
mainstream health care. In observing the websites
of hands-on manipulation in the treatment of
and promotional materials of newly graduated chi-
mechanical-type back pain will sometimes provide
ropractors, it appears that some of these chiroprac-
more immediate and dramatic relief of symptoms
tors are combining science and pseudoscience to
than other forms of therapy. A competent chiroprac-
support treatment methods based on the fundamen-
tor would release the patient when back-pain symp-
tal tenets of traditional chiropractic; that is, manipu-
toms have resolved, as opposed to subluxation-based
lating the spine for some unverifiable neurological
chiropractors who would continue to treat patients
effect that will affect general health or organ func-
for ‘subluxation correction’ to prevent illness.
tion. These chiropractors may claim to be primary
Endorsement of the use of manipulation in the treat-
care providers, combining spine care with health
ment of mechanical-type back pain is not an endorse-
care and wellness care in a holistic approach that
ment of chiropractic adjustments used to correct
entails treatment and prevention of the gamut of
subluxations or some other joint disturbance alleged
human ailments, using a variety of alternative
to cause illness or poor health.
healing methods. Going from one extreme to
another, chiropractic associations in New Mexico,
South Carolina and Alabama have introduced legis-
Chiropractic and alternative medicine
lation to allow chiropractors with an advanced prac-
While the chiropractic subluxation theory has been tice certification to prescribe drugs from a limited
rejected by the scientific community, and the formulary. Chiropractors would be required to have
92 Focus on Alternative and Complementary Therapies June 2013 18(2)

90 h of additional training in pharmacology. To Chiropractic is not physical therapy

date, such legislation has been stalled by chiroprac-
tors who feel that chiropractic should remain a The only thing unique about chiropractic is its basic
drugless healing profession defined by the basic definition as a method of adjusting vertebral subluxa-
principles of chiropractic.16 tions to restore and maintain health. Any other
The Council on Diagnosis and Internal Disorders physical treatment modality, including generic spinal
(CDID) within the American Chiropractic Associa- manipulation, is arguably physical medicine. The
tion (ACA) endorses a 300-h post-doctorate course subluxation theory has been the chiropractic profes-
that offers a Diplomate of the American Board of sion’s primary reason for existence since its inception
Chiropractic Internists, which trains chiropractic in 1895. Failure of the profession to establish itself
internists to use pharmacologic counselling and com- as a legitimate physical-treatment specialty with an
prehensive natural medical care in diagnosing and armamentarium that includes the use of generic
treating conditions and disease states that can spinal manipulation continues to leave the profes-
allegedly be resolved by utilising natural methods, sion dependent upon the basic principles of chiro-
without the use of drugs.17 It goes without saying that practic, perpetuating the use of unproven spinal
blanket chiropractic treatment of ‘disease states,’ uti- adjustments to treat a broad scope of ailments. Many
lising ‘natural methods,’ or spinal adjustments based chiropractors feel that if the chiropractic profession
on subluxation theory, with or without the use of discards the subluxation theory and specialises in the
drugs, would be problematic. care of neck and back pain and related musculoskel-
Until changes take place in chiropractic colleges etal problems, it will not be able to compete with
and state laws that limit chiropractic to the use of physical therapists and other musculoskeletal practi-
physical treatment methods in the care of back pain tioners who use manual therapy.
and related mechanical-type problems, it will not be It is important to understand that manipulation
possible to change the basic practice mode of chiro- used in the context of chiropractic, as defined by
practors in the field. With a foundation based on subluxation theory, is not done for the same reasons
an implausible subluxation theory that nurtures a guiding the use of manipulation by physical thera-
hodgepodge of dubious treatment methods, the chi- pists. With the exception of a properly limited
ropractic profession is divided by philosophies that science-based chiropractor who uses manipulation
go in many different directions. Chiropractic care appropriately in the care of back pain, chiropractors
may range from ‘straight chiropractic,’ which pro- generally manipulate or adjust putative vertebral
poses that most ailments can be treated by adjusting subluxations in a misguided attempt to restore
vertebral subluxations, to ‘mixed chiropractic,’ and maintain health. Physical therapists use spinal
which permits the use of alternative treatment manipulation-mobilisation primarily as an adjunc-
methods to treat a broad scope of ailments without tive treatment method to relieve pain and muscle
necessarily resorting to subluxation theory. A science- spasm and to restore mobility.
based chiropractor who volunteers to renounce Some chiropractors have accused physical thera-
subluxation theory would limit his or her scope of pists of stealing chiropractic manipulation. Nothing
practice to the care of musculoskeletal problems, could be further from the truth. Generic spinal
using physical treatment methods that include the manipulation has long been a part of physical medi-
use of generic spinal manipulation – practising in cine and is unrelated to subluxation-based chiroprac-
a manner that is more like physical therapy than tic. Chiropractors often say that the difference
chiropractic. between physical therapists and chiropractors is that
Some chiropractic colleges offer decent instruction chiropractors ‘adjust vertebrae’ while physical thera-
in the care of musculoskeletal problems but are pists ‘manipulate the spine’. Yet, efforts have been
tainted by subluxation theory that encompasses a made by chiropractors to prevent physical therapists
broad scope of ailments. Until all chiropractic col- from using spinal manipulation,18 claiming that
leges abandon the subluxation theory and are physical therapists who use such treatment are prac-
uniformly upgraded to training musculoskeletal spe- tising chiropractic. Actually, when chiropractors use
cialists exclusively, chiropractors cannot be recom- any physical treatment modality other than spinal
mended across the board. Physicians who refer adjustments, they are encroaching upon the practice
patients to chiropractors must be cautious in the of physical therapy.
selection of a chiropractor, and they must take Today, with increasing numbers of physical thera-
responsibility for the diagnosis, lest inappropriate pists incorporating manipulation in their treatment
treatment makes them vulnerable to liability for armamentarium, physicians and other healthcare
damages. Care must also be taken to make it clear providers can refer a patient to a department of
that referral to a selected chiropractor who uses physical therapy for spinal manipulation, thus avoid-
manipulation appropriately is not an endorsement of ing the problems associated with searching for a chi-
subluxation-based chiropractic. ropractor who uses manipulation appropriately.
 Perspective 93

Subluxationists: separate and distinct the weakest and dullest, who necessarily sets the
standard, since he cannot rise, while the other can
There are no indications that subluxation theory will
fall.’20
ever be discarded by all chiropractors. Unable to dem-
onstrate that a chiropractic subluxation or a real
orthopaedic subluxation can cause organic disease, Conflict of interest None declared.
a subluxation-based chiropractor may refer to a
vertebral subluxation complex, an asymptomatic and
undetectable joint dysfunction (involving nerves, References
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