complaint to chiropractic board of australia about light ... · page 1 of 6 dr nahum shalom drimer,...
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Complaint to Chiropractic Board of Australia about Light Chiropractic and Wellness
Page 1 of 6
Dr Nahum Shalom Drimer, CHI0000971076, is a chiropractor registered at: GLEBE NSW 2037, who practices at: Shop 1/198-206 St Johns Road Glebe NSW 2037.
He is listed at the Light Chiropractic and Wellness web site (http://lightchiro.com.au/) and presumably is responsible for its content:
We allege that certain claims made by Dr Drimer on his web site breach Section 133 of the National Law that prohibits advertising that:
• is false, misleading or deceptive or is likely to be so; • creates an unreasonable expectation of beneficial treatment, and • encourages the indiscriminate or unnecessary use of health services.
We also believe that the claims documented below are not in accord with the Chiropractic Board of Australia, Code of Conduct, (March 2014):
• s.2.2 (g): providing treatment/care options based on the best available information and practising in an evidence-based context and not being influenced by financial gain or incentives;
• s.2.4 (d): investigating and treating patients on the basis of clinical need and the effectiveness of the proposed investigations or treatment/care, providing necessary services and not providing unnecessary services or encouraging the indiscriminate or unnecessary use of health services, and
• s.9.6 (a): complying with the National Board’s Guidelines on advertising regulated health services, (the Advertising guidelines) and relevant state and territory legislation and Commonwealth law;
• s.9.6 (b) making sure that any information published about services is factual and verifiable.
The details of these allegations follow.
Claim 1: Screenshot 1 (from: http://lightchiro.com.au/chiropractic/what-is-chiropractic/)
Complaint to Chiropractic Board of Australia about Light Chiropractic and Wellness
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Comment: In 2005 in an article titled, “Subluxation: dogma or science?” Keating JC, et al,1 said:
“The dogma of subluxation is perhaps the greatest single barrier to professional development for chiropractors. It skews the practice of the art in directions that bring ridicule from the scientific community and uncertainty among the public. Failure to challenge subluxation dogma perpetuates a marketing tradition that inevitably prompts charges of quackery. Subluxation dogma leads to legal and political strategies that may amount to a house of cards and warp the profession's sense of self and of mission. Commitment to this dogma undermines the motivation for scientific investigation of subluxation as hypothesis, and so perpetuates the cycle.”
In May 2010 the General Chiropractic Council, the statutory regulatory body for chiropractors in the United Kingdom, issued guidance for chiropractors stating that the chiropractic vertebral subluxation complex "is an historical concept" and "is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease.2 Chiropractors were also reminded that,
1 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1208927/ 2 http://www.gcc-uk.org/UserFiles/Docs/What%20Can%20I%20Expect/Vertebral%20Subluxation%20Complex.pdf
Complaint to Chiropractic Board of Australia about Light Chiropractic and Wellness
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when advertising, claims for chiropractic care “must be based on best research of the highest standard” only. (GCC Guidance on Advertising, March 2010)
In addition, we are unaware of any scientific evidence that supports the statements,
“Subluxations affect the electromagnetic field of the body, as well as neuro-chemistry and neurological function”;
“Integration of the energy stored in a subluxation can result in improved wellbeing in all areas of a person’s life (including their thinking patterns and the way that they feel physically, emotionally and spiritually)”.
“People who enjoy regular chiropractic care experience an improved ability to adapt, self-heal and recover from stress. Their perceptions become clearer and their natural healing ability increases. They find that decision-making processes are easier and that they are able to be more loving. They are able to live in and enjoy the present moment, rather than reacting due to stored experiences from the past”.
“With each adjustment your system becomes better able to adapt, heal and self-correct. Getting adjusted helps you to move toward the flexibility, ease, flow and lightness that you experienced as a child”.
Conclusion Claim 1: we assert that statements above concerning “subluxation” and the alleged benefits from chiropractic “adjustment” lack substantiation and thus are in breach of s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).
Claim 2: Screenshot 2 (from: http://lightchiro.com.au/chiropractic/pregnancy-and-pediatrics/)
Comment: The claim that regular chiropractic care in pregnancy can lead to a reduction in labour time is attributed (on some other chiropractic web sites) to:
• Fallon J DC. Chiropractic and Pregnancy, a partnership of the future. ICA Review Nov/Dec 1990. (pg. 39-42) attached
We quote,
"Statistics from the author's case files were tabulated and a comparison of average labor time made. Twenty-seven primagravida and 31 multiparous women were compared as to their mean duration of labor. The results can be seen in Fig. 2. We can see by these statistics what with all else being equal, the mean labor times were reduced by 25 percent in the primagravida women, and by 31 percent in the multiparous women”. This in no way represents a controlled study..."
A search of http://www.ncbi.nlm.nih.gov/pmc/?term=(Fallon+J%5BAuthor%5D)+AND+Pregnancy) found no relevant entries.
Complaint to Chiropractic Board of Australia about Light Chiropractic and Wellness
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A broader search: http://www.ncbi.nlm.nih.gov/pmc/?term=Chiropractic+pregnancy also found no relevant entries.
