The "subluxation" issue: an analysis of chiropractic clinic websites

Mechanisms of manipulation: a systematic review of the literature on immediate anatomical structural or positional changes in response to manually delivered high-velocity, low-amplitude spinal manipulation

BACKGROUND

Spinal manipulation (SM) has been claimed to change anatomy, either in structure or position, and that these changes may be the cause of clinical improvements. The aim of this systematic review was to evaluate and synthesise the peer-reviewed literature on the current evidence of anatomical changes in response to SM.

METHODS

The review was registered with PROSPERO (CRD42022304971) and reporting was guided by the standards of the PRISMA Statement. We searched Medline, Embase, CINAHL, AMED, Cochrane Library all databases, PEDro, and the Index to Chiropractic Literature from inception to 11 March 2022 and updated on 06 June 2023. Search terms included manipulation, adjustment, chiropractic, osteopathy, spine and spine-related structures. We included primary research studies that compared outcomes with and without SM regardless of study design. Manipulation was defined as high-velocity, low-amplitude thrust delivered by hand to the spine or directly related joints. Included studies objectively measured a potential change in an anatomical structure or in position. We developed a novel list of methodological quality items in addition to a short, customized list of risk of bias (RoB) items. We used quality and RoB items together to determine whether an article was credible or not credible. We sought differences in outcomes between SM and control groups for randomised controlled trials and crossover studies, and between pre- and post-SM outcomes for other study designs. We reported, in narrative form, whether there was a change or not.

RESULTS

The search retrieved 19,572 articles and 20 of those were included for review. Study topics included vertebral position (n = 3) facet joint space (n = 5), spinal stiffness (n = 3), resting muscle thickness (n = 6), intervertebral disc pressure (n = 1), myofascial hysteresis (n = 1), and further damage to already damaged arteries (n = 1). Eight articles were considered credible. The credible articles indicated that lumbar facet joint space increased and spinal stiffness decreased but that the resting muscle thickness did not change.

CONCLUSION

We found few studies on this topic. However, there are two promising areas for future study: facet joint space and spinal stiffness. A research strategy should be developed with funding for high quality research centres.

Alternative cancer clinics' use of Google listings and reviews to mislead potential patients

Background

Alternative cancer clinics, who provide treatment associated with earlier time to death, actively seek to create favorable views of their services online. An unexplored means where alternative cancer clinics can shape their appeal is their Google search results.

Methods

We retrieved the Google listing and Google reviews of 47 prominent alternative cancer clinics on August 22, 2022. We then conducted a content analysis to assess the information cancer patients are faced with online.

Results

Google listings of alternative treatment providers rarely declared the clinic was an alternative clinic versus a conventional primary cancer treatment provider (12.8% declared; 83.0% undeclared). The clinics were highly rated (median, 4.5 stars of 5). Reasons for positive reviews included treatment quality (n = 519), care (n = 420), and outcomes (n = 316). 288 reviews presented the clinics to cure or improve cancer. Negative reviews presented alternative clinics to financially exploit patients with ineffective treatment (n = 98), worsen patients' condition (n = 72), provide poor care (n = 41), and misrepresent outcomes (n = 23).

Conclusions

The favorable Google listing and reviews of alternative clinics contribute to harmful online ecosystems. Reviews provide compelling narratives but are an ineffective indicator of treatment outcomes. Google lacks safeguards for truthful reviews and should not be used for medical decision-making.

A new role for spinal manual therapy and for chiropractic? Part I: weaknesses and threats

Spinal manual therapy is central to chiropractic history, clinical practice, and professional identity. That chiropractors have developed an expertise in this domain has provided some considerable advantages. However, we contend it is also at the crux of the ideological schism that fractures the chiropractic profession. In this article, which is the first in a series of two, we discuss chiropractors' understanding and use of spinal manual therapy and do so with particular emphasis on what we see as weaknesses it creates and threats it gives rise to. These are of particular importance, as we believe they have limited the chiropractic profession's development. As we shall argue, we believe that these threats have become existential in nature, and we are convinced that they call for a resolute and unified response by the profession. Subsequently, in part II, we discuss various strengths that the chiropractic profession possesses and the opportunities that await, provided that the profession is ready to rise to the challenge.

