544 Journal of Pain and Symptom Management Vol. 35 No.

5 May 2008

Review Article

Chiropractic: A Critical Evaluation

Edzard Ernst, MD, PhD, FRCP, FRCPEd
Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, Exeter,
United Kingdom

Abstract
Chiropractic was defined by D.D. Palmer as ‘‘a science of healing without drugs.’’ About
60,000 chiropractors currently practice in North America, and, worldwide, billions are spent
each year for their services. This article attempts to critically evaluate chiropractic. The
specific topics include the history of chiropractic; the internal conflicts within the profession;
the concepts of chiropractic, particularly those of subluxation and spinal manipulation;
chiropractic practice and research; and the efficacy, safety, and cost of chiropractic. A
narrative review of selected articles from the published chiropractic literature was performed.
For the assessment of efficacy, safety, and cost, the evaluation relied on previously published
systematic reviews. Chiropractic is rooted in mystical concepts. This led to an internal conflict
within the chiropractic profession, which continues today. Currently, there are two types of
chiropractors: those religiously adhering to the gospel of its founding fathers and those open to
change. The core concepts of chiropractic, subluxation and spinal manipulation, are not
based on sound science. Back and neck pain are the domains of chiropractic but many
chiropractors treat conditions other than musculoskeletal problems. With the possible
exception of back pain, chiropractic spinal manipulation has not been shown to be effective
for any medical condition. Manipulation is associated with frequent mild adverse effects
and with serious complications of unknown incidence. Its cost-effectiveness has not been
demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on
solid science and its therapeutic value has not been demonstrated beyond reasonable
doubt. J Pain Symptom Manage 2008;35:544e562. Ó 2008 U.S. Cancer Pain Relief
Committee. Published by Elsevier Inc. All rights reserved.

Key Words
Cerebrovascular accident, clinical trials, cost-effectiveness, evidence-based medicine,
side effects

Introduction
Chiropractic is a popular form of health care
The author has no conflict of interest. for which many definitions can be found1e12
Address correspondence to: Edzard Ernst, MD, PhD, (Table 1). ‘‘The ‘raison d’être’ of the chiroprac-
FRCP, FRCPEd Complementary Medicine, Penin- tic profession is the detection and correction of
sula Medical School, Universities of Exeter and spinal subluxations.’’13 In the ‘‘earliest known’’
Plymouth, 25 Victoria Park Road, Exeter EX2 4NT,
UK. E-mail: edzard.ernst@pms.ac.uk publication14 on the subject, its founder (Dan-
iel David Palmer) stated that, ‘‘chiropractic is
Accepted for publication: July 17, 2007. a science of healing without drugs.’’15

Ó 2008 U.S. Cancer Pain Relief Committee 0885-3924/08/$esee front matter

Published by Elsevier Inc. All rights reserved. doi:10.1016/j.jpainsymman.2007.07.004
Vol. 35 No. 5 May 2008 Chiropractic: A Critical Evaluation 545

Table 1
Recent Definitions of Chiropractic
Date Definition/description (quotes) Source (Ref.)

1998 A system of healthcare.which is based on the belief that the nervous system is the Segen1
most important determinant of a person’s state of health.
1994 A drugless, non-invasive manual form of outpatient treatment for musculoskeletal, Oths2
functional and other chronic disorders.
1996 A therapeutic system based on the premise that structure and function in the Lott3
human body are closely related and, in particular, the relationship between
the spinal column and the nervous system is the most important.
1998 A system of healing based on the belief that health is maintained when the spinal Bimonte4
column is in its proper position and the nervous system is not impinged.
1998 Chiropractic.is based on the body’s ability to heal itself. Central to improving the Shekelle5
body’s ability to heal itself, chiropractors assert, is the removal, or correction,
of malalignments of the spine (called subluxations) through the use of spinal
manipulation (called spinal adjustments).
1998 The medical profession that specializes in manual therapy and especially spinal Kaptchuk6
manipulation.
1999 A health profession concerned with the diagnosis, treatment and prevention of World Federation
mechanical disorders of the musculoskeletal system and the effects of these of Chiropractic7
disorders on the function of the nervous system and general health. There is an
emphasis on manual treatments, including spinal manipulation or adjustment.
1999 A profession which specializes in the diagnosis, treatment and overall management British Chiropractic
of conditions which are due to mechanical dysfunction of the joints, particularly Association8
those of the spine, and their effects on the nervous system.
1999 A branch of the healing arts which is concerned with human health and disease American Chiropractic
processes. Association9
2000 A branch of the healing arts.based on the premise that good health depends, Sportelli10
in part, upon a normally functioning nervous system.
2000 The chiropractic is not a technique. It is a health care profession, it has an Halder11
exclusive body of information which teaches, certifies, policies, purveys and
sometimes attempts to validate.
2003 A form of health care that focuses on the relationship between the body’s structure, NCCAM12
primarily of the spine and function.