In our opinion, the results of this uncontrolled (and unreplicated) 1990 case series reported by one author does not justify its widespread citation by chiropractic manipulation as to the benefits of chiropractic in reducing the time of labor.
Conclusion Claim 2: The claim that regular chiropractic care in pregnancy can lead to a reduction in labour by up to five hours lacks good evidence to substantiate it and thus is in breach of s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).
Claim 3: Screenshot 2 (from: http://lightchiro.com.au/chiropractic/pregnancy-and-pediatrics/)
Complaint to Chiropractic Board of Australia about Light Chiropractic and Wellness
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Comment: Dr Drimer makes numerous claims for the benefits of chiropractic care for children. With the exception of “improve spinal posture” we were unable to find good scientific evidence to substantiate these claims. Other reviews3, of the literature have noted that,
“in children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation”.
Conclusion Claim 3: The majority of the numerous claims made by Dr Drimer for the benefits of chiropractic care for children lack good evidence to substantiate them and thus are in breach of s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).
In summary, we believe that Dr Drimer makes a number of therapeutic claims on his web site that are not supported by sound evidence. We agree with Ernst and Gilbey (article appended) that such unsubstantiated claims constitute both an ethical and public health issue.
We ask the Chiropractic Board of Australia to determine if the above claims made by Dr Drimer have breached both the Chiropractic Board of Australia Code of Conduct and the National Law:
• AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014), s.6.2 & the • Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), s.2.4 (d) and s.9.6
(a) & (b)
If so, we ask that Dr Drimer be ordered to retract the offending claims and the determinations made in this case be published as a deterrent to others.
3 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841070/
Complaint to Chiropractic Board of Australia about Light Chiropractic and Wellness
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Yours sincerely,
Dr Ken Harvey 35a Mary St Hawthorn VIC 3122 M: 0419 181910 W: www.medreach.com.au E: [email protected]
Mal Vickers 2/45 Banff St Reservoir VIC 3073 [email protected]
Cc Mr Scott Gregson Executive General Manager, Consumer Enforcement Australian Competition & Consumer Commission Level 3, 23 Marcus Clarke St, Canberra, ACT, 2601 23 August 2015
BY JOAN M. FALLON, DC
"During pregnancy the pelvic joints and ligaments are relaxed and capable . of more extensive movements. This relationship renders the locking mecha- .. nism of the sacro-iliajoint less restrictive and permits greater rotation. This change allows alterations in the diameter of the pelvis at childbirth. The less the locking mechanism the more the strain of weight-bearing falls on the ligaments leading to frequent occurrence of sacro-iliac strain after pregnancy. After childbirth the ligaments become tightened up but in some cases the locking may occur in the position of rotation of the hip bones adopted during pregnancy. This so-called subluxation of the sacro-ilia joint causes pain by the unusual tension which it imposes on the ligaments and the reduction by forcible manipulation may be attempted."
T he tremendous changes that take place in the pregnant woman bear special signifi
cance to the chiropractor. Gray's Anatomy clearly gives the justification for adjustments during pregnancy and the post-partum period. It is important for the chiropractor to understand the physiological changes that take place which bring about alterations in the musculoskeletal system as well as in every system in the body. In this article we will explore those changes with respect to the biomechancis of the spine
Gray's Anatomy 36th British Edition
and the effects on the mother.
Physiological changes The physiological changes that occur in the mother during pregnancy can be broken down into two categories:
1. Hormonal 2. Biomechanical
While the biomechancial changes are seemingly most important to the chiropractor, the hormonal changes which are truly profound, overlap into the musculoskeletal system and thus affect the biomechanics of the spine.
Many of the neurological conditions seen during pregnancy have their origins in the hormonally induced changes in the pregnant woman. We will therefore begin our discussion with the hormones of pregnancy.
Hormones of pregnancy Progesterone and estrogen are the most important hormones which affect pregnancy. Progesterone which climbs as high as 250mg/day creates vast changes which result in an overall decrease in tonality thereby creating a
!CA INTERNATIONAL REVIEW OF CHIROPRACTIC NOVEMBER/DECEMBER 1990 39
stasis of activity. Some of progesterone's effects are as follows: a decrease in smooth muscle and vascular tone, and an increase in fat storage and temperature. Progesterone also acts with estrogen to increase development of the breasts for nursing.
Estrogen, which reaches a peak of 40mg!day during pregnancy, creates significant alterations in the connective tissue. This alteration results in an increase in joint mobility. As we will see later, this will have a significant effect on the "subluxation complex of pregnancy." In addition, estrogen has an important effect on the uterus and its control and function as well as on the growth and regulation of the fetus.
Cortisol, aldosterone, Human Chorionic Gonadotropin (HCG), Human Chorionic Somatomammotrophin (HCS), relaxin and prolactin also play an integral role in the changes during pregnancy.
