They are Bone Doctors, Aren’t They?

Chiropractors have an air of respectability about them. They style themselves, ‘Doctor’. They wear white coats and have brass plaques outside their offices with lots of letters after their name. My friends look at be puzzled when I say they are quacks. But that is what the evidence says. Their practice is founded on strange ideas about mysterious things called ‘subluxions’ and pseudoscientific beliefs in ‘inate intelligence’ running through our nerves and bones. We think of chiropractors as being for bad backs, but their founding beliefs state that cracking bones can be a panacea. You will still find chiropractors claiming treatments for all sorts of weird and wonderful things.

The evidence for the effectiveness of chiropractic is not good. What evidence does exist suggests it is just another placebo treatment. It might work for lower back pain – but probably no more than a couple of paracetamol. And the risks of bone cracking can be quite severe with deaths reported by stroke. More minor adverse reactions appear to be quite common.

In the UK, chiropractors can thank their regulated status for much of their standing and freedom from ridicule that other quackery attracts – like homeopathy. Chiropractors are statutorily regulated. You need to be registered to call yourself one. You can even call yourself Doctor as long as you do not imply that you are medically trained – but that is hard. Brass plaques. White coats. X-ray machines. My best guess is that most people think of chiropractic as a branch of medicine. It is not. It is quackery and a business.

Some times though we see them for their true colours. The New Zealand Medical Journal has just been threatened by a law suite for publishing research into how chiropractors (mis)represent themselves to the public by using the title ‘Dr’. Professor David Colquhoun wrote an editorial that put chiropractic deception into a wider context of their education and business practices. The response of the New Zealand Chiropractic Association was to get their lawyer to threaten to sue. The Medical Association has responded admirably by calling their bluff and asking for their evidence that what was being said is not true. “Let’s hear your evidence not your legal muscle.”

That is how it should be. As Ben Goldacre has responded, the real medical world is full of self-criticism – often very harsh. The way to respond is with science and argument – not with lawyers. Legal threats are a business technique, not the actions of medical practitioners. They expose their true self by calling their lawyers.

As Professor Colquhoun notes, since the invention of chiropractic, their business acumen has been sharper than their scientific and medical expertise. Consultancies on how to grow your bone crunching businesses are rife in the US. As Rose Shapiro notes, its all about building “high-volume, subluxation-based, cash-driven, lifetime family wellness practices.”

In the UK, we have similar chiropractors-turned-business gurus too. ‘Dr’ Terry Chimes, ex drummer with the Clash, is perhaps the highest profile. This year he has launched his ‘Chiropractic Heaven’ consultancy. Chimes promises to tell you the ‘The Secrets of the World’s Most Successful Chiropractors’. He does this over 120 weekly modules – all brimming with ‘golden nuggets of wisdom ‘. And he claims to be able to ‘Quadruple Your Practice in a Matter of Months. . . Ethically’.

Not all chiropractic business skills could claim to be ethical. Occasionally, the General Chiropractic Council of the UK is embarrassed enough to step in. In one case, a chiropractor was found to have “abused the trust of his patients, and coercing them, through alarmist scare tactics, into excessively protracted and unjustified treatment plans”. Chiropractic lends itself to such approaches: it deals with long term chronic conditions, such as back ache, uses mysterious and unverifiable X-ray diagnostic techniques to alarm customers, and recommends long courses of treatments. The chiropractor in question was accused of using unjustified courses of X-rays and misrepresented the gravity of the customer’s condition. The chiropractor was removed from the chiropractic register, but simply re-invented himself as a ‘osteomyologist’ – a sort of renegade and unregulated chiropractor in all but name.

It is amazing that all chiropractors cannot be charged with using unjustified X-rays. Since, their bone crunching cannot be showed to be medically effective, X-rays cannot be medically justified, and so applications of X-rays are in direct contravention of IR(ME)R regulations which demands medical justification for all exposures. One has to wonder how chiropractors get away with X-raying patients. One factor must be is that statutory regulation of chiropractors directly lead to their inclusion in the list of health workers who were allowed to refer for X-ray. Not that means that their referral is likely to be justified.

Such are the perils of regulating nonsense.

