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
All rapid responses
As a chiropractor residing in the United States I would like to share
some impressions I have of the field. First, because the entrance
requirements (grade point averages, no undergraduate degree requirement)
are lower the field attracts students who are not able to grasp the
theoretical mechanisms and competently assess the research, making them
therapists or technicians who are frozen in their own biases and the
limited training they receive from their college. Another problem is with
the college's themselves. It is erroneous to believe that chiropractic
schools teach modern systems of biomechanics, the underlying science which
you would think manipulation would be based. Instead, what I encountered
were outdated and erroneous biomechanical systems that were devised by
chiropractors in the 1950s but were taught as gospel to unknowing
students. For example, these methods do not account for joint tranlations
and have the wrong axis of rotation for the sacro-iliac joints (the
acetabulum instead of the pubic symphysis).
This lack of knowledge leaves student in a very disadvantaged
position as they end up losing their original goal of understanding and
improving spinal biomechanics to becoming back popping therapists who use
largely unreliable procedures to indiscriminately cavitate spinal facet
joints. Because of this many clinics are no more than back cracking
mills.
Another big problem is the lack of formalized training in myofascial
release. Many times patient's have apparrent joint fixations which are
actually due to muscular adhesions and myospasm. After releasing these
muscles the fixations spontaneously resolve.
The profession here has a "live and let live" mentality and is very
reluctant to standardize its methods and rout out the bad techniques.
This lack of a focus on quality makes the field very frustrating because
at many schools in the USA students are told that they are trained to
correct biomechanical problems yet they are actually trained only to
provide a limited therapy which temporary relaxes myospasm by cavitating
joints, no more.
I privately hope that if the chiropractic profession is incapable of
getting itself together that the Doctors of Physical Therapy can improve
the level of service by keeping a focus on true biomechanics and science.
Allen Botnick D.C.
Elizabeth, NJ, USA
Competing interests:
None declared
Competing interests: No competing interests
Apparently the good doctor feels that since chiropractors believe in
an "innate healing potential of the body" this clearly demonstrates that
the field clearly "is isolataed (good spelling Dr.) from common sense and
logic." Of course it would be ludicrous to suggest that for millions of
years, people have been living without modern medicine to heal them! It
would be clearly pseudo-scientific to suggest that a broken bone, set and
casted by an orthopedic surgeon, is actually HEALED by the body itself!
Malarky! And to suggest that there may be diminishing returns on many of
todays vaccines (live attenuated polio) would be downright bad science!
Since the good doctor suggests that there is no "innate healing potential
of the body" he must give medications to dead men.
Sincerely,
Pete Bomgarden
Competing interests: No competing interests
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
The article on complementary therapies was highly informative. Taking
into account the range of therapies discussed, I must congratulate the
authors for their effort. I agree that all therapies ,including
conventional medicine , should embrace Evidence Based approach for the
benifit of the patients. The authors have described The McTimoney method
of chiropractic as not being part of the main strem chiropractic. I would
like to know the criteria that have been used to decide whether a
chiropractic technique is main stream or not. I would also like to point
to the authors that they are erroneous in their assumption that McTimoney
method of chiropractic does not involve high velocity adjustments. Could
the authors state their source of information on the adjustment tecniques
used in the McTimoney method of chiropractic.
Competing interests: No competing interests
Whilst this article has lead to some criticism of the chiropractic
profession, it should be noted that the General Chiropractic Council (GCC)
and the chiropractic profession have been praised for the example they are
setting in statutory self-regulation.
Yvette Cooper, Parliamentary Under Secretary of State recently wrote:
At a time when my colleagues and I are actively promoting the need for all
health professions to have the most effective and transparent self-
regualtory systems, the General Chiropractic Council is setting a very
good example indeed of what can be achieved.
The GCC is further leading the way by being the only statutory
regulatory body in the health sector to ensure that all its Statutory
Committees are chaired by lay members. This should assist in countering
the perceptions of bias experienced by other bodies whose Committees are
chaired by practitioners.
Finally, the GCC will be one of the first regulatory bodies to
introduce compulsory CPD as a requirement for annual retention of
registration. A wide-spread consultation with the chiropractic profession
and other interested parties will be undertaken during 2000 and it is
proposed that the requirement for CPD will be introduced in 2001.
Competing interests: No competing interests
Regarding this article, my response was mixed. Although I am glad to
see chiropractic care receive more coverage, I was disappointed to see
what I believe to be errors going unchecked. In particular, the education
I received was four years undergraduate, and four years in graduate level
classes at a chiropractic college. In particular, chiropractic college
required about double the average uindergraduate load for each semester.