These hormones all enter into combination which alter and control the various organ systems of the body. 'The respiratory system, GI system, cardiovascular system, renal system and again the musculoskeletal systems all are profoundly affected by the hormones of pregnancy. Reduction of cardiac workload, augmentation of the inspiratory and expiratory volume of the lungs, increased absorption time for food, and strict regulation of urinary output and water retention are just a few of the effects that the hormones have on the body.
Bio mechanical considerations of pregnancy In addition to the alteration of supporting structures by the hormones, there is another significant change which occurs in the pregnant woman that alters her biomechanics. This is the large increase in weight gain over a relatively short period of time. The customary weight gain for the pregnant woman varies between 25 to 35 lbs. However, a weight gain of 40+ lbs. is not uncommon. This gain is a result of the weight of the fetus and maternal organs, an increase in the volume of blood and interstitial fluid as well as an
40
increase in protein and fat storage.
Subluxation complex of pregnancy In 1947, Drs.Janse, Houser and Wells, in their definitive work "Chiropractic Principles and Technic" proposed a model of lordotic subluxation which we shall apply to pregnancy. In their model they state: "If the head and chest are thrown too far backward and the weight is thrown upon the articular processes, the inferior articular processes will have a tendency to slide backward on the superior articular process of the vertebra below, and in this way will force the latter forward into the intervertebral foramen (Fig. 1). Such a condition which might be termed 'physiological lordosis' is seen very commonly in fleshy people who in order to maintain their balance lean backward and by doing so throw the lumbar portion of the spine forward. This model of lordotic subluxation proves to be extremely useful when looking at pregnancy. When one speaks of the "pride of pregnancy" we are looking at the extreme exaggeration of the lumbar lordosis and the flattening of the kyphotic curve of the dorsal spine.
Neurological conditions associated with subluxation in pregnancy There are many conditions that are associated with subluxations in pregnancy and they include the following:
Meralgia paresthetica - compression of the lateral femoral cutaneous nerve as it passes beneath the inguinal ligament. Pain and most often paresthesia are seen in the lateral aspect of the upper thigh.
Brachial neuralgia - compression of the brachial plexus characterized by tingling and numbness of the shoulder and arm.
Intercostal neuralgia - compression of the intercostal nerves resulting in radiating pain in the thorax in between the ribs.
Sciatic neuralgia- compression of the lumbar plexus resulting in pain in the pelvic region and/or pain radiating
Figure 1
down the leg. Coccydynia-pain at the site of the
coccyx due directly to subluxation. Often seen during delivery but also seen during the last trimester.
Separation of the syrnphsis pubis -When the symphysis pubis separates more than one cm it is characterized as a subluxation. This subluxation will cause pain at the syrnphysis pubis and at the SI joint.
Carpal tunnel syndrome - compression of the median nerve under the flexor retinaculum resulting in pain at the wrist joint.
Bell's Palsy - compression of CN VII within the temporal bone. Paralysis of the facial muscles is seen. This condition most often occurs during the third trimester but is also seen one week to 10 days after delivery.
Traumatic neuritis - motor and sensory deficits ofL5, SI, and S2 nerve roots after labor. It may be a result of one or more of the following:
-disc protrusion at IVF -traction of lumbosacral trunk
(forceps) -compression of lumbosacral
trunk by fetal head -compression of popliteal nerve
due to positioning
Effects of chiropractic care on labor Statistics from the author's case files
!CA INTERNATIONAL REVIEW OF CHIROPRACTIC NOVEMBER/DECEMBER 1990
were tabulated and a comparison of average labor time made. Twenty-seven primagravida and 31 multiparous women were compared as to their mean duration of labor. Only woman who were first seen from the first to tenth week of pregnancy were used for comparison purposes. The term "labor" was defined as the time rhythmic contractions could be discerned and followed by timing. The results can be seen in Fig. 2.
We can see by these statistics what with all else being equal, the mean labor times were reduced by 25 percent in the primagravida women, and by 31 percent in the multiparous women. This in no way represents a controlled study, but does reflect concise accurate records which are kept by the author with respect to nearly every aspect of the pregnancy of each patient seen.
Conclusion In conclusion, it is easy to see how significantly a woman's body is affected by the hormonal changes that occur during pregnancy, and how these changes profoundly affect the musculoskeletal system. Subluxation is an inherent part of pregnancy and thus the chiropractor's role is defined. The success of the chiropractor-obstetrician
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Figure 2
!CA INTERNATIONAL REVIEW OF CHIROPRACTIC NOVEMBER/DECEMBER 1990
Without Chiropractic
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With Chiropractic
Care
Multiparous
41
TREATMENT PROTOCOL
RULE OF THUMB-Women who have a history of back problems especially sciatica will usually benefit from the hormonal influences of "relaxation" during pregnancy. Those women who generally have "healthy" backs will suffer from the hormonal influences which feel as though there is a lack of support.
In the author's office a combination of manual manipulation and softtissue techniques are employed on a hi-lo with the fall away thoracic/ abdominal section. Any number of chiropractic techniques can be employed with excellent results. Fig. 3 shows the case management protocol used in the author's office.