Today, some chiropractors view chiropractic chiropractic profession is thus growing rapidly;
as an ‘‘alternative form of healthcare,’’16 but in more than 4,000 students graduate each year
most countries, chiropractic is seen as an from about 30 chiropractic colleges in the
adjunct to rather than a replacement of con- United States, and the total number of U.S.
ventional medicine. Chiropractors have legal chiropractors is predicted to reach 100,000
recognition in about half of the world, whereas by 2010.23,24
in the other half, such recognition is lacking. This article critically analyzes the history,
In India, China, former Russia, parts of Eu- rationale, and practice of chiropractic. It asks
rope, and most of South Africa,17 chiropractic the question: Does chiropractic generate
is not legally recognized. more good than harm? It draws mainly on the
In the United States, between $2.4 and $4.0 published chiropractic literature, including
billion is spent each year on chiropractic several articles that have previously reviewed
care.18,19 Chiropractic is covered by Medicare, chiropractic.6,10,11 The scarcity of critical in-
a substantial proportion of private and public depth analyses is noted; its implications are
insurance plans, all state-workers compensa- described.
tion systems, all forms of managed care, most
health maintenance organizations, and private
health insurance plans.20 All 50 U.S. states, History
Puerto Rico, the District of Columbia, and The history of chiropractic is ‘‘rooted in
the Virgin Islands license chiropractors.3,21 quasi-mystical concepts.’’20 Bonesetters of vari-
About 60,000 chiropractors currently practice ous types are part of the folk medicine of most
in North America, a number that has tripled cultures,25e27 and bonesetting also formed
between 1970 and 1990.16,22 The proportion the basis on which chiropractic developed.
of the population using chiropractic services The birthday of chiropractic is said to be
has doubled in the last two decades.22 The September 18, 1895. On this day, D.D. Palmer
546 Ernst Vol. 35 No. 5 May 2008

manipulated the spine of a deaf janitor by the man as a microcosm of the universe where ‘‘in-
name of Harvey Lillard, allegedly curing him nate intelligence’’ determines human health as
of his deafness.28 Palmer’s second patient, much as ‘‘universal intelligence’’ governs the
a man suffering from heart disease, was also cosmos; the discovery of the ‘‘innate intelli-
cured.29 About one year later, Palmer opened gence’’ represents a discovery of the first order,
the first school of chiropractic.29 ‘‘a reflection of a critical law that God used to
There is evidence to suggest that D.D. govern natural phenomena.’’34
Palmer had learned manipulative techniques
from Andrew Taylor Still (1828e1917), the Chiropractic as a Religion
founder of osteopathy.30 He combined the Early chiropractic displayed many character-
skills of a bonesetter with the background of istics of a religion. Both D.D. Palmer and his
a magnetic healer and claimed that ‘‘chiro- son, B.J. Palmer, seriously considered establish-
practic was not evolved from medicine or any ing chiropractic as a religion.34 Chiropractic
other method, except that of magnetic.’’31 ‘‘incorporated vitalistic concepts of an innate
He coined the term ‘‘innate intelligence’’ (or intelligence with religious concepts of univer-
‘‘innate’’) for the assumed ‘‘energy’’ or ‘‘vital sal intelligence,’’ which substituted for sci-
force,’’ which, according to the magnetic ence.40 D.D. Palmer declared that he had
healers of that time, enables the body to heal discovered the answer to the timeworn ques-
itself. The ‘‘innate’’ defies quantification. ‘‘Chi- tion, ‘‘What is life?’’ and added that chiroprac-
ropractic is based on a metaphysical epistemol- tic made ‘‘this stage of existence much more
ogy that is not amenable to positivist research efficient in its preparation for the next
or experiment.’’32 stepdthe life beyond.’’39
The ‘‘innate’’ is said to regulate all body Most early and many of today’s chiropractors
functions but, in the presence of ‘‘vertebral agree: ‘‘Men do not cure. It is that inherent
subluxation,’’ it cannot function adequately. power (derived from the creator) that causes
Chiropractors therefore developed spinal wounds to heal, or a part to be repaired. The
manipulations to correct such subluxations, Creator.uses the chiropractor as a tool.chir-
which, in their view, block the flow of the ‘‘in- opractic philosophy is truly the missing link
nate.’’33 Chiropractic is ‘‘a system of healing between Religion or Power of the various reli-
based on the premise that the body requires gions.’’41 Today, some chiropractors continue
unobstructed flow through the nervous system to relate the ‘‘innate’’ to God.42 Others, how-
of.innate intelligence.’’34 Anyone who did ever, warn not to ‘‘dwindle or dwarf chiroprac-
not believe in the ‘‘innate’’ or in ‘‘subluxa- tic by making a religion out of a technique.’’43
tions’’ was said to have no legitimate role in
chiropractic.35 External Conflict
‘‘Innate intelligence’’ evolved as a theological Initially, the success of chiropractic was con-
concept, the representative of Universal Intelli- siderable. By 1925, more than 80 chiropractic
gence (¼God) within each person.36 D.D. schools had been established in the United
Palmer was convinced he had discovered a nat- States. Most were ‘‘diploma mills’’ offering an
ural law that pertained to human health in the ‘‘easy way to make money,’’29 and many ‘‘were
most general terms. Originally, manipulation at one another’s throats.’’41 Chiropractors
was not a technique for treating spinal or mus- believed they had established their own form
culoskeletal problems, it was a cure for all of science,44 which emphasized observation
human illness: ‘‘95% of all diseases are caused rather than experimentation, a vitalistic rather
by displaced vertebrae, the remainder by luxa- than mechanistic philosophy, and a mutually
tions of other joints.’’37 Early chiropractic pam- supportive rather than antagonist relationship
phlets hardly mention back pain or neck pain, between science and religion. The gap be-
but assert that, ‘‘chiropractic could address tween conventional medicine and chiropractic
ailments such as insanity, sexual dysfunction, thus widened ‘‘from a fissure into a canyon.’’34
measles and influenza.’’38 The rivalry was not confined to conventional
D.D. Palmer was convinced that he had ‘‘cre- medicine; ‘‘many osteopaths asserted that
ated a science of principles that has existed as chiropractic was a bastardized version of
long as the vertebra.’’39 Chiropractors envision osteopathy.’’30
Vol. 35 No. 5 May 2008 Chiropractic: A Critical Evaluation 547