As to the term "Doctor" being merely a "courtesy", who decided that? I
refer to all educated professionals who have attained doctorate level
training with this courtesy.
I would suggest that any primary care physicians who are even the
slightest bit interested in the care their patients are receiving at the
hands of chiropractors or osteopaths take the time to visit a few members
of those professions. I feel sure that most medical physicians who are
asked by their patients about chiropractic would venture forth with an
opinion. However, how many have actually learned much about this
profession, rather than simply repeating the same old tired
generalizations.
I realize that many tradional physicians are uncomfortable with
dealing with treatment philosophies that are different from the way they
have been trained. However, many physicians in my area are taking an
interest in learning more about why chiropractic care is so popular with
patients, rather than hiding from it.
Pick up a phone, call a chiropractor or an osteopath, and go for a
visit. I'm sure once you see what goes on in those offices you will have
much greater understanding than this or any article can convey.
Sincerely,
Mark A. Kestner, DC
Competing interests: No competing interests
I would like to simply remind the readers that manipulation is a
small part of the practice of chiropractic and osteopathy.
I too, who
lecture, have been guilty of focusing in on the role of manipulation in
both practices. This was unfair and inaccurate. To believe that either a
DC or DO has only one thing to offer is rather frightening.
The world of
physical medicine is vast, and yes, although essentially a musculo-
skeletal practitioner, I am consulted for other medical conditions for
which my patient's trust me, to refer them to the proper medical
specialist, who may be you! It may be my (our) patient with diarrhea
following cervical fusion who concurrently is vomiting (projectile),
losing weight, has night sweats, myalgia, and backache. Could this be
segmental dysfunction (subluxation) or C. difficile and a Zenker's
diverticulum secondary to the c spine fusion? Only a ________ would know
for sure. Come now, we are all doctors and we need to rise to the
occasion, how do we help this patient? I suppose I can adjust his back
before the GI/GU consult, it might make him more comfortable this evening.
Competing interests: No competing interests
It is disappointing to see that so many practitioners are still
engaging in unashamed denegration of recognised professions.
Surely the
primary concern of any treatment protocol is the patient. I am a third
generation chiropractor and now a chiropractic educator. I am also a
private practice owner, employing chiropractors, osteopaths and
physiotherapists in my clinic's. We dont work individually but as a team,
selecting the best in-house treatment protocol for the patient or refer
back to the General Practitioner, ensuring patient's get the best
treatment available. There is no doubt that each profession offers
something, and that equally every profession suffers from the extremist
behaviour seen in all walks of life (Bosnia, Northern Ireland, ACA, AMA
etc etc) and bad pratitioners. Let's keep the debate and research centred
on relevant clinical issues and stay away from personal vindictive attacks
on professions. Every profession has its black sheep, who are conducting
themselves in ways that cannot be condoned, this also applies to the
medical establishment. Anybody who has been in practice long enough
should have realised that patients vote with their feet, and that you are
only as good as your last consultation. If you are busy, then you must be
doing something good.
Competing interests: No competing interests
Numerous responses to the "ABC on osteopathy and chiropractic" have
pointed out, in short, that things are a bit different in the USA." I did
actually know this but would like to point out that the paper was
published in the British Medical Journal, aimed at a British audience and
written under a strict word limit. Obviously, it's going to be difficult
to give a full description of variations in training, qualifications and
approaches in different countries of the world....
Competing interests: No competing interests
Re: Osteopaths and Chiropracters are not the same in the US.
It is interesting that as Academic Director of a hospital Warren S
Goff would have his facts so twisted. He states as a principle difference
between chiropractic and osteopathy, "chiropractic delivers a thrust over
a diffuse area and osteopathy is typically deliverved to a localized
area". The opposite is actually true. Osteopaths typically employ a long
lever techniques, with out direct doctor contact with the spine and rarely
specific to a particular joint complex. Chiropractic adjustments are
specific to the individual joint complex, the direction of joint
restriction and are delivered by direct contact to the spine. In regards
to the safety of chiropractic, serious sequelae to chiropractic
adjustments are generally defined in the ones of millions. Conventional
medicine including osteopathy have a much more sinister iatrogenic
morbidity and mortality rate as evidenced by actuarial analysis and the
resulting malpractice insurance costs payed by them.
Competing interests:
None declared
Competing interests: No competing interests