Incomplete reporting of manual therapy interventions and a lack of clinician and setting diversity in clinical trials for neck pain limits replication and real-world translation. A scoping review

INTRODUCTION

Neck pain is a leading cause of disability, and manual therapy (MT) is a common intervention used across disciplines and settings to treat it. While there is consistent support for MT in managing neck pain, questions remain about the feasibility of incorporating MT from research into clinical practice. The purpose of this scoping review was to assess the adequacy of MT intervention descriptions and the variability in clinician and setting for MT delivery in trials for neck pain.

METHODS

Medline (via PubMed), CINAHL, PEDRo, and the Cochrane Central Registry for Controlled Trials were searched for clinical trials published from January 2010 to November 2021. A 11-item tool modified from the Consensus on Exercise Reporting Template was used to assess appropriateness of intervention reporting. Clinicians, subclassifications of neck pain, and clinical settings were also extracted.

RESULTS

113 trials were included. A low percentage of studies provided the recommended level of detail in the description of how MT was delivered (4.4%), while 39.0% included no description at all. Just over half of trials included clinician's qualifications (58.4%), dose of MT (59.3%), and occurrence of adverse events (55.8%). The proportion of trials with clinicians delivering MT were physical therapists (77.9%), chiropractors (10.6%), and osteopaths (2.7%).

DISCUSSION/CONCLUSION

These results reveal incomplete reporting of essential treatment parameters, and a lack of clinician diversity. To foster reproducibility, researchers should report detailed descriptions of MT interventions. Future research should incorporate a variety of MT practitioners to improve generalizability.

Avoiding nocebo and other undesirable effects in chiropractic, osteopathy and physiotherapy: An invitation to reflect

INTRODUCTION

While the placebo effect is increasingly recognised as a contributor to treatment effects in clinical practice, the nocebo and other undesirable effects are less well explored and likely underestimated. In the chiropractic, osteopathy and physiotherapy professions, some aspects of historical models of care may arguably increase the risk of nocebo effects.

PURPOSE

In this masterclass article, clinicians, researchers, and educators are invited to reflect on such possibilities, in an attempt to stimulate research and raise awareness for the mitigation of such undesirable effects.

IMPLICATIONS

This masterclass briefly introduces the nocebo effect and its underlying mechanisms. It then traces the historical development of chiropractic, osteopathy, and physiotherapy, arguing that there was and continues to be an excessive focus on the patient's body. Next, aspects of clinical practice, including communication, the therapeutic relationship, clinical rituals, and the wider social and economic context of practice are examined for their potential to generate nocebo and other undesirable effects. To aid reflection, a model to reflect on clinical practice and individual professions through the 'prism' of nocebo and other undesirable effects is introduced and illustrated. Finally, steps are proposed for how researchers, educators, and practitioners can maximise positive and minimise negative clinical context.

Digging deeper: exploring chiropractors online claims about non-musculoskeletal disorders

Background

Some chiropractors suggest that chiropractic treatment is appropriate for health issues other than musculoskeletal problems. The prevalence of such claims on individual clinic websites has previously been reported as approximately one-in-four in Denmark. The underlying rationales for such claims may reflect convictions about traditional chiropractic subluxations paradigms, but are not self-evident and has not previously been studied.

Methods

An exploratory qualitative case interview study of Danish chiropractors with websites which contain claims about chiropractic efficacy in the treatment of non-musculoskeletal disorders. Websites were identified from a nation wide random sample (57%) of all chiropractic clinic websites.

Results

Of the original 139 websites, 36 were identified as mentioning non-MSK conditions. When revisited, 19 of those clinic websites still mentioned non-MSK disorders and were contacted. Eleven (11) declined our invitation to participate. Interviews were conducted with the responsible chiropractor from each of the remaining 8 clinics.

Five distinct themes were identified in the rationales for treating non-musculoskeletal disorders: ‘Positive side-effects,’ ‘Experience,’ ‘Web page,’ ‘Communication’ and ‘Conviction.’

Conclusions

A minority of Danish chiropractic websites suggest that non-musculoskeletal disorders are within the chiropractic scope of practice. Those that do, do so for varying reasons—poor communication and website maintenance were commonly cited problems. An explicitly stated adherence to traditional chiropractic subluxations concepts was uncommon. By contrast, a more tempered rationale that suggested a potential beneficial side-effect of chiropractic on non-musculoskeletal health issues were more common and was typically presented in softer-language and/or with some reservations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00407-z.