Rather than arguing over issues such as effi- ‘‘mixers’’ are somewhat more open to science
cacy, education, or professional authority, the and conventional medicine, use treatments
American Medical Association insisted that all other than spinal manipulation, and tend to
competent health care providers must have see chiropractors as back pain specialists.6,28
adequate knowledge of the essential subjects Father and son Palmer warned that the
such as anatomy, physiology, pathology, chem- ‘‘mixers’’ were ‘‘polluting and diluting the
istry, and bacteriology.34 By that token, the sacred teachings’’ of chiropractic.39 Many
American Medical Association claimed, chiropractors agreed that the mixers were
chiropractors were not fit for practice.28 ‘‘bringing discredit to the chiropractic.’’41
Some ‘‘martyrs,’’ including D.D. Palmer The ‘‘straights’’ are now in the minority but
himself, went to jail for practicing medicine nevertheless exert an important influence.
without a licence.6,41 They have, for instance, recently achieved
Chiropractors countered that doctors were election victories within the British General
merely defending their patch for obvious finan- Chiropractic Council.49 Today, two different
cial reasons (ironically, chiropractors today of- chiropractic professions exist side by sided
ten earn more than conventional doctors30), ‘‘one that wishes to preserve the non-
that orthodox science was morally corrupt empirical, non-positivist, vitalist foundations
and lacked open-mindedness.34 They attacked (the straights) and the other that wishes to be
the ‘‘germo-anti-toxins-vaxiradi-electro-microbio- reckoned as medical physicians and wishes to
slush death producers’’44 and promised a medi- utilize the techniques and mechanistic view-
cine ‘‘destined to the grandest and greatest of point of orthodox medicine (the mixers).’’32
this or any age.’’31 The International Chiropractic Association
Eventually, the escalating battle against the represents the ‘‘straights’’ and the American
medical establishment was won in ‘‘the trial Chiropractic Association the ‘‘mixers.’’
of the century.’’6 In 1987, sections of the U.S.
medical establishment were found ‘‘guilty of
conspiracy against chiropractors,’’45 a decision Core Concepts
which was upheld by the U.S. Supreme Court The three main hypotheses of modern chi-
in 1990.6 In other countries, similar legal bat- ropractic have been summarized as follows:16
tles were fought, usually with similar out-
 There is a functional relationship between
comes.46,47 Only rarely did they not result in
the spine and health mediated through
the defeat of the ‘‘establishment:’’ In 1990,
the nervous system.
a Japanese Ministry of Health report found
 Subluxations adversely affect health.
that chiropractic is ‘‘not based on the knowl-
 Correction of subluxation by spinal
edge of human anatomy but subjective and
manipulation improves or restores health.
unscientific.’’48
‘‘Give me a simple mind that thinks along
Internal Conflict single tracts, give me 30 days to instruct him,
These victories came at the price of ‘‘tam- and that individual can go forth on the high-
ing’’ and ‘‘medicalizing’’ chiropractic.46 In ways and byways and get more sick people
turn, this formed the basis of a conflict within well than the best, most complete, all around,
the chiropractic professiondthe dispute unlimited medical education of any medical
between ‘‘mixers’’ and ‘‘straights’’da conflict man who ever lived.’’50 This remark by B.J.
which continues to the present day. Palmer implies that naivety is required to
The ‘‘straights’’ religiously adhere to D.D. accept the implausibility of the chiropractic
Palmer’s notions of the ‘‘innate intelligence’’ concepts. The founders of chiropractic created
and view subluxation as the sole cause and myths and denied scientific discoveries; B.J.
manipulation as the sole cure of all human Palmer, for instance, rejected the existence of
disease. They do not mix any nonchiropractic the sympathetic nervous system,14 and early
techniques into their therapeutic repertoire, chiropractors denied the existence of the
dismiss physical examination (beyond search- germ theory of disease, which has important
ing for subluxations) and think medical implications for public health today (see
diagnosis is irrelevant for chiropractic.33 The below).
548 Ernst Vol. 35 No. 5 May 2008

