Confessions of a Quackbuster

This blog deals with healthcare consumer protection, and is therefore about quackery, healthfraud, chiropractic, and other forms of so-Called "Alternative" Medicine (sCAM).

Friday, September 22, 2006

There is a big difference between an adjustment and a manipulation

Here I comment on an email from Paul Giles


> My view has been the same with regards to bone out of place, pinched
> nerve, disc slipped out etc...if this truly happens then it is rare,
> i.e 1-5% of all spine cases. Additionally, I agree that subluxation
> is not an appropriate term for chiropractors because it implies a
> semi dislocation...manipulation would only make it worse if applied!

You're on to something there.

There is a big difference between an adjustment and a manipulation, which is not a physical difference,
but a philosophical one. The results may physically be very similar, but the perception of results because
of mental manipulation can have life-long consequences for the patient's desire to continue chiropractic
care, even in the absence of any symptoms or disease processes.


DCs like to make the artificial distinction, that they are the only ones that can "adjust", while all others can
"only" manipulate. Philosophically speaking (from a DC's viewpoint), this is true, since a chiropractic
"adjustment" is for the purpose of "correcting a subluxation". This is a purely chiropractic delusion. This
delusion has been perpetuated by it being made the legal umbrella under which DCs work.

A manipulation by an MD, PT or DO, on the other hand, is not performed for the purpose of correcting a
non-existent entity. Therefore it certainly does not, and never should, get any priority or legal status as a
method for the "correction of subluxations"!

DCs (usually young, newly educated ones) who derogatorily speak of other's ability to "only manipulate", are
guilty of at least two faults:

(1) they overrate the usefulness of "adjustments"; and

(2) they reveal their ignorance of what other professions can do, why they do it, and especially, when and
why they DON'T do it.

The "service" of manipulation of the spine "to correct a subluxation" is a service that only DCs claim to provide.
PTs & MDs cannot and will not contribute to this deception. It is also an unnecessary extra expense and risk for
taxpayers, insurance companies and patients. The wording, "to correct a subluxation", should be removed and
replaced with some real diagnoses, for which spinal manipulation can be helpful as a part of legitimate,
scientific therapy.

The artificial distinction between "adjust" and "manipulate" is not consistently upheld by DCs. The term
"manipulation" is often used by them. The reason for this ambiguity lies in something more than the words. In
reality, they would like to eliminate any other profession's right to "manipulate" or "adjust", call it what you
will, for whatever purpose. Exclusivity is the issue. They want a patent on the use of all manipulative techniques,
especially HVLA.

There's much more on this page.....


> However...
> Biomechanically, chiropractic adjustments look to break adhesions
> within the joint capsule. This restores functional mobility. There is
> also suggestions that there may be the release of trapped meniscoids
> within the joint capsule following an adjustment?

These are indeed some of the theoretically possible explanations for what really is happening. I don't know how
much evidence there really is for them, but don't have any problem with the adhesions one. As far as I know of,
there has never been found evidence for a trapped meniscoid, even after all these years with CT and MRI scanning.
I personally have some other ideas on the subject. Things like reflex relaxation of local, tensed muscles ......Just
another possibility.

My problem with traditional chiropractic's use of and explanations for adjustments, as currently taught in most schools,
is that the claims are too great. There is still no proof that adjustment/manipulation impacts any organic disease process
or improves health in any way. (See the NACM statement further down in this mail.) That it actually does provide relief
for neuromusculosketal ailments here and now, is another matter. No problemo. But I can achieve many of the same
results without using manipulation, even though I can and occasionally do perform it. While chiropractic does "equal"
adjustments, by their own definitions, manipulation does not "equal" chiropractic. There's plenty of research on
manipulation, but that's not the same as proof for or against chiropractic. Manipulation is done by DCs, MDs, DOs,
and PTs. While DCs should be experts at it, it's actually not as essential or important as they would like us to believe.
The same problems can often be dealt with without the use of manipulation, and by other practitioners.