On this theme…

46 Comments on They are Bone Doctors, Aren’t They?

  1. Even if their bonecrunching can be shown to be medically effective, are their “subluxations” actually detectable on X-rays?

  2. According to Ernst they aren’t:

    “Many chiropractors employ X-rays for diagnosing ‘misalignment’ or ‘subluxation’ of the spine, although mainstream scientists have demonstrated experimentally that ‘subluxation of the vertebra as defined by chiropractic…does not occur’.”

    -snip-

    “The validity of chiropractors’ X-ray diagnoses is not well established. Small vertebral displacements or malalignments have no proven clinical relevance, dynamic studies have no proven value, and plain radiographs yield little relevant biomechanical information…..In conclusion, the current, albeit incomplete, data suggest an overuse of spinal radiography by the chiropractic profession.”

    http://bjr.birjournals.org/cgi/reprint/71/843/249.pdf

  3. If I may answer for Andy, I thought it manifest in his article what he thought of osteopaths. If he is scornful of the branch of bone manipulators that is closely regulated despite being evidence free as for efficacy then can’t guess what he thinks of a completely unregulated group of bone manipulators using an evidence free technique?

    BTW I have scientific speciality in physiology, anatomy and musculoskeletal systems so try me.

  4. Osteopaths are regulated in very similar ways to chiropractors. I see them as very similar just without the guts to crack bones.

    • Osteopath’s and chiropractors are not what they were.
      The general osteopathic council and general chiropractic council have regulated the teaching to death

  5. Over the last 17 years I have been to 5 different Osteopaths.
    The first time I went was when I pulled my back whilst lifting a washing machine. At the gym I went to at the time the owner recommended I see a physio or an osteopath, but not to go to a chiropratictor, unless I didn’t walk again.
    I went to an osteopath as there wasn’t a local physio I could get by bus.
    When I first visited the osteopath he explained what it could do, and what it couldn’t do. Basically he saw it as helping with bad backs, pulled muscles.
    Osteopaths use gentle stretching and massage to promote mobility. After 3 visits I was fully mobile and didn’t go again until I put back when lifting a heavy weight 4 years later. Again 3 visits and all was OK.

    When I moved a few years ago, I did my back in shifting the boxes and went to a different osteopath. This guy to be frank was odd, eg all exercise is bad for you! Also he was a natruopath, which I have since found out what that involves. This guy kept on wanting me to return again and again and I decided to change to another one, and she has the same outlook as the original guy I saw.

    She sees treating bad backs as a good thing,and if that is all osteopathy is good for, then that ain’t a bad thing. She said you have to know your limits.

    Interestingly she is the first osteopath who did some work on my neck as I had ricked it and a shoulder when lifting logs. She took nearly 5 minutes to twist my head around and at no time did she use violent movements to twist it around. This time I only needed 2 visits.

    A work collegue pulled his back at around the same time I had trouble after the log lifting. He went to a chiroprator twice a week for 7 weeks with no real improvement in his condition. He couldn’t make any appointments for a couple of weeks and during that time he improved so much that he didn’t make any more appointments.

    The osteopath charged me £30 a session, the chiropractor charged £65 a session.

  6. Nash, up here the orthopaedic dept at the hospital runs a sort of triage service via the NHS physios. Your sort of problems you go see your GP, get given a form, ring up make appointment and go. It is free. Why pay an osteopath?

    I have been put back together again by physios more times than I care to remember and never paid for it once.

  7. I’m going to add something here – and, in doing so, I’m going to be skating on very thin ice. As an osteopath (small ‘o’, and a Mr. to boot – but I NEVER let people think I’m a surgeon!!!) I’m tarred with the same brush as the chiropractors, but only in the same way that a manipulative physiotherapist is. Broadly speaking, on a VA scale you have non-manipulative physio in the left corner, chiroqaucktors in the right and I fit somewhere in the middle.

    Now, I’m a bit of a professional let-down for my peers – largely due to the fact that I work full-time for the NHS and, more recently, due to my blog.

    http://jonathanhearsey.com

    For the NHS I have a strict brief where I practise only where (limited) evidence says I might be a reasonable alternative (see my blog). This has worked well for the last 12 years.