Frequency of Visits
1 XWeek
2 Xmonth 2 Xmonth
1 Xmonth 1 Xmonth
--------------- - - - - - - - - - -1 20 40
GESTATION POST-PARTUM
WEEKS
Figure 3
relationship rests on the chiropractor's ability to constructively contribute to the care and education of the pregnant woman. With the increasing awareness of environmental effects on the fetus and the increased stress on the pregnant woman, chiropractic's natural and effective methods are quickly coming into the mainstream of care of the pregnant woman.
Bibliography Carpenter,M.B. HumanAnatomy. 7th Ed.; Williams and Wilkins 1976.
Janse, Howser, Wells. Chiropractic Principles and Technic; 2nd Ed 1978 (1948); National College of Chiropractic.
Gary Govan et al. Obstetrics Illustrated; 3rd Ed.; Churchill Livingstone 1980.
Haldeman, Scott. Modern Developments in the Principles and Practice of Chiropractic; Appleton, Century, Croft 1980.
McMullen, Maxine. Unpublished notes 1982.
Sutherland, S. Meningeal Neural Relations in the Intervertebral Foramen; ]. Neurosurgery 1974; 40:756
Fulton, J.F. Physiology of the Nervous System; 3rd Ed., Oxford University Press 1949
Tedeschi, CG. Neuropathology: Methods and Diagnosis; Little and Brown 1970.
Gray's Anatomy; Williams and Wilkins; 36th British Ed.
Palmer, M.H. Chiropractic Anatomy; 5th Ed., Palmer College of Chiropractic 1923
Leach, Robert H. The Chiropractic Theories: A Synopsis of Scientific Research; 2nd Ed., Williams and Wilkins 1986. II
JoanM. Fallon, DC is a graduate of Palmer College of Chiropractic. Dr. Fallon has a private practice in Bronxville, New York, where she special
izes in obstetrics and pediatrics. She also serves as assistant professor at Yeshiva University in the department of natural sciences and mathematics. Dr. Fallon has been interviewed on TV in the NYC metropolitan area on children and chiropractic care and pregnancy. She recently presented a paper on biomechanics and pregnancy at the 1990 Annual Convention and Symposium of the American Public Health Association.
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42 !CA INTERNATIONAL REVIEW OF CHIROPRACTIC NOVEMBERJDECEMBER 1990
THE NEW ZEALAND MEDICAL JOURNAL
Journal of the New Zealand Medical Association
NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 36
URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA
Chiropractic claims in the English-speaking world
Edzard Ernst, Andrew Gilbey
Abstract
Background Some chiropractors and their associations claim that chiropractic is
effective for conditions that lack sound supporting evidence or scientific rationale.
This study therefore sought to determine the frequency of World Wide Web claims of
chiropractors and their associations to treat, asthma, headache/migraine, infant colic,
colic, ear infection/earache/otitis media, neck pain, whiplash (not supported by sound
evidence), and lower back pain (supported by some evidence).
Methods A review of 200 chiropractor websites and 9 chiropractic associations’
World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom,
and the United States was conducted between 1 October 2008 and 26 November
2008. The outcome measure was claims (either direct or indirect) regarding the eight
reviewed conditions, made in the context of chiropractic treatment.
Results We found evidence that 190 (95%) chiropractor websites made
unsubstantiated claims regarding at least one of the conditions. When colic and infant
colic data were collapsed into one heading, there was evidence that 76 (38%)
chiropractor websites made unsubstantiated claims about all the conditions not
supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%)
associations made claims about lower back pain, whereas 179 (90%) websites and all
9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated
claims were made about asthma, ear infection/earache/otitis media, neck pain,
whiplash in at least half of all chiropractor websites.
Conclusions The majority of chiropractors and their associations in the English-
speaking world seem to make therapeutic claims that are not supported by sound
evidence, whilst only 28% of chiropractor websites promote lower back pain, which is
supported by some evidence. We suggest the ubiquity of the unsubstantiated claims
constitutes an ethical and public health issue.
