Why Choose Evidence-Based Chiropractic?

There is currently a significant divide within the chiropractic profession.

It involves the belief systems chiropractors base their approach on. These different beliefs affect everything from how a practice is run, to how a patient is treated. It is therefore important for potential patients to learn about these differences so they can make an informed decision on which type of chiropractic treatment suits them best.

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The Two Main Chiropractic Philosophies

The Vitalistic Philosophy:

Those who follow the traditional beliefs of the founding chiropractors.

Although few chiropractors now follow the strict original philosophy of the founders, many still hold onto core aspects of their belief system. They often label themselves as “wellness chiropractors”.

The Materialistic Philosophy:

Those who follow what the science says can be achieved with chiropractic.

Generally an “evidence-based chiropractor” only believes and promotes the scientific research findings related to chiropractic treatment and/or manipulative therapy.

These belief systems lie at opposite ends of a spectrum, with most chiropractor’s likely sitting somewhere in the middle. Below we’ll detail the difference between the two.

The Difference In Theories

The Difference In What Is Treated

The Difference In Treatment Approaches

Summary

The Difference In Theories

Chiropractic was invented by an American named D. D. Palmer in 1895. He realised that there are spots in your spine that don’t appear to behave normally. He called these spots “vertebral subluxations” and treated them with spinal joint manipulation.

He came to believe that these subluxations are detrimental to your health in a variety of ways and was quoted as saying:

“A subluxated vertebra … is the cause of 95 percent of all diseases … The other five percent is caused by displaced joints other than those of the vertebral column.”

The medical profession dismissed this idea. However, to this day chiropractors are still taught that vertebral subluxations are a real phenomenon can have a raft of negative effects on your health.

Until recently, many chiropractic colleges (including New Zealand’s) used the following definition of a subluxation:

“A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.”

Wellness chiropractors tend to have a belief system along these lines. They believe that chiropractic treats subluxations and therefore it helps improve a variety of body functions and general health.

In 2015 a different group of chiropractic colleges from around the world put out the following statement:

“The teaching of the vertebral subluxation complex as a vitalistic construct that claims that it is the cause of disease is unsupported by evidence. Its inclusion in a modern chiropractic curriculum in anything other than an historic context is therefore inappropriate and unnecessary.”

What are chiropractors (and other manipulative therapists) treating?

The truth is, we don’t know.

There is research findings backing some theories, including:

  • The neuroplasticity model, developed by Dr Heidi Haavak et el. It basically states that altered sensory input from a dysfunctional area in the spine leads the brain interpreting the surrounding world incorrectly. This then leads to less than optimal control of the body and further spinal dysfunction. Spinal manipulation breaks this negative feedback loop and restores normal function.
  • The adhesion model, researched by Dr Gregory Cramer. The models premise is that adhesions build up around the spinal joints when they are not used frequently. Spinal manipulation is a way of breaking up these adhesions and restoring normal joint function.

There are other theories out there, but there is no universally understood answer to how or why spinal manipulation works. Science hasn’t provided us with a clear picture yet and more research is needed.

An evidence-based chiropractor will likely admit they don’t have all the answers and will tell patients the evidence for some of the theories.
A wellness chiropractor may not be as open to this kind of uncertainty. They are more likely to tell patients that they are suffering from ‘vertebral subluxations’ and will insinuate that they are negatively impacting their general health and wellbeing.

The Difference In What Is Treated

Ask a chiropractor what they can help you with and you could get a variety of answers.

Let’s look into the scientific evidence for what can be achieved with spinal manipulation. When it comes to health science research, there are two main types:

Applied Research:

Research that explores whether an intervention is safe or effective for patients. These studies usually use a large group of people as test subjects, testing whether an intervention is able to solve a current problem.

Not all studies are created equal due to test group size, sources of bias and study design. Meta-analysis studies and systematic reviews are the most trusted form of applied research, followed by randomised controlled trials.

Basic Research:

Studies that investigate the fundamental science of what is going on. They are often performed in a laboratory by scientists with the goal to answer questions about the core underlying structures and functions.

Chiropractic basic research is usually performed on a small number of people, looking into very specific changes to the body in a highly controlled setting. This inevitably makes the results less applicable to real-world scenarios.

Research into chiropractic (i.e. spinal manipulation) has found that the treatment can influence numerous aspects of the body. The following details the areas where there is at least some evidence for spinal manipulation having an effect:

Applied Research:

Meta-Analysis & Systematic Review Findings

•  Treatment for acute [1] [2] , sub-acute [2] and chronic [3] [4] lower back pain.