The ‘‘mixers,’’ however, saw the insistence integrity and may influence organ systems
on the ‘‘innate’’ as ‘‘religious baggage.’’51 function and general health.’’70 One year later,
Today many chiropractors are anxious to sever the U.S. Foundation for Chiropractic Educa-
all links with this concept,6 fearing that it tion and Research published a monograph
might jeopardize chiropractics’ acceptance stating that subluxation ‘‘embraces the holistic
into the mainstream.52e54 nature of the human body, including health,
well-being, the doctor/patient relationship,
Subluxation and the changes in the nerve, muscle, connec-
Some chiropractors prefer terminology such tive tissue, and vascular tissues which are un-
as ‘‘vertebral subluxation complex,’’55 ‘‘manip- derstood to accompany the kinesiologic
ulable spinal lesion,’’56 ‘‘chiropractic lesion,’’57 aberrations of spinal articulations.’’71 Today,
or ‘‘vertebral blockage,’’58 yet most modern 88% of U.S. chiropractors believe that subluxa-
chiropractors accept the concept of subluxa- tion contributes to over 60% of all visceral
tion.13 The term as used in chiropractic means ailments and 90% think it should, therefore,
something different from subluxation in regu- not be limited to muskuloskeletal conditions.72
lar medicine. Here, I refer to the term as used In other countries, for example, Canada, these
in chiropractic. For D.D. Palmer, it was ‘‘a static percentage figures are usually lower.73
malalignment of a single vertebra.’’6 Subluxa-
tions are believed to impinge on spinal nerves,
therefore blocking the flow of the ‘‘innate Spinal Manipulation
intelligence’’ (according to ‘‘straights’’) or Subluxations can be corrected with spinal
causing disease in some other way (according manipulations or ‘‘adjustments,’’ a term pre-
to ‘‘mixers’’). ferred by some chiropractors.20 Today most
Many ‘‘straights’’ adhere to B.J. Palmer’s the- chiropractors agree with D.D. Palmer that spi-
ory that atlas subluxations impinge on the nal manipulation has to be specific, that is, at
spinal cord;40 ‘‘chiropractic gets sick people the correct spinal segment.74 There is, how-
well by adjusting vertebral subluxations of atlas ever, less agreement on the optimal direction
and axis only.’’59 This ‘‘narrowed the search for or the level of manipulation.75,76 Chiroprac-
specific causes of patients’ maladies by narrow- tors even disagree about the term spinal
ing the area of the search to the upper manipulation.77,78 In its broadest definition,
spine.’’14 Until recently, such chiropractic the- it describes the ‘‘application of a load (force)
ories were left unquestioned and untested.60 to specific body or tissues with therapeutic
Chiropractic was (and arguably is) a matter intent.’’20
of belief rather than evidence. Spinal manipulation moves vertebrae
Several theories have been advanced to beyond their physiological range of motion
explain how subluxations might cause health (chiropractors speak of ‘‘end feel’’ and ‘‘para-
problems,61e63 for example, through edema physiological space’’)13 but not far enough to
around intervertebral foramina64 or twisting destroy joint structures:6 ‘‘between the normal
the dura mater.65 However, none of these range of motion and the limits of its normal
have been independently confirmed and the integrity.’’13 Chiropractors believe that spinal
specific mechanisms involved are not manipulation breaks fibrous adhesions within
known.29,66 In fact, subluxations have never joints, or that it ‘‘releases small tags from the
been proven to constitute a relevant entity. joint capsule that might be entrapped within
Critics have repeatedly pointed out that even the joint,’’ or that it affects the mechanorecep-
severe nerve root compression does not cause tors of the joint, or that it modulates central
organic disease.67e69 Regardless of such nervous system excitability,21 or that it inhibits
doubts, the U.S. Association of Chiropractic C-fiber mediated pain perception.79 None of
Colleges reached a consensus in 1996 that ‘‘chi- these theories are, however, supported by
ropractic is concerned with the preservation sound evidence.80
and restoration of health and focuses particu- Numerous forms of spinal manipulation exist
lar attention on the subluxation. A subluxation but ‘‘the short-lever techniquedtouching the
is a complex of functional and/or pathological vertebrae directly at high velocity and low ampli-
articular changes that compromise neural tude, i.e., by moving a small distancedwith the
Vol. 35 No. 5 May 2008 Chiropractic: A Critical Evaluation 549

spinal or transverse process as a fulcrum, is con- might present a risk to patients.’’93 Some chi-
sidered the typical chiropractic manoeuver.’’6 ropractors refer patients to homeopaths,
iridologists, or paranormal healers.94 Many
chiropractors use unproven or disproven
methods themselves such as homeopathy
Chiropractic Practice (46%), applied kinesiology (38%),95 or trac-
The Profession(s) tion.94 In fact, applied kinesiology is rated to
Many chiropractors (mixers) view them- be among their most reliable diagnostic
selves as primary care providers30,81 or general methods.77
practitioners with ‘‘an important role in health ‘‘Widespread unjustified claims which
promotion and injury or disease preven- chiropractors routinely make’’ have become
tion.’’82,83 ‘‘Integrative medicine’’ is often a concern even for some chiropractors.96 A
seen as ‘‘the next step in gaining access to comparison of practice guidelines issued by
patients.’’84 various chiropractic organizations disclosed
Overall, estimates of the use of chiropractic ‘‘discrepancies in the strength of recommen-
services by the general population range dations, the type of recommendations and
from 3% to 18%.21 Health care professionals even the evidence upon which the recommen-
usually prefer other forms of complemen- dations have been based.’’32
tary/alternative medicine to chiropractic.85,86
Chiropractors predominantly treat patients Patients
with musculoskeletal problems, about 60% of About 90% of chiropractic patients are self-
whom suffer from low back pain. In the United referred,84 and payment often comes (35%)
States, 13% of all back pain sufferers consult directly from the patient.90 Chiropractic pa-
a chiropractor.87 Another domain is neck tients are more likely than medical patients
pain, which chiropractors usually treat with to be obese, lack a regular doctor, have few
upper spinal manipulation. One report indi- chronic conditions, take few drugs, and be
cates, however, that only 11% of all cervical uninsured and dissatisfied with health care.97
manipulations are ‘‘appropriate.’’88 A sizable proportion of U.S. chiropractic pa-
Spinal manipulation is also practiced in tients (20%e30%) receive in excess of 11 treat-
other professions (e.g., osteopaths, physiother- ments sessions.81 For neck pain, an average
apists, and doctors) but chiropractors deliver number of 25 visits was recently reported,
more than 90% of all spinal manipulations.20 and 2% of these patients received more than
Treatment is often continued for over three 80 treatment sessions.98 In other countries,
months, even in the absence of clinical im- for example, Canada, these percentages may
provement.89 Consultations last for an average be considerably lower.99
of 22 minutes.90 Many U.S. chiropractors use Reasons for patients not to consult chiro-
‘‘practice building seminars’’ (often organized practors include the fear of adverse effects
by Scientologists) to convince their patients of and ‘‘lack of scientific proof.’’84 In general,
the value of their treatments.91 Chiropractors the public seems to prefer medical doctors as
work mostly in single practices (67%) and their primary care providers.100 In some parts
have an average of 3.8 years of basic training.90 of Canada (British Columbia and Ontario),
Their income frequently exceeds that of chiropractic services have recently been de-
conventional primary care physicians.30 listed, and the Ontario government estimated
that $100 million will be saved through this
The Treatments move.101
In addition to spinal manipulations,
‘‘mixers’’ also use other modalities such as Indications
heat, cold, and electrotherapy; they also may Chiropractic services are used mostly, but by
advise on supplement usage, lifestyle, weight no means exclusively, for the management of
loss, or relaxation.20 Maintenance chiropractic musculoskeletal conditions. The American Chi-
care is promoted as a preventative measure for ropractic Association stresses, however, that
both musculoskeletal and visceral problems92 chiropractic care is ‘‘not limited to back pain,
even though ‘‘such unnecessary manipulation neck pain’’ or other neuromusculoskeletal
550 Ernst Vol. 35 No. 5 May 2008