The raison d'être of chiropractic “is to enhance the natural healing abilities of the
body by correcting a malfunction of the spine called a vertebral subluxation through
adjustment”.1 Chiropractic is advocated as being “much more than a way of seeking
relief from back pain”,1 “the third largest healthcare profession in the world”,
2 and
“entering the healthcare mainstream”.3
The relationship between chiropractic and mainstream medicine has, at times, been
somewhat uneasy. For example, Chiropractic’s founder, DD Palmer, was once
imprisoned for practising medicine without a licence in America4—and, in New
Zealand in the 1970s, the medical profession argued that chiropractic is “an unproven
treatment directed at an unlimited range of disorders”.5 More recently, in a survey of
chiropractic brochures provided by 9 national organisations in the United States and
NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 37
URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA
Canada, all were found to have made “claims for chiropractic services that have not
been scientifically validated”.6
Similarly, a survey of World Wide Web claims of chiropractic colleges in the United
States and Canada found that 8 out of 16 made “unsubstantiated claims for the value
of chiropractic clinical care”.7 In response to a fictitious email enquiry sent to 13 New
Zealand chiropractors, purportedly from a concerned parent about their child’s asthma
and recurrent ear infection (conditions for which there is no sound evidence to support
chiropractic interventions), 12 encouraged a consultation, 9 suggested that they could
treat asthma, and 8 that they could treat ear infection.8
In a small pilot study of chiropractors’ claims in their World Wide Web websites, 9 of
10 United Kingdom clinics were found to have made unsubstantiated claims about the
effectiveness of chiropractic.9
Criticisms regarding unsubstantiated claims have been raised even by Doctors of
Chiropractic, two of whom suggested that those outside the chiropractic profession
may interpret widespread unsubstantiated claims of effectiveness as “evidence of a
lack of professionalism and of quackery” that have evolved within a “tradition of
dogma, fallacious reasoning, and unconventional attitudes about research and
science”.6
Contrarily, many chiropractic associations and practitioners believe chiropractic is
essentially based in scientific principles and supported by research, the same as is
orthodox medicine.10,11
This debate may be of esoteric interest only, as chiropractic is
clearly thriving irrespective of criticism.3,12
Although there is evidence that some chiropractic brochures, colleges, and phone
advice make claims not supported by evidence,6,7,8
apart from a small pilot-study of
10 UK chiropractors,9 no studies have so far tested claims made or implied on
chiropractors’ Websites, from which potential first-time users of chiropractic may
seek information.
The purpose of the current study was therefore to investigate the websites of
chiropractic associations and practitioners, in Australia, Canada, New Zealand, the
United Kingdom, and the United States, regarding direct or indirect claims to treat
seven conditions that are not supported by sound evidence from well-designed
controlled trials: asthma, headache/migraine, infant colic, colic, ear
infection/ache/otitis media, neck pain, and whiplash (Table 1). These conditions were
chosen for investigation as from experience we were aware that they frequently
appear in chiropractic literature, despite a lack of sound supporting evidence.
We accept that some studies purportedly demonstrate the effectiveness of
chiropractic. However, when case studies, non-controlled, non-randomised, or non-
peer reviewed studies were excluded, as they do not constitute quality evidence in any
hierarchy of which we are aware, and systematic reviews or randomised control trials
(if systematic reviews were not available) were consulted instead, we could find no
evidence of chiropractic effectiveness for the seven conditions. Claims regarding
lower back pain were also reviewed as evidence suggests it may respond to
chiropractic spinal manipulations13
and thus might reasonably be expected to be
robustly promoted in chiropractors’ websites.
NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 38
URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA
Table 1. The best current evidence for conditions commonly referred to by
chiropractors
Condition Type of evidence (ref) Conclusions
Asthma Cochrane review 14
There is insufficient evidence to support the use
of manual therapies for patients with asthma*
Back pain (lower) Cochrane review13
No evidence that spinal manipulation is superior
to other standard treatments for acute or chronic
low back pain*
Colic None found No evidence
Infant Colic Health Technology Report 15
No convincing evidence*
Ear infection/ache/otitis media Only a feasibility study is
available16
No sound evidence
Headache/migraine Systematic review 17
…no rigorous evidence…*
Neck pain Cochrane review 18
…evidence did not favour spinal
manipulation/mobilisation done alone…*
Whiplash Systematic review19
No controlled clinical trials…* *Verbatim.
Method
A search for chiropractors’ websites and chiropractic associations on the World Wide Web was carried
out between 1 October 2008 and 26 November 2008, using the internet search engine Google, with the
appropriate domain extension for Australia, Canada, New Zealand, the United Kingdom, and the
United States. The keywords, were ‘chiropract*’AND ‘association’, ‘chiropract*’AND ‘organisation’,
‘chiropract*’AND ‘society’, and ‘chiropractor’.
All international and national associations and the first 40 chiropractors’ websites returned for each
country would form the sample for review. Sponsored links were not included, as these may be high
profile practices with little in common with the average practice.
Our convenience sample was limited to 40 websites for each country as most chiropractors were clearly
using one of two common templates for their websites and further data collection would therefore
contribute little. We believe that a convenience sample is the best strategy for the current study as it
would replicate the results of a World Wide Web based search by a member of the public seeking
information about chiropractic; had we randomly sampled from a register of practitioners in each
country, then we may have found websites not readily returned on a member of the public’s search of
the World Wide Web.
In the first 300 New Zealand search results, using the keyword ‘chiropractor’, 32 chiropractor websites
were returned. To increase the New Zealand sample size, a second search using the keyword
‘chiropractic’ was conducted; as a result, 8 further chiropractor websites were returned. All reviewed
materials were saved in both electronic and hard copy.
The material thus located was systematically checked by one author (AG) for evidence of claims
regarding any of the above-named conditions. The criterion deemed sufficient to conclude evidence of
a claim was that the condition would be mentioned by name on the website. Evidence would thus
include direct claims (e.g. chiropractic may help with headaches) or indirect claims (e.g. conditions for
which people consult chiropractors include headache).