    At the risk of distancing myself further from my peers I really must agree with the main ‘thrust’ of this post (ignore the pun). Chiros have always had the upper hand on the commercial front – it’s in their blood. As CAMs ‘develop’ there is always the chiro-example-of-success to spur them on. I see a growing trend of a more commercial-bent to modern CAM practitioners and this scares me more than the lack of evidence that their disciplines have. With commercial success comes the delusion of power and with this delusion comes the wealth of protection borne from the association with lawyers, accountants and other such professionals.

    To me, science is like the debating society at school – you argue during the lunch-break but are friends when the bell goes for double maths. Chiropractors in NZ are not playing the game – they don’t want to debate, they just want to steel your curly-whirly and give you a wedgy. Why? Because they can.

    Keep these posts going – and please support the quacks that do know their place.

    JH

  8. @ Peter in Dundee and Nash

    At West Sussex PCT we run the same triage service. GP – ESP (for triage) – Physio OR Osteo. It works really well. I (the osteo) ONLY treat conditions that the ‘science’ says I ‘might’ be good at and, with an open passage of communication the service is a fantastic one. I have all but finished with private patients now so I agree – ‘why pay an osteopath’.

    There needs to be some control though – I do not take on patients that just want free ‘whacky-quackery’ though – that wouldn’t be right. Low backs and necks – not a subluxation in sight!

    JH

  9. So what do you guys think of Cranial Osteopathy especially in babies and young children. And forgive me but I thought that there was a recognised qualification here as an osteopath – taught at London College Of Osteopathic Medicine just outside of Marylebone station and at the European College of Osteopathy in Maidstone Kent that was recognised/established here and isn’t it recognised in the US with the DO qualification? – please if I am wrong then correct me, my nephew was born at 28 weeks and has significant health and development problems and it’s something we as a family have looked at.

  10. @ Anon (re. Cranial Osteopathy)

    Not wanting to hijack this post so I am happy for us to have this conversation via email (use your savvy and you’ll find my address) but, to parents in your position I always say the same.

    Trust the opinions of your MEDICAL advisors.

    Good luck,

    JH

  11. Anonymous, just because there is a college teaching something is no guarantee that that thing is valid. Remember, there are still NHS homeopathy hospitals and that is just sympathetic magic gone haywire.

    I am not familiar with physio training in this country but back home in NZ it was university based. In my dept, physiology, the physios did the same as the science students. The cadavers for anatomy, the arms and legs below the shoulders and hips were reserved for the physios, the medics weren’t allowed to touch them*. So they are educated in a medical school environment. I would be most surprised if the osteopathy colleges you mention could match that.

    *this is in part why you don’t ask your GP which muscle you have pulled. You just ask to be referred to a physio.

    Bear in mind that the heads of infants are plastic and designed to deform during birth and they can take some time to reshape. Head binding is practiced in some cultures and apparently does no harm, but why medicalise a normal process?

  12. Cranial Osteopaths? What do I think of them? Well it depends on which type you see. The two types are: (a) deluded idiots ; (b) fraudsters.

    Cranial osteopaths believe they can feel pulses in heads and these pulses relate somehow to health. In studies, CO’s have been unable to agree between themselves about what they ‘feel’. It looks like pure pseudoscientific gibberish.

    Plus, as has been noted, children’s’ skull bones may not yet be fully fused. Bargepoles spring to mind.

  13. I am not sure that I would want to be referred to someone who calls himself a quack. Knowing your place in the system is fair enough but to call yourself a quack…
    Or I didnt I get the joke.
    Surely the money would be better spent on an NHS physiotherapist then?

  14. Cranial Osteopaths are deluded idiots or fraudsters in the opinion of the black duck. Osteopaths in the black ducks opinion are quacks. Does this mean that Osteopaths are also deluded idiots or fraudsters or are they just quacks?
    I cant quanitify the difference between a deluded idiot, a fraudster and a quack. Any equations would be helpful.

  15. Deluded or fraudsters? That is one of the most fascinating and probably unanswerable questions in quackery. Knowing people’s genuine motivations is always hard.