disorders;9 11%e19% of all chiropractic deliver babies,127 but in most U.S. states,
patients suffer from nonmusculoskeletal obstetrics is specifically prohibited to them.
conditions.102,103 This figure seems to be con- Conventional U.S. doctors are unlikely to
siderably lower outside the United States.94,104 make formal referrals to chiropractors.128
Most chiropractic texts discuss spinal manip-
ulation as a treatment for visceral disor- Ethics
ders,13,16,105,106 and it has been noted that, A comparison of Californian disciplinary ac-
‘‘there have been over 1,200 published studies tions (1998e2002) against chiropractors and
linking spinal trauma to visceral disease.’’107 medical doctors showed that there were 4.5
Nonmusculoskeletal problems regularly such actions per 1,000 chiropractors per year,
treated by chiropractors include respiratory a figure which was 98% higher than that for
conditions, nonspinal injuries, digestive system doctors. The incidence rate per 1,000 for fraud
disorders, menstrual problems, ear infections, was 1.99 for chiropractors, 895% higher than
pregnancy-related conditions, infectious and that for doctors. The incidence rate for sexual
parasitic conditions, dermatological diseases, boundary transgressions was 1.01 for chiro-
and acute urinary conditions.81 Chiropractors practors, 339% higher than that for doctors.129
cite uncontrolled studies in support of spinal Informed consent is a serious concern in
manipulations for indications such as dysmen- chiropractic practice. Of 150 randomly
orrhea, asthma, otitis media, hypertension, selected UK chiropractors, only 23% reported
IBS, and peptic disorders.108e112 The chiro- always discussing serious risks with their pa-
practic literature is rife with claims related to tients before treatment, a behavior that clearly
nonspinal indications, for example, ‘‘the judi- is in conflict with the UK ethical code.130
cial use of chiropractic services in cancer pa-
tients appears to offer many economical and
effective strategies for reducing the pain and
suffering of cancer patients..’’113 Research
The terms ‘‘research’’ and ‘‘science’’ appear
Diagnostics frequently in the chiropractic literature with
The reliability of diagnostic techniques used a variety of meanings ‘‘unfamiliar to most sci-
by chiropractors is generally poor.75,114e121 entists’’33 (Table 2). Many early chiropractors
Plain static radiograph and functional radio- felt the need to obtain an ‘‘aura of scientific re-
graph investigations are viewed as the most re- spectability’’ as marketing ploys for promoting
liable methods for diagnosing subluxations.77 their practice to the public.33 This attitude
Thus, practically all new (96.3%) and most seems to be still prevalent. A leading Canadian
continuing (80%) U.S. chiropractic patients chiropractor, for instance, was quoted saying
undergo radiography, with an average number that research ‘‘is something that you have to
of views per new patient of 3.4.102 Yet, guide- do, no question. We have to have the research
lines state that a competent chiropractor to be accepted properly.’’131 The concept that
‘‘does not do routine radiographs on every pa- research is a means of improving future health
tient.’’122 The majority of U.S. chiropractors care does not seem widespread within the
(86%) have their own X-ray equipment,102 chiropractic profession.
whereas elsewhere, for example, in Holland, The little research that did take place during
this figure is lower (58%).94 Although most pa- the early years of chiropractic was of remark-
tients consulting a chiropractor have a radio- ably low quality. Research was initiated to
graph taken,123 only 4% of UK back pain prove rather than to test chiropractic.33 The
patients in general practice have the proce- data that thus emerged were subject to
dure.124 Most experts today caution that radio- ‘‘zealous overinterpretation.’’33 For instance,
graphic investigations for nonspecific back observational studies were wrongly character-
pain are frequently unnecessary125 and ized as controlled clinical trials.132 The current
harmful.126 chiropractic research literature continues to
Many U.S. chiropractors also do blood and be overtly biased. An evaluation of the 29
urine analyses and some engage in minor sur- recent reviews of spinal manipulation for
gery.81 In Oregon, chiropractors are allowed to back pain concluded that those authored by
Vol. 35 No. 5 May 2008 Chiropractic: A Critical Evaluation 551

Table 2
Quotes from the Chiropractic Literature Related to Science
Date Author Quote