If an association or advertisement mentioned a condition of interest as not suitable for chiropractic
treatment (e.g. a person suspecting they had condition X should consult their general medical
practitioner), then it would not be interpreted as an unsubstantiated claim. Whenever the phraseology
used in the reviewed materials was ambiguous about a particular condition, we (EE & AG) classified
the website or association as not making an unsubstantiated claim. Evidence of claims for other
conditions was also noted in a non-systematic fashion if they seemed sufficiently extraordinary to be
noted.
NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 39
URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA
Results
Two international and 7 national chiropractic associations were identified (see note 1
to Table 2 for names/countries of the associations). Chiropractic associations and
chiropractors’ claims (direct or indirect) about the 8 conditions are shown in Table 2.
Table 2. Chiropractic association and chiropractor website claims regarding the
eight conditions
There was evidence that 190 (95%) chiropractor websites make unsubstantiated
claims regarding at least one of the conditions. Only 56 (28%) chiropractor websites
and 4 of the 9 (44%) associations appeared to explicitly mention lower back pain,
although tentative evidence suggests it may respond to chiropractic manipulation,13
whilst 179 (90%) websites and all 9 associations mentioned headache/migraine,
which is not supported by sound evidence. When claims for colic and infant colic
were collapsed into a single heading, 76 (38%) of chiropractor websites were found to
make unsubstantiated claims about all the conditions for which there is a lack of
sound supporting evidence.
NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 40
URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA
There was evidence that some chiropractic associations make unsubstantiated claims
about conditions outside the scope of this survey; for example, allergies, arthritis,
immune system, longevity, osteoarthritis. There was also evidence that some
chiropractor websites make unsubstantiated claims regarding conditions outside the
scope of this survey; for example, attention deficit hyperactivity disorder, cancer,
epilepsy, immune function, infertility. In the case of infertility, one chiropractor’s
website printed what we believe is the extraordinary claim of research showing that
14 of 15 women unable to conceive, some for up to 10 years, had given birth after
beginning regular chiropractic care.
Discussion
Our results provide evidence that the professional chiropractic organisations of
Australia, Canada, New Zealand, the United Kingdom, and the United States make or
imply therapeutic claims that are not backed up by sound scientific evidence. Perhaps
as a consequence, many chiropractor websites of these countries follow suit.
Most healthcare professionals associate chiropractic with musculoskeletal problems.
Yet, several of the conditions claimed to respond to treatment are clearly not
musculoskeletal by nature (e.g., asthma, otitis, colic). One way to understand this
finding is to consider it within the wider context of chiropractic history.
The birthday of chiropractic is said to be September 18, 1895. On this day, D. D.
Palmer manipulated the spine of a deaf janitor allegedly curing him of his deafness.20
Palmer’s second patient, a man suffering from heart disease, was also claimed to be
cured.21
Following these early successes, Palmer articulated his theory of chiropractic,
coining the term “innate intelligence” (or “innate”) for the “energy” or “vital force”
he believed to be the essence of life. The “innate” is said to regulate all body
functions. The presence of a “vertebral subluxation” inhibits, according to Palmer, its
flow. Chiropractic is “a system of healing based on the premise that the body requires
unobstructed flow through the nervous system of…innate intelligence”.22
Based upon this notion, chiropractors use spinal manipulations to correct subluxations
to treat a very broad range of conditions: “95% of all diseases are caused by displaced
vertebrae, the remainder by luxations of other joints”.23
Broadly similar to our
findings, early chiropractic pamphlets hardly mention back pain or neck pain, but
assert that, “chiropractic could address ailments such as insanity, sexual dysfunction,
measles and influenza”.24
More recently the chiropractic profession split into those aligned to Palmer’s original
teachings (the “straights”) and those who also used treatments other than spinal
manipulation and focussed on musculoskeletal problems (the “mixers”). For many
years it seemed that the mixers dominated and chiropractors tended to fashion
themselves as back pain specialists using many forms of non-pharmacological
treatments. Now there is evidence that this process might be reversing. In 1991,
hardly any UK chiropractors admitted treating conditions other than spinal
problems.25
In 2003, 69% of all UK chiropractors felt confident to treat
visceral/organic conditions,26
currently this figure stands at 74%.27
In the US, “nearly 80% of chiropractors teach a relationship between subluxation and
internal health”,28
88% of US chiropractors believe that subluxation contributes to
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over 60 % of all visceral ailments and 90% feel that chiropractic treatments should not
be limited to musculoskeletal conditions.29
The American Chiropractic Association
stresses that chiropractic care is not limited to back pain, neck pain or other
musculoskeletal disorders,30
and most chiropractic texts discuss spinal manipulation
as a treatment for “visceral disorders”e.g.31,32,33,34
Based on the data presented here, the
situation seems to be similar in the other English-speaking countries.
Unsubstantiated claims of the nature described above may put patients at risk and are
simply at odds with the notion that chiropractic is in any way scientific. As evidence
of these claims is so widespread, we suggest this amounts to a public health issue. If,
for instance, a child suffering from severe asthma is treated with ineffective spinal
manipulation instead of effective drug therapy, there is an increased chance that this
patient’s life might be lost. In this context, one must, of course, also consider the
direct risks of spinal manipulation, which evidence suggests may be
considerable35,36,37
(although it is noted that orthodox medicine is by no means free of
risk38
).