    Take, for example, the homeopathic ‘pharmacies’, Ainsworths, Nelsons etc. There must be people there, doing a job, that know that stuffing little while sugar pills into a bottle is a nonsense. All those magical concoctions: hyena saliva, shipwreck, light from venus, eel serum etc. Do they all really believe such stuff? Are they happy just to collect a wage? Or is there a genuine passion for magic voodoo pills? Who knows?

  16. Most of the dispensary staff at the main Pharmacies are homeopaths.
    Many have given up a well paid job having had some sort of experience with homeopathy and they believe in what they are doing. Most are ok that homeopathy cant be explained other than by placebo as they are happy with their experiences.
    Others know that there is a need for some evidence base other than anecdotes and that that some scientists will take the piss and that there will be changes. In France and Germany things are different but that doesnt help much here.

    Remember though there are a lot of the public who will never listen to placebo arguments as they exercise their right to believe in homeopathy.
    Most orders are boringly classical ie Nux Vomica 200c , Pulsatiila 30c ect. There arnt many orders for remedies like Venus light and Shipwreck but a few homeopaths have been experimenting with these inponderables for some time.
    By law people are entitled to their beliefs . This section of homeopaths see the world in their own spiritual way and they treat people who see the world as they do. They are not defrauding anyone as all patients are usually referred by word of mouth. Remember most homeopaths treat through referals. Very few contacts are through Yellow pages.
    I would rather be called delusional than a fraudster although fraudster almost sounds better.
    If I could take up your £100 challange and win I would argue with you more.

  17. @ JohnChemist

    I don’t get your point? If you are comparing homeopathy with osteopathy then you are clearly misinformed.

    Furthermore – don’t put cranial osteopathy in the same bag as osteopathy. There really is no comparison.

    CAMs and quacks are not all idiots – you might remember this.

    Take a look at my blog

    http://jonathanhearsey.com

    (sorry, Andy – another plug)

    Read the blog – skip the useless, self-indulgent bits. You might get a different opinion of what some of us are trying to achieve.

    Then, and only then – take a look at some ‘way-out’ CAM sites and look at the crap that they are pushing. You can see the problem that some of us face.

    JH

  18. i dont think all CAM practitioners are idiots.

    I know some very successfull Osteopaths locally who practice cranial Osteopathy and get loads of referrals for cranial Osteopathy and have hugely successfull practices and are highly regarded locally.

    I dont think Osteopaths are quacks.

    I dont know much about Chiropractors

  19. Le Canard Noir wrote
    What is stopping you taking up the $100 challenge?

    The Black duck challenge should be done- or at least some research done along these lines-That is a personal opinion that may not go done well with everyone. Remember that I dont speak for homeopaths or any company or group. The homeopaths involved with provings want nothing to do with challenges from sceptics at present as far as I know. There is just total mistrust and suspicion. Any group called quacks and fraudsters by another group is going to get defensive and suspicious. The more nasty the attacks then the more defensive and the less likely the group is to have anything to do with such challenges.

    I would prefer to test for any potential small temperature changes in humans on taking remedies. Say 10 bottles all coded with 9 being ‘placebo’ and 1 being a remedy.

    I have access to the equipment but no funding and I have no mandate to go ahead. Many would say it was all pointless- but I disagree.

  20. This is off topic – but interesting.

    Sceptics often call homeopaths fraudsters or deluded precisely because they will not subject their claims to objective levels of testing. When such tests are so straightforward, one can only be suspicious. By showing simple tests work, like the one I have suggested, there could be no more accusations of deceit.

    The simple fact is that homeopaths will not engage in any simple test that could show their beliefs to be wrong. They will not countenance the idea that their convictions are mistaken. That charge cannot be levied at sceptics who would willingly subject their beliefs to test – as I a doing by proposing this challenge.

    And, JohnChemist, I must include you in that group who will not test. You have access to resources, equipment and people. You do not need ‘a mandate’. You do not need cash. Just volunteers and time. It would be no more trouble than organising a cake stall at a village fete. My guess is though that your colleagues would do everything in their power to stop you.

