Clinical Review ABC of complementary medicine

The manipulative therapies: osteopathy and chiropractic

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7218.1176 (Published 30 October 1999) Cite this as: BMJ 1999;319:1176

Chiropractic patients more satisfied with chiropractic treatment

Most recently, Meade (1) has argued that improved patient
satisfaction justifies chiropractic treatment for low back pain. Since
satisfaction is a psychological factor, and others have suggested the
results are artifactual, it could be instructive to evaluate the claims in
the Meade et al (2, 4) study in light of current criteria for empirically
supported therapies (3).

In the Meade study, a large number of measurements were
taken in the data collection stage and a large number of possible tests
were possible as a result. The Oswestry scores used in the analysis yield
a hundred possible tests and 29 additional scores result from subsidiary
measures. Adding these measurements together, gives a total of 129
potential tests. If we wish to maintain a .05 overall significance level,
this requires a probability below .000388 if any individual test is to be
considered significant.

In light of current criteria for empirically supported therapies,
Meade's study does not show that chiropractic treatment can be considered
efficacious for low back pain, because a treatment manual or its logical
equivalent was not used, the data analysis was not appropriate, and
superiority has not been shown in at least two independent research
settings.

If we disregard these deficiencies, we can conclude from the study
that back patients previously treated by chiropractors are more satisfied
with chiropractic treatment and that they report less pain at six months.
The fact that chiropractic patients are more satisfied with chiropractic
treatment can hardly be considered a finding that supports the
efficaciousness of chiropractic. It does, however, suggest that there is
some kind of commitment or indoctrination process operating. It is well
known that commitment and suggestion can have powerful effects on pain,
and this is directly used, for example, in medical hypnosis. Thus, the
fact that there was less pain reported is hardly meaningful.

We have reviewed some of the factors operating within chiropractic
treatment that could generate commitment. The American Medical Association
has characterized chiropractic as "an unscientific cult." Some of the
informational materials distributed by chiropractors in the United States
of America have been denounced as misleading, even by chiropractic
practitioners. Consumers Union (5) concluded that "chiropractic is a
significant hazard to many patients" and "urge that chiropractors be
prohibited from treating children."

The British Medical Journal failed in its duty to prevent the
publication of misleading reports in its pages. The Meade studies do not
meet the journal's current criteria for acceptance and should not have
been published. Chiropractic has achieved its acceptance by a combination
of political action and professionalization. The appearance of a journal
article pretending to show the benefit of chiropractic treatment, whether
valid or not, is used by chiropractic practitioners as "proof" of the
validity of their method in public statements and in the press. Even when
operating at their best, the scientific controls over publication are not
appropriate for the political arena, within which chiropractic operates to
maintain its accreditation. When a profession systematically distorts
findings about its practices, it is outside the realm of science. Thus,
scientific journals are not an appropriate venue for "studies" of
chiropractic.

1. Meade TW. Patients were more satisfied with chiropractic than
other treatments for low back pain. BMJ 1999 Jul 3; 57: 319.

2. Meade TW, Dyer S, Browne W, Frank AO. Randomised comparison of
chiropractic and hospital outpatient management for low back pain: results
from extended follow up. BMJ 1995 Aug 5; 311: 349-51.

3. Chambless DL, Hollon, SD. Defining empirically supported
therapies. J. Consulting & Clinical Psychology 1998; 66: 7-18.

4. Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of
mechanical origin: randomised comparison of chiropractic and hospital
outpatient treatment. BMJ 1990; 300: 1431-37.

5. Editors of Consumers Reports Books. Health Quackery. Mount Vernon,
New York: Consumers Union; 1980.

Competing interests: No competing interests

03 September 2000
David S Stodolsky
DSS: Senior Scientist; JDC: Sports/Research Physical Therapist
Jonathan D Comins
DSS: Institute for Social Informatics, Copenhagen, DK; JDC: Bispebjerg Hospital, Copenhagen, DK