A survey of UK chiropractors shows that 90% of them believe they support evidence-
based practice principles,39
and their code of ethics states that “chiropractor’s
provisions of care must be evidence-based...”.40
The data summarized above suggest
that chiropractors fail to abide by their own rules, although we suspect this is not
intentionally but due to the paucity of science in their curriculum.
The same code of ethics also regulates chiropractor’s advertising and provides that
“the information used must be factual and verifiable. The information must not be
misleading or inaccurate in any way.”40
The ethical guidelines in Canada, New
Zealand, and the United States are similar, but the Chiropractors’ Association of
Australia does not appear to prescribe guidelines for advertisements. Claims such as
those disclosed here in chiropractors’ websites, in our view, violate the most
fundamental rules of medical ethics: beneficence, non-maleficence and autonomy.41
This has further important practical implications; for instance, informed consent is not
a realistic possibility if it is given based on misleading information.42
Our analyses have some important limitations. Web-based information can only
generate an indirect picture of what might happen in actual clinical practice, even
although it may be the first place that potential patients may use. However, more
direct ways to ascertain such information seem to confirm the bleak impression
gained by our surveys: direct questioning of chiropractors, for instance, revealed that
the advice issued by them is frequently not responsible. New Zealand and UK
chiropractors have been shown to recommend chiropractic for childhood asthma,8,43
Canadian chiropractors have recommended treatment for an 11 year old female
assessed as healthy by an experienced paediatric orthopaedic surgeon,37
and many UK
chiropractors advise parents against immunisation of their children.43
Future research in this area should seek to explore differences in the degree to which
the practices of “mixers” and “straights” are successful; that is, does claiming to treat
conditions that are clearly not of musculoskeletal origin lead to a more successful
practice; for example, in number of consultations and financial remuneration. The
extent to which chiropractor websites make unsubstantiated claims could also be
explored in relation to length of time since graduating in chiropractic, as new
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graduates are more likely to believe their scope of practice extends beyond the
treatment of back, head, and neck pain.37
Finally, the healthcare community at large might investigate ways of minimizing the
risk to patients caused by unsubstantiated claims, particularly insofar as patients may
delay or fail to seek out orthodox care.
In conclusion, we have presented evidence that many of the direct or indirect claims
made by chiropractors and their organisations around the world are not supported by
current sound evidence. This, we feel, raises important issues and may even put lives
at risk. We therefore urge the chiropractic community to address this situation
adequately and urgently.
Competing interests: None known.
Author information: Edzard Ernst, Director, Complementary Medicine, Peninsula
Medical School, University of Exeter, Exeter, England; Andrew Gilbey, Lecturer,
College of Business, Massey University (Turitea Campus), Palmerston North,
New Zealand
Correspondence: Andrew Gilbey, College of Business, Massey University,
Private Bag 11 222, Palmerston North, New Zealand. Email:
References:
1. New Zealand Chiropractor’s Association. Frequently asked questions: Do I still need to see a
chiropractor if there is no pain? http://www.chiropractic.org.nz/frequently-asked-questions
Accessed 1 December 2008.
2. Roughan S. Setting the record straight: New Zealand Chiropractors' Association response. N Z
Med J. 2008;121(1280):72–73. http://www.nzma.org.nz/journal/121-1280/3222/content.pdf
3. Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and
alternative medicine. Ann Intern Med; 2002;(136):216–27.
4. Kremer R. Strength in diversity: Professional and legislative opportunities in primary care by
the recognition, defining and promotion of the licensure of chiropractic medical education,
competencies and skills. J Chiropr Med. 2002;1(4):139–148.
5. Dew, K. Apostasy to orthodoxy: debates before a commission of inquiry into chiropractic.
Sociol Health Illn. 2002;22(3):1310–1330.
6. Grod JP, Sikorski D, Keating JC. Unsubstantiated claims in patient brochures from the largest
state, provincial and national chiropractic associations and research agencies. J Manipulative
Physiol Ther. 2001;24:514–9.
7. Sikorski D, Grod JP. (2003). The Unsubstantiated Web Site Claims of Chiropractic Colleges
in Canada and the United States. J Chiropr Educ. 2003;17(2):113–119.
8. Holt S. The responses of alternative practitioners when approached about common childhood
illnesses. N Z Med J. 2008;121(1283):114–116.
9. Ernst E. The ethics of chiropractic. N Z Med J. 2008;(121)1281:96.
10. Roughan S. Colquhoun's opinion versus science—a response from the New Zealand
Chiropractors' Association. N Z Med J. 2008;121(1281):99–101.
11. The Canadian Chiropractic Association. Chiropractic Health Care Commission – Manitoba.
http://www.ccachiro.org/client/cca/cca.nsf/web/A667B070372C0BCA85256D3600559607?O
penDocument Accessed 21 January 2009.
