Having your spine popped like bubble wrap might feel beneficial but the evidence that spinal manipulation is effective is less satisfactory.
For the past few years I’ve had a guilty pleasure. I’ve visited osteopaths and chiropractors. Guilty, because I’m a science writer and know about the scientific question marks hanging over both professions. A pleasure, because I’m a science writer and spend much of my time hunched over a laptop – when you’ve got a bad back, there are few things more satisfying than having your spine popped like bubble wrap. Then cranial osteopathy happened.
Lying down wearing only my underwear in an osteopath’s front room, I was waiting expectantly for the back-popping to begin. Instead, to my toe-curling horror, he started lightly fingering my head and telling me he was channeling energy through the plates of my skull. With his touch, apparently, he’d reset my “internal rhythms” and cure my pain. I didn’t think my back could get much stiffer. It turns out I was wrong. With this unsolicited venture into a wacky branch of both osteopathy and chiropractic came a question I should have asked a long time ago: how much of these professions is scientifically legitimate and how much, as others have asked before me, is bogus?
I got an answer I was secretly not expecting. “Even in the case of low-back pain where the claims are most plausible,” says David Colquhoun, a pharmacologist at UCL and outspoken critic of pseudo-medicine, “there is little reason to believe that manipulation works. People get better at much the same rate regardless of treatment.”
Manipulation, or manual therapy, the joint-thrusting treatment both professions are best known for, has been tested for low-back pain with apparently positive results, but the studies have been largely panned for being too small or of poor quality. When all studies are pooled and analysed together, the procedure flops, coughing and spluttering, just short of the finish line. Analyses show low-to-medium evidence of short-term effectiveness, and – importantly – that the procedure is no better than any other treatment, including placebos.
Odd, given that the idea seems so logical. Manual therapy from both professions is even included in the 2009 Nice (National Institute for Health and Care Excellence) guidelines for low-back pain, which are undergoing revision and due to be published at the end of next year. However, the NHS Choices website says “some uses of chiropractic treatments are based on ideas and an ‘evidence base’ not recognised by the majority of independent scientists” and “the use of osteopathy isn’t always based on scientific evidence”. Colquhoun suspects that “chiropractic and osteopathy will have a less lenient assessment [from Nice] this time around. I hope logical thinking and common sense will win out.”
The misconception of manual therapy has even crept into physiotherapy, says Adam Meakins, a London physiotherapist. Most backaches resolve spontaneously, he says, and the truth is that nobody really knows how to treat them.
“We do know that staying active helps,” he says. “The lines between physiotherapy, chiropractic and osteopathy have become blurred. As physiotherapists we should be giving only education and exercise-based advice. We believe in self-management, giving patients ownership to get themselves better and not looking for repeat business.”
“In the 120 years since chiropractic and osteopathy were invented, there is no convincing evidence that either works” -David Colquhoun, Pharmacologist
Lack of evidence of effectiveness aside, perhaps most damning – and surprising for anybody who has paid for the treatment – is that nobody can explain how manipulation would theoretically work, even the practitioners. Matthew Bennett, the president of the British Chiropractic Association (BCA), says that one explanation they’re working on is that a physical force through the spine removes stiffness, though it is unclear what causes this “stiffness” or, therefore, how a physical force might remove it. Another is that it changes the body’s perception of pain. “We’ve spent 100 years or more going through various other hypotheses,” he says, “but those seem to be the ones where most of the encouraging work is going on.”
Sometimes, trial and error is a valid scientific approach to generate ideas, but only if proper tests are then done to confirm the hunches. But, as Colquhoun points out, “in the more than 120 years since chiropractic and osteopathy were invented, there is still no convincing evidence that either works, even for back pain, never mind the much more far-fetched claims that their practitioners often make.” Such far-fetched claims include being able to treat excessive childhood crying, asthma, ear infections, bedwetting, and learning and behavioural difficulties.
Here, understanding the origins of both professions can help answer why both can be so liberal with their claims. “They were both started by complete quacks,” scoffs Edzard Ernst, emeritus professor of complementary medicine at Exeter University. “Chiropractic dates back to DD Palmer 120 years ago who thought that if the vertebrae are subluxated [misaligned] then the inert energy, which you can almost replace with divine energy in this case, can’t flow properly and therefore the vital force is impeded and therefore we fall ill.” It’s on this basis that many chiropractors believe that by manipulating the spine they can treat non-spinal disorders and some diseases.
Though poorly recorded, he says, DD Palmer is supposed to have nabbed the concept from Andrew Still, who founded osteopathy several years earlier. Still, a medical doctor, was looking for a drug-free alternative to medicine, which was not an entirely unnecessary pursuit at the time given that his colleagues were still dishing out the highly toxic mercury for disorders such as syphilis.
“Chiropractic in its initial phase was not at all about backs,” explains Ernst. “The first patient was a deaf person and the second was one with coronary heart disease.” Though the BCA and General Chiropractic Council in the UK put out a statement in 2010 saying there was no evidence that vertebral subluxation causes disease, a quick Google shows how widely the concept is still being peddled. “You have chiropractors who still believe subluxation causes disease, those who pretend not to believe in it, and those who actually don’t believe in it,” Ernst adds.