"Chiropractic is manual therapy, not talk therapy": a qualitative analysis exploring perceived barriers to remote consultations by chiropractors

Background

Remote consultations (RCs) enable clinicians to continue to support patients when face-to-face appointments are not possible. Restrictions to face-to-face care during the COVID-19 pandemic has accelerated a pre-existing trend for their adoption. This is true for many health professionals including some chiropractors. Whilst most chiropractors in the UK have used RCs in some form during the pandemic, others have not. This study seeks to understand the views of chiropractors not using RCs and to explore perceived potential barriers.

Methods

A national online survey was completed by 534 registered practicing UK chiropractors on the use of RCs. Respondents had the opportunity of providing open-ended responses concerning lack of engagement in RCs during the COVID-19 pandemic. Textual responses obtained from 137 respondents were coded and analysed using thematic analysis.

Results

The use of RCs provided an opportunity for chiropractors to deliver ongoing care during the COVID-19 pandemic. However, many chiropractors expressed concern that RCs misaligned with their strong professional identity of providing ‘hands-on’ care. Some chiropractors also perceived that patients expected physical interventions during chiropractic care and thus considered a lack of demand when direct contact is not possible. In the absence of a physical examination, some chiropractors had concerns about potential misdiagnosis, and perceived lack of diagnostic information with which to guide treatment. Clinic closures and change in working environment led to practical difficulties of providing remote care for a few chiropractors.

Conclusions

The COVID-19 pandemic may have accelerated changes in the way healthcare is provided with RCs becoming more commonplace in primary healthcare provision. This paper highlights perceived barriers which may lead to reduced utilisation of RCs by chiropractors, some of which appear fundamental to their perceived identity, whilst others are likely amenable to change with training and experience.

The Hypothesis of Biotensegrity and D. D. Palmer's Hypothesis on Tone: A Discussion of Their Alignment

OBJECTIVE

The purpose of this article is to compare D. D. Palmer's hypothesis of tone with the modern hypothesis of biotensegrity.

DISCUSSION

Although researchers have been using the hypothesis of biotensegrity for over 40 years to explain the mechanics of movement within biological systems, it has experienced revived support in the last 25 years. Biotensegrity as a concept is applied at the molecular, cellular, tissue, and organ levels, revealing a different understanding of the architecture of biological organisms. Biotensegrity offers a way of exploring the human body in the field of functional anatomy. The model has become popular among bodywork and movement practitioners, as it recognizes the wholeness of the human body. D. D. Palmer used tone to explain the origin of disease; biotensegrity, instead, explains why certain diseases may develop.

CONCLUSION

The concept of tone hypothesized by D. D. Palmer is different from the modern concept of biotensegrity. Although biotensegrity offers a different way of seeing how the human body functions, using it as a theoretical framework to explain the effects of manual therapies such as chiropractic may be premature. The use of the biotensegrity hypothesis requires further research and investigation before application in clinical settings.

Chiropractic students call for action against unsubstantiated claims

Background

The 2019 coronavirus pandemic is a current global health crisis. Many chiropractic institutions, associations, and researchers have stepped up at a time of need. However, a subset of the chiropractic profession has claimed that spinal manipulative therapy (SMT) is clinically effective in improving one’s immunity, despite the lack of supporting scientific evidence. These unsubstantiated claims contradict official public health policy reflecting poorly on the profession. The aim of this commentary is to provide our perspective on the claims regarding SMT and clinically relevant immunity enhancement, drawing attention to the damaging ramifications these claims might have on our profession’s reputation.

Main text

The World Federation of Chiropractic released a rapid review demonstrating the lack of clinically relevant evidence regarding SMT and immunity enhancement. The current claims contradicting this review carry significant potential risk to patients. Furthermore, as a result of these misleading claims, significant media attention and public critiques of the profession are being made. We believe inaction by regulatory bodies will lead to confusion among the public and other healthcare providers, unfortunately damaging the profession’s reputation. The resulting effect on the reputation of the profession is greatly concerning to us, as students.