1897 Palmer DD Chiropractic is a science of healing without drugs

1906 Palmer DD, Palmer BJ The science of chiropractic
1910 Palmer DD The science, art and philosophy of chiropractic
1911 Palmer BJ The philosophy, science and art of chiropractic nerve tracing
1917 Carvor The first scientific statement of the science of chiropractic
1946 Ratledge TF The ultra-scientific nature of the chiropractic concept
1985 Dishman Scientific basis for the chiropractic subluxation complex
1994 Martin SC The demonstration of a new scientific law that healed the sick was
an important contribution to the revealing of God’s beneficence

chiropractors tended to generate positive re- chiropractic in Great Britain) stated that ‘‘chi-
sults, whereas the others failed to demonstrate ropractors primarily treat: spine, neck and
effectiveness.133 shoulder problems, joint, posture and muscle
Today’s ‘‘straight’’ chiropractors believe that problems, sciatica, sports injuries, tension
research ‘‘never establishes truth’’42 and deny headaches and benefit may also be seen for
the relevance of science to chiropractic.35 some types of asthma, digestive disorders,
‘‘We cannot second guess whether the innate migraine, infant colic, menstrual pains.’’136
intelligence of the body can heal a disease.’’42 This statement clearly implies that chiropractic
Belief in subluxation is an essential prerequi- is helpful for these indications. Yet the evidence
site for any chiropractordso much so that from rigorous clinical trials fails to confirm this.
questioning this belief is grounds for banish- Numerous controlled clinical studies of chi-
ment from the profession; therefore, scientific ropractic are now available, but their results
investigation of chiropractic, which obviously are far from uniform. Rather than selecting
requires questioning that belief, is (by single studies according to their findings, it
definition) not possible for chiropractors.33 is, therefore, preferable to consider the totality
There is ‘‘a shortage of chiropractic clini- of this evidence. Table 3 gives an overview of
cians who have the experience and training the most up-to-date systematic reviews by indi-
to conduct clinical research.’’112 A survey of cation.137e144 These systematic reviews usually
Californian chiropractic students suggested include trials of spinal manipulation regardless
that 52% of them are interested in research, of who administered it. Thus, they are not ex-
26% have research experience, 19% thought clusively an evaluation of chiropractic. Collec-
research training should be in their curricu- tively, their results fail to demonstrate that
lum but ‘‘most students.were reluctant to spinal manipulation is effective. The only pos-
take on extra courses in research.’’134 It is, sible exception is back pain. For this condi-
therefore, not surprising that ‘‘many of the tion, manipulation may be as effective (or
key clinical trials.were conducted in Europe ineffective) as standard therapy.137
and Canada.’’13 Many national guidelines recommend
chiropractic for acute or chronic low back
pain.145e149 The reason may not be the
Current Evidence convincingly demonstrated effectiveness of
Efficacy chiropractic care but the fact that no therapy
Kusserow noted that, ‘‘overtly aggressive so far has been shown to make a real differ-
marketing [is].deliberately aimed at mislead- ence for back pain sufferers. Recent studies
ing patients and the public regarding the effi- suggest that a prospectively identifiable
cacy of chiropractic care.’’135 In fact, subgroup of patients with back pain may bene-
unsubstantiated claims regarding the efficacy fit from spinal manipulation, whereas others
of chiropractic continue to be made, not do not.150e153 If this turns out to be true, it
merely by overenthusiastic individuals but could help to explain the so far unconvincing
also by official organizations. For instance, a pa- trial results. Other recent data suggest that, for
tient brochure published by the UK General back pain, educational programs may be
Chiropractic Council (the body that oversees preferable to treatments such as spinal
552 Ernst Vol. 35 No. 5 May 2008

Table 3
Systematic Reviews of (Chiropractic) Spinal Manipulation
First Author (Year) Interventions Condition n Meta-analysis Overall resulta Comment

Assendelft et al. Any type of SM Low back pain 39 Yes No evidence that Also included
(2004)137 SM is superior RCTs of
to other standard mobilization
treatments for
acute or chronic
low back pain
Gross et al. Any type of SM Neck problems 33 Yes .evidence did not Combined with
(2004)138 and mobilization favor SM/ exercise, SM
mobilization was beneficial
done alone
Fernandez-de-las- All types of manual Tension type 6 No ‘‘.no rigorous 2 RCTs were of
Penas et al. therapies (3 trials headache (TTH) evidence that high quality
(2006)139 of spinal manual therapies but generated
manipulation) have a positive contradictory
effect on the results
evolution of
TTH’’
Ernst (2003)140 Chiropractic SM Neck pain 4 No The notion that Included only
chiropractic SM RCTs of
is more effective chiropractic
than conventional SM.
exercise.was not
supported by
rigorous trial data
Proctor et al. Any type of SM Primary and 5 No There is no 4 of the 5 RCTs
(2001)141 secondary evidence that were of high
dysmenorrhea SM is effective velocity, low
amplitude
thrusts
Husereau et al. Any type of SM Infantile colic 4 No No convincing Most trials were
(2003)142 evidence of low
methodological
quality
Balon and Mior Chiropractic care Asthma/allergy 6 No No evidence to 4 of the 6 trials
(2004)143 support the use of tested SM; 3
chiropractic SM of these studies
were negative
Reid and Rivett Manual therapy Cervicogenic 9 No .there is limited Only one of the
(2005)144 mainly dizziness evidence at trials was
manipulation and present to support randomized.
mobilization the use of manual
therapy in
treating
cervicogenic
dizziness.
This table includes all indications for which systematic reviews are available. If for any indication more than one systematic review exists, the most
recent one was chosen.
n ¼ number of trials included, SM ¼ spinal manipulation, RCT ¼ randomized clinical trial.
a
Quote from authors’ conclusions.