•  Treatment for neck pain. [5]

•  Treatment for cervicogenic headaches and dizziness [6], tension-type headaches [7] and migraines. [8]

•  Treatment for sciatica. [9]

High Strength Study Designs

Applicable To Real-World Scenarios

Applied Research:

Randomised Control Trial Findings

•  Back pain prevention. [10]

•  Sacroiliac joint dysfunction. [11]

•  Pain related to a lumbar disc injury. [12]

These studies are yet to be investigated with the more trusted study designs.

Moderate Strength Study Designs

Applicable To Real-World Scenarios

Basic Research:

  • Changed brain function in the pre-frontal cortex. [13]
  • Altered and enhanced muscle function in the general population. [14]
  • Decreased reaction times. [15]
  • Increased muscle strength in the upper and lower limbs. [16]
  • Prevention of muscle fatigue from developing in certain areas. [17]
  • Increased muscle strength and cortical drive in stroke patients who had muscle weakness. [18]
  • Increased neck range of motion. [19]
  • Reduced joint position sense error. [20]
  • Improved feed-forward activation of core stabilising muscles. [21]
  • Improved sensorimotor function related to falls risk of community dwelling older adults. [22]
  • Improved or altered visual acuity and visual field size. [23]
  • Altered spinal cord reflex excitability. [24]
  • Reduced pain thresholds for those suffering from lateral epicondylalgia. [25]
  • Changes in the way the brain processes sensory and motor information. [26]
  • Improved spinal function. [27]

High Strength Study Designs

Less Applicable To Real-World Scenarios

An evidence-based chiropractor would likely promote the above findings, noting the limitations of each of the studies and where more research is needed to improve the veracity of the results.

Wellness chiropractors also promote the above findings (who wouldn’t), but they often don’t stop there.

The basic research shows that chiropractic can help with specific aspects of nervous system function, mostly related to the musculoskeletal system. Wellness chiropractors have a deep belief that chiropractic can improve general health and often use the results of the basic research as evidence that chiropractic can help all aspects of nervous system function.

It could be argued that the nervous system controls all functions of the human body. With this in mind, these chiropractors often make unsubstantiated claims, such as being able to help asthma, improving immunity, digestion and organ function.

When Chiropractors Are Not Evidence-Based

In 2016 a study found 56% of New Zealand chiropractor’s websites claimed that they could treat health conditions which had no scientific evidence for support.

This study followed a well-publicised event in the UK in 2008. A popular article published in The Guardian was critical of chiropractors who over-advertise their abilities. Following this, a quarter of the members of the British Chiropractors Association (BCA) went under formal investigation and the BCA sued the author. They eventually dropped the case. The ordeal helped motivate the formation of a new law to protect freedom of speech (in favour of the article’s author).

In 2019 the Australian state of Victoria commissioned an independent review of the practice of spinal manipulation on children under 12 years. This followed public outrage caused by a video of a chiropractor holding the 2 week old upside down by the feet and using an adjusting tool on the infant.

Treatment of toddlers/infants can be a touchy topic for chiropractors. Although most trusted clinical research shows little benefit [6] [28] for a variety of conditions, there is possibly some evidence for infantile colic. A meta-analysis study found favourable evidence for reduced crying times. [29] However a different meta-analysis released around the same time found the evidence to be inconclusive [30] and another trusted study found that the majority of the positive results had a high risk for bias. [31]

The Difference In Treatment Approaches

Chiropractic Techniques

A chiropractic technique specifies the protocol a chiropractor follows when treating a patient. The technique often details the patient analysis procedure, patient positioning instructions, where to put the hands/tool on the patient and how to apply the corrective intervention.

There are well over 100 chiropractic techniques, each with their own ideas about what is going on in the spine/body and how best to treat it.

The previous section detailed all of the scientific evidence for chiropractic care. The entirety of this research investigated the effectiveness of high velocity, low amplitude (HVLA) spinal manipulation and no other form of chiropractic. HVLA spinal manipulation utilises a quick thrust over a short distance. It is usually applied to the spine to push it slightly past the normal joint range of motion.

An evidence-based chiropractor will use this type of spinal manipulation as their primary form of treatment as it is the only form of chiropractic that has solid evidence behind it.

It is likely that not even half of those 100+ techniques involved HVLA spinal manipulation. If a chiropractor doesn’t use this technique they are basically shooting in the dark. There are two possible outcomes:

Outcome 1 – The technique is an effective form of treatment, only no well designed research has been conducted to show this yet.

Outcome 2 – The technique has no effect, a placebo effect or a negative effect. It wastes the patients time and money, potentially delaying them from seeking a more effective treatment option.

Without research, we cannot be sure that chiropractic care without HVLA spinal manipulation doesn’t fall under Outcome 2.