Conclusion

It is our hope that all regulatory bodies will protect the public by taking appropriate action against chiropractors making unfounded claims contradicting public health policy. We believe it is the responsibility of all stakeholders in the chiropractic profession to ensure this is carried out and the standard of care is raised. We call on current chiropractors to ensure a viable profession exists moving forward.

Words matter: the prevalence of chiropractic-specific terminology on Australian chiropractors' websites

BACKGROUND

Chiropractors use words and phrases in unique ways to express traditional, chiropractic-specific theories. This lexicon represents concepts that reinforce the separation of chiropractic from other health care professions. It may impact referrals both to and from chiropractors, lead to public confusion about health care issues, and reduce cross-disciplinary research. Therefore, it is important to understand how prevalent chiropractic-specific terms are in publicly available media.

METHODS

Five chiropractic terms were selected: subluxation, adjustment, vital (-ism/-istic), wellness, and Innate (Intelligence). States and territories in Australia were proportionately sampled according to population of chiropractors using a Google search for chiropractors' private practice websites. The top results were recorded. Websites were word-searched on every publicly available page for the five terms. Context was checked to count only terms that were used to support a chiropractic-specific concepts. The number of occurrences of each term was recorded, tallied nationally and by state/territory. Descriptive statistics were applied to determine prevalence.

RESULTS

Three hundred sixty-nine websites were sampled, based on an estimate of 5500 chiropractors practising in Australia. Nationally, 85% of chiropractors used one or more terms. The term adjust (-ing/-ment) occurred most frequently, being found on 283 websites (77%) with a total of 2249 occurrences. Wellness was found on 199 websites (54%) with 872 occurrences; subluxation was found on 104 websites (28%), 489 occurrences; vital (-ism/-istic) on 71 websites (19%) with 158 occurrences; and Innate was least used, being found on 39 websites (11%) with 137 occurrences.

CONCLUSION

A majority of the Australian chiropractors sampled used one or more chiropractic-specific terms on their websites. Future research should explore the effects of chiropractic language on the public, policy-makers, and other health care professionals.

A cross-sectional study of website claims related to diagnoses and treatment of non-musculoskeletal conditions

BACKGROUND

The Danish Authorisation Act sets out the chiropractic scope of practice. Under this legislation the scope of practice is diagnostics, prevention and treatment of biomechanical disorders of the spine, pelvis and extremities. Despite this and an international movement toward a scientifically active, evidence-based profession with a focus on treatment of musculoskeletal disorders, a large proportion of chiropractors still offer treatment of non-musculoskeletal disorders. This study aimed to investigate the content and characteristics of website claims by chiropractors in Denmark on non-musculoskeletal conditions and to assess whether these were aligned with the Danish Authorisation Act of the chiropractic scope of practice.

METHODS

In this cross-sectional study data on a representative sample were collected from chiropractic clinic websites in Denmark. Information on non-musculoskeletal conditions from the websites was categorised. For each non-musculoskeletal condition, it was noted whether a clarifying explanation justifying the presence of the diagnosis was available and what it said. These explanations were assessed and categorised according to agreement or disagreement with the chiropractic scope of practice as defined by the Danish Authorisation Act. In addition, data on geographic location, clinic size, reimbursement coverage, country of education and special clinical focus (children, athletes, etc) were collected. Differences in characteristics of the clinics and the frequency of reporting non-musculoskeletal conditions were tested using Pearson's chi-squared or Fisher's exact test.

RESULTS

A geographically stratified, random sample of 139 (57%) websites was included from chiropractic clinics in Denmark. In total, 36 (26%) of the sampled websites mentioned conditions of non-musculoskeletal origin that was not accompanied by a clarifying explanation in agreement with the chiropractic scope of practice. A positive association between advertising infant or children's care and advertising treatment for non-musculoskeletal disorders (without adequate explanation) was observed.

CONCLUSIONS

A total of 36 (26%) of the sampled chiropractic websites in Denmark mentioned diagnoses or symptoms of non-musculoskeletal origin on their websites without presenting an adequate clarifying explanation in agreement with the chiropractic scope of practice as defined by the Danish Authorisation Act. This could be misleading for patients seeking care for non-musculoskeletal conditions and consequently lead to inappropriate treatment.