manipulation, which tend to medicalize back to the perceived benefit of chiropractic. Some
pain sufferers.154 even felt that ‘‘at least half’’ of the chiropractic
Few of the primary studies have been ade- success is due to placebo effects.155
quately controlled for placebo effects, an objec- According to the chiropractic literature,
tive which is difficult but not impossible to absolute contraindications of chiropractic in-
achieve. Thus, some of the benefit reported in clude osteoporosis, local malignancies, bone
the above-mentioned studies could be due to fractures, bone infections, and bleeding disor-
a placebo response. A survey of 34 Australian ders,21 as well as active inflammatory arthro-
‘‘leaders of the chiropractic profession’’ sug- pathy, ligamentous laxity, hypermobility,
gested that the majority of chiropractors agree local metastases, dislocations, myelopathy,
that the placebo effect is a major contributor and cauda equina syndrome.16 Relative
Vol. 35 No. 5 May 2008 Chiropractic: A Critical Evaluation 553

contraindications include severe spondylosis, update reviewed the latest evidence.169 In to-
distant malignancies/metastases, local benign tal, this disclosed around 700 serious complica-
tumors, spinal trauma, chronic sponylarthrop- tions and about 50 deaths. Five surveys have
athy, history of spinal surgery, acute soft tissue been published asking doctors to report in-
or disc injuries, history of verbrobasilar insuffi- stances where their patients have experienced
ciency, and osteopenia.16 serious adverse effects after spinal manipula-
tion.170e174 The results invariably disclosed
a multitude of complications after chiropractic
Safety manipulation. More importantly, they demon-
strated that these instances had not previously
Direct Risks. ‘‘Chiropractic is safe’’82din the been reported in the medical literature. In
chiropractic literature, statements like this other words, underreporting had been 100%.
can be found abundantly. Table 4156e164 Therefore, it seems highly doubtful whether
depicts some of the arguments currently used reliable incidence figures can presently be cal-
by chiropractors to deny that spinal manipula- culated. A recent systematic review found 14
tion can cause harm or to trivialize its risks. cases of adverse effects of spinal manipulation
In 2001, a systematic review of five prospec- in children, 10 of which involved serious com-
tive studies concluded that mild-to-moderate, plications such as subarachnoidal hemorrhage
transient adverse effects are experienced by or paraplegia.175 Table 5 lists a selection of
about half of all chiropractic patients.165 Local recently published case reports176e191 associat-
or radiating pain, headache, and tiredness are ing chiropractic treatments with serious
the most frequent adverse effects. Since then, complications.
two further prospective studies (n ¼ 465 and
336, respectively) reported that such adverse
effects occur in 61% and 30% of pa- Indirect Risks. Further safety concerns relate
tients.166,167 Therefore, there is undeniable ev- to indirect risks of chiropractic. The above-
idence that chiropractic is associated with an named review175 noted 20 cases of delayed or
exorbitantly high incidence of minor adverse missed diagnoses through consulting a chiro-
effects. practor. A similar but better researched indi-
Spinal manipulation of the upper spine has rect risk is the attitude of many chiropractors
frequently been associated with serious vascu- toward immunization. The early chiropractic
lar accidents. A systematic review summarized literature is littered with statements against
the data up to November 2001,168 and an immunization. Palmer’s original concepts

Table 4
Quotes from the Recent Chiropractic Literature Regarding Safety
Date Author Quote Ref. No.
156
2001 Cohn The occurrence of cerebral vascular accidents (CVAs) in the general
population is 0.224% while the occurrence of CVAs in the chiropractic
population is 0.000008%.
157
2001 Filippi .this latest ungrounded association [of chiropractic] with stroke etiology
serves as a final straw in a long and tedious process of professional identity.
158
2002 Michaud .vigorous manipulation of the upper cervical spine is possible without
injuring an already damaged vertebral artery.
159
2003 Haneline et al. The medical literature does not support a clear causal relationship between
chiropractic manipulative therapy and internal carotid artery dissection.
160
2003 Haneline and Croft .a causal relationship [between chiropractic manipulation and internal
carotid artery dissection] is not supported by the literature.
161
2003 Mirallas-Martinez .mortality due to surgical interventions of lumbar spine is 300 times
greater than due to post-cervical manipulation stroke.
162
2004 Refisch and Bischoff .the relationship between cervical manipulation and lesions of the cervical
arteries.must be negated.
163
2004 Oliphant An estimate of the risk of spinal manipulation causing a clinical worsened
disk herniation or cauda equina syndrome.is calculated.to be less than
1 in 3.7 million.
164
2005 Haneline and Triano The direct evidence suggests that the healthy vertebral artery is not at risk
from properly performed chiropractic manipulative procedures.
554 Ernst Vol. 35 No. 5 May 2008

Table 5
Recent (2001e2006) Case Reports of Serious Adverse Events After Chiropractic Spinal Manipulation
First Author (Year) Patient(s) Adverse Event Outcome
176
Jeret (2001) 34-year-old man with neck Dural tear, positional dizziness Full recovery
pain after whiplash injury
Siegel and Neiders 33-year-old woman with Vertebral artery dissection Permanent, severe
(2001)177 headache followed by pontine infarct neurological deficit
Parwar et al. (2001)178 44-year-old man with Dissection of right internal carotic Not reported
shoulder pain artery, Horner’s syndrome
Schram and Vosik 47-year-old man with neck Phrenic nerve injury, Residual dyspnea
(2001)179 and shoulder pain diaphragmatic paralysis,
severe dyspnea
Jeret and Bluth (2002)180 31-year-old woman Dissection of left vertebral artery Complete recovery
Sedat et al. (2002)181 42-year-old woman with Dissection of extracranial Residual headache and
neck pain port of the right PICA stiffness on discharge
from hospital
Jay et al. (2003)182 26-year-old woman with Bilateral dissection of vertebral Not mentioned
headache and sinusitis arteries followed by bilateral
occipital-parietal hemorrhagic
infarction and visual impairment
Menendez-Gonzalez et al. 33-year-old patient Dissection of vertebral artery Not mentioned
(2003)183 followed by Wallenberg’s
syndrome
Wojcik et al. (2003)184 46-year-old female patient Dural tear Complete recovery
with neck pain
185
Beck et al. (2003) 40-year-old female patient Wallenberg syndrome No information provided
Nadgir et al. (2003)186 34-year-old man Bilateral internal carotic and Residual left-side
vertebral artery dissection hemianesthesia and
dysesthesia
Oehler et al. (2003)187 31-year-old woman with Bilateral dissections of vertebral Not mentioned
headache arteries
Yokota et al. (2003)188 38-year-old man Dissection of left vertebral artery Not mentioned
followed by Dejerine syndrome
Izquiedo-Casas et al. 37-year-old woman Dissection of vertebral artery Fibrinolysis resulted in
(2004)189 followed by tertraparesis complete recanalization
of the artery
Saxler and Barden 27-year-old woman Epidural hematoma Complete recovery
(2004)190 extending from cervical
to sacral spine
Tome et al. (2004)191 40-year-old patient Multiple cervical disc Not mentioned
herniation
In all cases, causality was deemed to be certain or likely, and in all instances was the therapist a chiropractor.