Side Note 1:

Personally, I have seen a variety of treatment types through the years. Some involve barely brushing the skin, others involved bringing vials of “allergens” close to the patient’s body and seeing if their muscles weaken. There was even one chiropractor who just hovered his hands over the patient.

I was also taught a variety of questionable things at chiropractic college. These included:

  • Scanning the body for heat and electrical differences to use as an indicator of nervous system function.
  • Establishing “continuity” by lightly stroking the body (part of a technique called BGI, a real rabbit hole of pseudoscientific beliefs).
  • Activator method which involves touching and moving the patient’s body in various ways and then checking to see if it alters their leg lengths. If the legs move, it somehow tells you to work on a specific vertebrae.
  • “Chiropractic Philosophy” classes 1-2 time a week for a total of 4 semesters. In these classes we were given an in-depth education on the founding chiropractors philosophies about chiropractic. These classes went further than just a history lesson and felt more like training for a cult. We spent far less time on arguably more important subjects, such as rehabilitation, nutrition, risk management and pharmacology.

We even had an anti-vaxxer come in for a lecture and a fringe scientist visit every year to teach us his ideas.

Appointments

Most of the solid research evidence for chiropractic care involves the treatment of a condition or symptoms that are already present. Therefore, an evidence-based chiropractor often has appointment lengths to allow for a full investigation of the condition and follow up appointments tailored to progressively improving the symptoms until the patient has fully recovered. They aim to get you better to the point that you do not need to come in frequently.

On the other hand, wellness chiropractors are more likely to have a view that chiropractic is an essential part of a healthy lifestyle. As important as a healthy diet or regular exercise. They will likely attempt to convince you to come in for ongoing visits for general “wellness”, whether you have symptoms or not. They may try to convince you to sign up for multiple appointments on the first or second visit, roping you in.

Side Note 2:

A chiropractor friend once said to me “there’s a lot of money in wellness” with a smirk on his face. He wasn’t wrong.

Appointments times do not have to be long if patients are coming in for chiropractic care without any major issues. It’s not uncommon to hear of chiropractors who see 3 to 5 patients within 15 minutes. By the time I’ve seen one patient, they’ve seen up to 8 people. That’s some good cash flow.

But is it moral? I would wager that these clinics have systems in place that manage to convince a lot of people that chiropractic will give them something that science hasn’t proven.

Summary

When you use a product or service you want to be sure it does what it says it will do.

Evidence gathered through scientific studies affects every one of our professions and laws, it enables our new discoveries and technological breakthroughs. It tells us what’s going on, what works best, what doesn’t work and what is actually detrimental.

It makes sense for healthcare to be evidence-based. What is more important than our health?

By visiting a truly evidence-based chiropractor, you will know that the advice and treatment you receive has some science behind it.

An evidence-based chiropractor only has one main objective with their treatment approach:

To offer the best care possible.

It’s no secret that the chiropractic profession has a history of flirting with the fringes of science. Unfortunately, it continues to this day in many practices. If you go to a chiropractor that isn’t evidence-based you run the risk of wasting your time and money.

You may be told the following:

  • That you are suffering from a condition that isn’t accepted in the health science community.
  • That the treatment and techniques they use will help you in ways that are unproven.
  • That you need frequent chiropractic care for the foreseeable future. Not just for your symptoms, but for general health and ‘wellness’. Not that there’s any great scientific reason for it.

Spotting the difference in chiropractic approaches can be hard. Even some clinics that advertise being evidence-based are clearly not. It could be a possible warning sign if a chiropractic clinic does any of the following:

  • Use of the following words: wellness, innate intelligence, energy flow, vitality.
  • Say they are able to make your entire nervous system function better.
  • Advertise that they see infants, babies or perform paediatric care.
  • Use techniques such as Applied Kinesiology (AK), Bio-Geometric Integration (BGI) and Neuro Emotional Technique (NET).
  • Claim to treat a condition that is not mentioned in the list above.
  • Insist you get full spine x-rays when it’s unlikely that you have a condition affecting the entire spine.
  • Try to sign you up for long term treatment.
  • Advise you to stop prescription drugs or avoid vaccinations.

Evidence-Based   [ˈev.ɪ.dənsˌbeɪst]
(adjective)

Denoting an approach to medicine, education, and other disciplines that emphasizes the practical application of the findings of the best available current research.

The opinions expressed on this page are that of the websites owner and do not necessarily represent the views held by other chiropractors or that of the profession as a whole.

References

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  2. Walker BF, French SD, Grant W, Green S. Combined chiropractic interventions for low‐back pain. Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD005427. DOI: 10.1002/14651858.CD005427.pub2.
  3. Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low‐back pain. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD008112. DOI: 10.1002/14651858.CD008112.pub2.
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