  21. JohnChemist – do you not have a will of your own? Are you beholden to your ‘superiors’? You know full well that the HRI will not commit to a unambiguous test of homeopathy and that the Faculty of Homeopaths would never dare risk killing the goose that lays the golden eggs of royal patronage.

    My test requires a single brave homeopath to commit to it. Your faith in the homeopathic groups is thoroughly misplaced. They all have too much to loose by such a test – and I guess they know they will fail. That is why it is quite appropriate to use words like fraudsters.

  22. Yes. I am beholden (thats a good word) to my superiors and I know my place- what am I doing here though?
    I have faith in those groups to provide evidence and it is up to them. You only started asking the $100 question this year so you will have to wait. As you know this cant be rushed.
    This has to be done properly as I am sure you will agree.
    Should this answer make you angry, could I suggest Staphisagria 10M – Oh and Rescue Remedy

  23. Well we have had 200 years for homeopaths to come up with some basic evidence of their beliefs. I guess another century or two will not change anything. In the meantime, homeopaths are incompetent and/or fraudulent.

    I thought for a moment you might want to take up the challenge. But John, you have come up with the best excuse so far. ‘You know your place’ and your place is not to question authority (or your employers).

  24. I would love to do the test black duck but I have no experience of research or provings. It has to be done through the right channels.
    Lets leave it to those who have taken up the research mantle.
    You can call me what you like, but I have every confidence that no reasonable person would call any director of the HMI incompetent or fraudulent.
    You have already made up your mind on
    Homeopaths- quacks
    Osteopaths-quacks
    Chiropractors-quacks
    Reflexologists-quacks
    Acupuncturists-quacks
    Herbalists-You tell me-Half a quack?
    Oh dear the duck has quacked rather a few times too many. People can now rather easily make their own mind up about you.
    You persistently use insults like fraudulent and incompetent to describe large groups of people that you disagree with. Some may consider that it is yourself that you are in fact describing.

  25. I would suggest that alternative medicine is the new type of religion – you need something to believe in, it used to be god but he is now old hat – if the placebo effect helps some people then great. Maybe Andy is a heretic to you John but there are too many sellers of snakeoil out there who are all too ready to take your money, money that some of us can ill afford, but if you have a sick child then you want to believe. Its interesting that the biggest followers of alternative medicine are middle aged, middle class women, its like any business – if there is a demand then there will be a rise in supply. If in taking recommendations from a nutritional therapist for example would the general public know that under the BANT code of ethics that the nutritional therapists is allolwed to take a commission from the supplements they sell?
    I think we are still blinkered with regard to alternative medicine, if it works then great fantastic – but it should be shown to work and any trials should be able to be reproduced and substantiated. Why should we expect anything less than this.

  26. I must clarify this bit:
    Osteopaths-quacks

    On the other side of the pond in the USA osteopaths have taken a different path. The schools of osteopathy have moved away from spinal adjustments and towards real medicine. So much so that that now in the USA osteopaths with an “OD” after their name get board certified and practice medicine very much like those who have the letters “MD” after their name.

  27. HCN

    I’m not entirely sure that your argument holds much water really. Using US osteopaths whom ‘practice medicine very much like those who have the letters “MD” after their name’ is a dreadful example. How is that a good thing?

    If I (a UK Osteopath) was going to be bothered to do all that study I’d probably become a ‘proper’ medic. Your example is a close to the true definition of the term ‘quack’ as you can get!

    Osteopaths that use physical therapy techniques for simple low back pain are similar to manipulative physiotherapists and we work very closely, just in slightly different ways. There is evidence to suggest that we are just as good (not better) and that is that. Osteopaths that do ‘other’ things might fit in to your ‘quack’ group but osteopaths, pretending to be MDs – I’d rather eat my left arm than see a ‘pretend’ medic rather than a real one!

    UK Osteopaths that perform evidence-based therapy in a consultant lead environment = Quack? (Are you sure?)

    US Osteopaths that are ‘much like’ medics = ? How about YOU do the MATH???

  28. HCN

    Not wishing for another teenager style response, your point is?

    You are right that the DO’s in the US are different – I know that. My concern is that I think that they really are an ALTERNATIVE to MDs.