Timothy Mirtz, a former chiropractor who now works in physical education research at Bethune-Cookman University in Florida, was one of those who did not believe in it. In 2009, he and his colleagues, two of whom were also chiropractors, did a comprehensive search and found “not a scrap of evidence for subluxations causing disease. We made some chiropractors angry but the truth is that there is more physical evidence for the North American ape, Bigfoot, than there is for subluxations causing disease,” he chortles. Bennett points out that while the Advertising Standards Authority restricts claims that chiropractors make to only those of a musculoskeletal nature such as back pain, the UK legislation does not restrict their scope of practice once a patient is in their clinic.
“Manipulation is not appropriate in the neck at all – it can occasionally cause stroke. There’s a definite risk of harm” -Philip Sell, Spinal Surgeon
But according to an investigation by Good Thinking, a charity set up by Simon Singh, the science writer unsuccessfully sued by the BCA in 2008 for writing an article that was critical of their profession, some practitioners are still making these claims. Good Thinking says it was assured by both a chiropractor and an osteopathic clinic that they could treat childhood colic despite, as the charity wrote on their website, “no evidence that such treatment is anything but a waste of time and money”. The chiropractic clinic involved also implied that vaccination is unnecessary and that chiropractic could reduce the need for medication.
It’s such unjustified and unethical behaviour – especially so within a vocal group of chiropractors in the US – that gets the goat of scientists such as Colquhoun and Ernst. Aside from dangerous misinformation, some chiropractors and osteopaths charge for expensive treatment on the unfounded assumption that regular adjustments can ward off disease or discomfort. Some also sell treatment to pregnant women and their newborn babies, a population with strong emotional buy-in, despite no evidence of worth.
And then there’s safety. Think of a chiropractor and you’ll picture a white-coated person leaning over a patient and giving them a short, sharp, vertebrae-crunching twist to the head. Let us not forget that this was James Bond’s method of choice when killing low-level henchmen he found in his hotel room.
Philip Sell, an NHS spinal surgeon, says that “manipulation is not appropriate in the neck at all – it can occasionally cause stroke. There’s a definite risk of harm and it is not recommended.” As Singh concluded in his article that led to the lawsuit with the BCA, “if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market”.
Surprisingly, Sell isn’t completely dismissive of chiropractic or osteopathy for people with low-back pain, for which he says there is probably no harm. He concedes that there’s little evidence that spinal manipulation works, and that there’s little reason to think that it would, but adds: “What they do with their hands isn’t particularly important, it’s what they end up saying to the person that might help them manage pain better and keep active.”
Michael Hyland, a professor of health psychology at Plymouth University, agrees. “The placebo effect isn’t magic,” he says. “It’s a bio-psychological process that happens to a greater or lesser extent even in modern medicine.” Much like the brain acts on information it receives from pharmaceuticals in the blood, it can also act on information it receives through the eyes and ears. Give somebody placebo dopamine, he says, and their brain will start to produce dopamine. Placebo morphine is a more effective pain reliever than placebo aspirin, red pills are more effective than white pills, and two pills are more effective than one.
“People can also get comfort from having a therapist tell them that they can sort out their problem,” he says. “The therapist gives them a rationale – whether or not that rationale is true – and the person goes along with it. It’s a story and stories are quite important to patients,” says Hyland.
With something as potentially dangerous as asthma, he adds, patients would be wiser to get proper prophylactic treatment from conventional medicine: “Placebos don’t mend broken bones and you can’t get heart transplants from them. If you look at these professions as complementary to rather than alternative to medicine then I think you’re on much safer ground.”
Owen Hughes, a consultant psychologist in pain and fatigue management, adds that any psychological effect is increased because if you pay for something you value it more. If somebody is sold – and sold on – the treatment, it might even change, for instance, a parent’s perception of their child’s crying.
“People get distressed and go and see someone who is charismatic and convincing and it gives them faith; there’s a lot in the old adage that a problem shared is a problem halved,” he says. “They end up thinking it works, even though it might all be a bit like the emperor’s new clothes.”
If like me you find yourself in front of an osteopath or chiropractor in only your underwear, given the lack of evidence and price of treatment, that’s probably a wise analogy to remember.
Complementary therapies: does the science add up?
Homeopathy There are several NHS homeopathic hospitals and some GPs offer the treatment, but a 2010 Commons committee report on homeopathy said the principles on which it was based were “scientifically implausible”.
It is not recommended by the National Institute for Health and Care Excellence (Nice) for treatment.
Chinese herbal medicine NHS advice: “Herbal remedies are medicines made up of plants, trees or fungi. However, being natural doesn’t necessarily mean they’re safe for you to take. Herbal remedies, just like pharmaceutical medicines, have an effect on the body and can potentially be poisonous.”
Acupuncture Nice recommends considering it as an option for chronic lower back pain, chronic tension headaches and migraines.
Aromatherapy Listed by various NHS healthcare trusts as a complementary therapy that may help ease symptoms of anxiety states. Nice has no advice on aromatherapy, but its archives contain several studies, none of which shows strong evidence it works.
Reiki Offered as a therapy at various NHS trusts. Sherwood Forest hospitals claim reiki can be used to “make you feel less stressed” and “promote physical, mental and spiritual feeling of wellbeing”. Jennifer Toes
Source: The Guardian
“Chiropractic and osteopathy – how do they work?”