I read with interest the comments from a chiropractor left on a recent series of posts. It reminded me of a few things. First, there are plenty of thoughtful, intelligent chiropractors. Just because there are also a lot of wackos doesn’t mean many of them aren’t trying to do good.
But his presentation of evidence left me feeling a bit empty, as if more “modern” chiropractors are looking for a scientific basis for their practice but not yet finding much meat, at least compared to usual medical literature. The starting point seems to be “well, we know this stuff works, but not yet why, and here are some plausible hypotheses, some of which we’ve tested.” It seems a bit “wrong way ’round” scientifically. In most of medicine, we come up with a hypothesis, either through reasoning from scientific plausibility or via serendipity, and test it before applying it. The chiropractors that have moved away from the fantastical “subluxation complex” idea are working from an assumption that what they do actually works.
The sum of the literature at this point does not point to a strong effect from chiropractic for most situations, although it may be equal to usual care for back pain. But it’s just not real strong evidence, the kind we would expect from a medical intervention. That isn’t to say real medicine has done much better for functional musculoskeletal pain, it’s just that chiropractic doesn’t appear to have additional benefit—at this point. It would be better to find out if some sort of standardized chiropractic treatment actually worked consistently, and then look for a mechanism of action.
And just as in medicine we recognize a risk-benefit ratio associated with our interventions, chiropractors must learn to do the same. It’s time for them to acknowledge that vertebral artery dissection, while quite rare, does appear to be associated with neck manipulation, and given the limited benefit of the intervention, it shouldn’t be done.
Perhaps some day, one or more specific, standardized chiropractic approaches will find a valid use, but after more than a century, we’re just not there.
In real medicine, we also need to clean house a bit. Doctors need to take a look at the physical therapy centers they use. Some are based on typical range of motion and strengthening maneuvers, but there are plenty of odd practices going on, such as reiki and cranial-sacral therapy. “Consult PT” often leads to interventions you might not have intended.
In addition to warning my patients away from chiropractic neck manipulation, I also remind them that recovery from back and neck pain requires a great deal of patience. Any doctor who claims to be able to entirely relieve their pain isn’t being honest. And surgery is an option saved for those who have significant pain or weakness that a surgeon really thinks would respond to surgery. If there is no impending spinal catastrophe, it’s always good to get a second opinion.
Lest you think me heartless, I’ve shared with you my own back troubles, and when I was at my worst, I just wanted to get better. I thought about chiropractic, acupunture, anything, but my research led me away from it (especially given the huge hunk of disc sitting near my spine). And like most patients, I improved spontaneously over time. It’s hard to be patient when you hurt, but sometimes it’s still the best plan.