12. Cooper RA, Laud P, Craig L, Dietrich CL. Current and Projected Workforce of Nonphysician
Clinicians JAMA. 1998;280:788–794.
NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 43
URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA
13. Assendelft WJJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low-back pain.
Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD000447. DOI:
10.1002/14651858.CD000447.pub2.
14. Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database of
Systematic Reviews 2005, Issue 2. Art. No.: CD001002. DOI:
10.1002/14651858.CD001002.pub2.
15. Husereau D, Clifford T, Aker P, et al. Spinal manipulation for infantile colic. Canadian
Coordinating Office for Health Technology Assessment 2003; (Technology report no 42).
16. Sawyer CE, Evans RL, Boline PD, et al. A feasibility study of chiropractic spinal
manipulation versus sham spinal manipulation for chronic otitis media with effusion in
children. J Manip Phsiol Ther 1999;22(5):292–267.
17. Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadroado ML. Are manual therapies effective
in reducing pain from tension-type headache?: A systematic review. Clin J Pain.
2006;22(3):278–285.
18. Gross A, Hoving JL, Haines T, et al. Manipulation and mobilisation for mechanical neck
disorders. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004249.
DOI: 10.1002/14651858.CD004249.pub2.
19. Ernst E. Chiropractic spinal manipulation for whiplash injury? A systematic review of
controlled clinical trials. FACT. 2009;2:85–86.
20. Wardwell W. History and evolution of a new profession. St. Louis, MO. Mosby-Yearbook;
1992.
21. DeVocht JW. History and overview of theories and methods of chiropractic: a counterpoint.
Clin Orthop Relat Res. 2006;444:243–249.
22. Martin SC. The only truly scientific method of healing. Chiropractic and American Science
1895-1990.1994;85:207–227.
23. Homola S. Bonesetting, chiropractic and cultism. Panama City, FL: Critique Books; 1963.
24. Palmer BJ. Chiropractic proofs. Davenport, Iowa; 1903.
25. Pedersen P. A survey of chiropractic practice in Europe. Europ J Chiropractic. 1994;42:3–28.
26. Wilson FJH. A survey of chiropractors in the United Kingdom. Eur J Chiropract.
2003;50:185–198.
27. Pollentier A, Langworthy JM. The scope of chiropractic practice: a survey of chiropractors in
the UK. Clin Chiropractic. 2007;10:147–155.
28. Chiropractic News Digest 2003, June 11, http://www.chirobase.org/18CND/03/03-02.html
Accessed 3 December 2008.
29. McDonald W, Durkin K, Iseman S, et al. How Chiropractors Think and Practice. Ada, OH;
Institute for Social; Research, Ohio University; 2003.
30. American Chiropractic Association. About chiropractic.
http://www.amerchiro.org/level2_css.cfm?t1id=13&t2id=61 Accessed 3 December 2008.
31. Redwood D. Chiropractic. In Micozzi MS, ed. Fundamentals of complementary and
integrative medicine. (3rd Edition). St Louis: Elsevier; 2006.
32. Gay RE. Chiropractic. In Yuan CS, Bibber EJ, Brent AB. eds. Textbook of complementary
and alternative medicine. 2nd ed. Abingdon: Informa Healthcare; 2006.
33. Wiles MR. Visceral disorders related to the spine. In: Gatterman MI, ed. Chiropractic
management of spine-related disorders. Baltimore: Williams & Wilkins; 1990;379–96.
34. Swenson RS. Clinical investigation of reflex function. In: Haldeman S. ed. The modern
developments in the principles and practice of chiropractic. 2nd ed. rev. Norwalk, CT:
Appleton Century Crofts. 1992;105–14.
35. Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med.
2007;100:330–8.
36. Rubinstein SM, Leboeff-Yde C, Knol DL, et al. Predictors of adverse events following
chiropractic care for patients with neck pain. J Manip Phys Ther. 2008;31:94–103.
NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 44
URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA
37. Benedetti P, MacPhail W. Spin doctors: The chiropractic industry under examination.
Toronto, Ontario: Dundurn Press; 2002.
38. Helmreich RL (2000). On error management: lessons from aviation. BMJ 2000;320: 781–785.
39. General Chiropractic Council. Consulting the profession: A survey of UK chiropractors.
http://www.gcc-uk.org/files/link_file/ConsultTheProfession.pdf Accessed 1 December 2008.
40. General Chiropractic Council. Code of Practice and Standard of Proficiency. http://www.gcc-
uk.org/files/link_file/COPSOP_8Dec05.pdf Accessed 1 December 2008.
41. Fisher F. Medical ethics today: its practice and philosophy. London, England: British Medical
Association; 1993.
42. Ernst E, Cohen M. Informed consent in complementary and alternative medicine. Arch Intern
Med. 2001;161:2288–92.
43. Schmidt K, Ernst E. Letter to the Editor: Are asthma sufferers at risk when consulting
chiropractors over the Internet? Respiratory Med. 2003;97:104–5.
44. Schmidt K, Ernst E. MMR vaccination advice over the Internet. Vaccine. 2003;21:1044–7.