    Just because it is fact in the US does not mean that it is a GOOD thing.

    (Don’t get me, and others no doubt, started on the US)

    JH

  29. In response to
    ' Even if their bonecrunching can be shown to be medically effective, are their "subluxations" actually detectable on X-rays? '

    Spinal Haematoma's are not directly detectable on x-rays, does that mean they don't exist? Of course not, by the same account, just because movement disorders are not detectable on static films does not mean they can not be detected in other ways

  30. HCN:
    The whole point of osteopathy was that the man who created it lost his family because of the failure of the (at-the-time) incompetency of then-modern medicine. US osteopaths are not true to the original beliefs of a holistic profession. One of the principles is that the body has the ability to heal itself, without having medicine imposed. The doctors in the US are doctors with an osteopathic qualification, not osteopaths with a medicinal degree, so they're XXX MD, DO. Sure they help in different ways, but US and UK osteos are 100% incomparable, in the same way that osteos and cranial osteos are.
    Black Duck:
    Chiropractors and Osteopaths share a history, the most famous intersecting arguement being that of Palmer (father of Chiropractic) was accused by Still (father of Osteopathy) of copying his practice and altering it to call his own form of medicine. Osteopaths use much the same techniques as Chiropractors, so I think you'll find that we *do* have the guts.
    Peter:
    As an Osteopathic Student, my course may not be on campus, but is regulated by Surry University and we DO use cadavers using our contacts in St George's medical school – like other schools of osteopathy.

    It's wrong to say that there is no evidence for osteopathic benefits to treatment. Read a book like Kuchera and Kuchera – "Osteopathic Considerations in Systemic Dysfunction". Although written by an American osteopath and as such, suggests using medicine to treat patients, the references contain the real gems, being research articles detailing the conditions that can be treated. It's as simple as instigating a physiological reaction just by touching their skin with yours.

  31. Matt D – perhaps you would like to reconcile your statements that US and UK osteopaths are '100% incomparable' with your attempt to use a US osteopathic text to justify UK osteopathic practice.

  32. Black Duck – As I stated, it's the research articles that are important, not the book, nor the source of which, to which I'm referring.

  33. As a student of anthropolgy in possession of a degree in sociology and (three weeks hence) marketing I am more skeptical of statistics than I am of what works for me. What’s more, the ridiculous reactions of allopaths (yes, that’s a jab) to my wife’s excellent experiences with midwifery versus her terrible experience with hospital birth serve to deflate my confidence in the medical profession. My experiences with MDs are consistently negative and my experiences with other practitioners are consistently positive. How does each profession handle the common cold?

    Nutritionist – Recommends eating foods that break up mucus and improve immunity, like grapefruit. Also recommends removing mucus-forming substances from the diet (like dairy and flour) and drinking plenty of water to aid renewal of fluids.
    Holistic – Rinse your sinus with a neti pot of salt water, which loosens and removes mucus and hydrates your sinus. Instant results, but must be repeated. Also recommends drinking plenty of water to balance humors.
    Herbalist – Breathe steam of steeping mint. Clears sinus instantly, opens sinus cavity and clears eustachian tubes. Feels great; must be repeated. Also recommends drinking plenty of water to speed mucus elimination.
    Chiropractor – Adjust cervical spine to reduce tension in the neck and improve autonomic nerve response in sinus and eustachain tubes. Also recommends drinking plenty of water to replace spinal fluid and waste bound in the muscle.
    Medical Doctor – Mucinex to dry out your mucus membranes. Enjoy your sinus infection. Also recommends drinking plenty of water so you don’t get dehydrated. (To be fair, it is not the MD’s fault that no one ever drinks plenty of water without a more mystical explanation.)

    I could tell you about how the last 7 times I went to a doctor they couldn’t solve the problem when the alternative practitioner I visited afterward solved it instantly, but It’s all moot since my wife became a certified herbalist. We haven’t had anything more serious than vomiting from food poisoning (from not practicing what we preach and ordering Panda Express). We still believe Doctors are good for surgery–that’s their specialty–but if I need anything non-invasive, I prefer not to get a prescription for something Merck advertises on an MD’s notepad… or a surgery when manipulation will do.

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