were seen by chiropractors as a complete ex- U.S. and U.K. because it was realized that the
planation of all medical conditions, their pre- vaccinated suffered the worst effects of the dis-
vention, and treatments. Infectious diseases, ease;’’195 or the risks of immunization are exag-
therefore, put the gospel of D.D. Palmer in gerated: ‘‘The dangers of vaccination to the
doubt (see above); consequently, their exis- young child are profound. in some cases,
tence was denied, and so was the benefit of the vaccine acts non-specifically to increase
immunization. The faculty and administration a child’s pre-existing chronic disease ten-
of Williard Carver’s ‘‘Chiropractic Research dency.’’196 Other sources state that immuniza-
University’’ were even jailed for refusing ‘‘to tion is useless and harmful: ‘‘Immunisation
submit to the compulsory vaccination law of programmes continue on the premise of pre-
the District of Columbia.’’14 vention’’ but ‘‘it cannot be said that the.prog-
The current chiropractic literature con- ramme has been proven successful.and the
tinues to promote ‘‘hostile opposition to complication rates for the vaccines continues
health prevention based upon immunization to claim the lives of children via disability
procedures’’192 and repeatedly stresses that and/or death.’’197 Others again report that,
immunization is hazardous and ineffec- ‘‘vaccination appears to increase the risk of
tive.193,194 In doing so, facts are distorted: allergies and related respiratory symptoms.’’198
‘‘Smallpox vaccination was stopped in the There is no shortage of strong statements in the
Vol. 35 No. 5 May 2008 Chiropractic: A Critical Evaluation 555

chiropractic literature warning patients of ‘‘hav- per Quality Adjusted Life Years as £3,800 for
ing toxic filth squirted into the bodies’’ of their combined treatment and £4,800 for
children.192 Even though some chiropractors manipulation.
would probably deny this, the anti-immuniza- A retrospective analysis of the U.S. worker’s
tion lobby of chiropractors is still very strong; compensation payment data from a single
the only place where chiropractors are pro- insurer analyzed the figures from individuals
hibited from lobbying against immunization is suffering from work-related low back injuries
in Ontario, Canada.199 between 1999 and 2002.205 The results showed
A U.S. survey was aimed at identifying chiro- that restrictive payment policies were associ-
practors’ attitudes toward immunization.200 A ated with lower cost of chiropractic care and
random sample (1%) of all U.S. chiropractors lower number of services per visit, but did
was provided with a choice of policy state- not affect the visits or services per person.
ments. One-third of the sample agreed with Legorreta et al.206 retrospectively analyzed
the statements that there is no scientific proof claims data of more than one million members
that immunization prevents disease, that it of a U.S. health care plan. Access to chiroprac-
causes more disease than it prevents, and tic care was associated with lower cost for neu-
that contracting an infectious disease is safer romuscular complaints and back pain. This
than immunization. Another survey was per- effect could be due to these patients being
formed on 150 licensed chiropractors from younger and healthier than nonchiropractic
Boston. About 30% of them reported to patients.207 Others have noted that users of
recommend active immunization and 7% rec- chiropractic are also high users of conven-
ommended their clients against immuniza- tional health services,208 which renders cost
tion.201 A Canadian interview study recently savings an unlikely prospect.
confirmed that some chiropractors provide to
their patients ‘‘information of a negative,
anti-vaccination nature.’’202
Conclusion
Cost
A World Health Organization-sponsored, This overview will be rejected by proponents
systematic review of cost analyses in comple- of chiropractic for being biased or one-sided,
mentary medicine included seven investiga- but its purpose was to offer a critical
tions related to spinal manipulation or evaluation. At present, such an assessment
chiropractic care.203 It concluded that ‘‘there has not been provided by chiropractors, yet
is no evidence to suggest that chiropractic is progress in any field is difficult without critical
a more cost-effective treatment option than evaluation.
physiotherapy or hospital outpatient treatment Chiropractors’ belief in the ‘‘innate,’’ sub-
for low back pain.’’203 Since then, several new luxation, or spinal manipulation is not ratio-
studies have become available. A UK trial nal. Current chiropractic practice raises
compared disability scores after spinal manipu- numerous concerns. The effectiveness, safety,
lation (carried out by chiropractors, osteo- and cost of spinal manipulation are uncertain.
paths, or physiotherapists), exercise classes, More and better quality studies are, therefore,
or manipulation followed by exercise in required. Until convincing data are available,
addition to care for chronic back pain by gen- we might question the value of this popular
eral practitioners.204 Exercise was superior to approach to health care.
primary care at three months but not after
one year. Manipulation alone or followed by
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