> Neurologically, the chiropractic adjustment



> ......stimulates
> mechanoreceptors in the facet capsule and localised muscle
> spindles/golgi tendon organs from muscles such as intertransversarii
> & rotatores (these muscles have been shown to so small that the
> force they generate is quite minimal). Their role is more
> proprioceptive and may therefore act as motion and position sensors
> within the vertebra. Your could add the sub occipital musculature for
> the atlas/axis/base of skull (C0-C1-C2 complex). Muscle spindles are
> extremely dense here and this might explain the results/changes
> chiropractors have with certain patients with regards to dizziness,

I suspect that you're probably referring to muscular tension and related stiffness in the neck, which then
causes referred pain and these symptoms in the head. Treatment of the muscles can effectively provide often
immediate relief, even without using manipulation. Since the neck is a very sensitive area, manipulation of
this area is also the type of manipulation most fraught with danger. "The literature does not demonstrate
that the benefits of MCS outweigh the risks." (below)

Precisely dizziness can be a sign of impending disaster, if the dizziness follows the adjustment.

For a bone-chilling account of watching the beginning of death on a chiropractor's table, click here and
turn on your speakers. It's the mother of the now dead patient speaking:

More here:

Of all the chiropractor-induced injuries I've seen in my practice, spinal compression fractures and spinal stenosis
(from a swollen spinal cord) have potentially been some of the worst. Not a pretty picture, and impossible to "repair".
Manipulation of the spine is not only rarely necessary in patients of all ages, it is decidedly risky in older individuals.
This applies, no matter who does the manipulating: DC, PT, DO, or MD. PTs usually consider it contraindicated in
elderly patients.

The results of DC's attitudes towards the use of manipulation in patients of all ages are reflected in the following
statistics. A summary regarding the cervical spine follows here:

"Manipulation of the cervical spine (MCS) is used in the treatment of people with neck pain and muscle-tension headache.
The purposes of this article are to review previously reported cases in which injuries were attributed to MCS, to identify
cases of injury involving treatment by physical therapists, and to describe the risks and benefits of MCS. One hundred
seventy-seven published cases of injury reported in 116 articles were reviewed. The cases were published between
1925 and 1997. The most frequently reported injuries involved arterial dissection or spasm, and lesions of the brain
stem. Death occurred in 32 (18%) of the cases. Physical therapists were involved in less than 2% of the cases, and no
deaths have been attributed to MCS provided by physical therapists. Although the risk of injury associated with MCS
appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be
avoided with the use of mobilization (non-thrust passive movements). The literature does not demonstrate that the benefits
of MCS outweigh the risks. Several recommendations for future studies and for the practice of MCS are discussed.
[Di Fabio RP. Manipulation of the cervical spine: risks and benefits." (Physical Therapy 1999;79:50-65.)

The graphs are interesting, especially Figure 2:

... where the type of practitioner was adjusted according to the findings by Terrett. PTs were involved in less than 2% of all
cases, with no deaths caused by PTs. DCs were involved in a little more than 60% of all cases, including 32 deaths.

Before adjusting the numbers according to the findings by Terrett, it looked like DCs were involved in more cases than
was actually the case. The revised figures made DCs look a very little bit better, but were still far too high. A casual
glance at these numbers could lead to the partially incorrect conclusion, that manipulation, when performed by a
chiropractor, is much more dangerous than when performed by other practitioners. No, that would not be entirely
correct. They should be seen more as a reflexion of the fact that manipulation is most often performed by DCs.

Regardless of who performs the manipulation - the more it gets done, the greater the risk. Sooner or later someone is
going to get hurt. It needs to be used much more judiciously, by whoever it is that uses it, than most DCs use it today.
If a PT or MD were to use spinal manipulation in the same way, extent and frequency that DCs do, they would be exposing
their patients to the same risks that chiropractic patients are exposed to every day. The statistics would then reveal
more injuries from PTs and MDs.

While the technique itself is potentially problematic, the attitude of most chiropractors towards it makes it doubly so
when applied by them.


> ..... jaw pain, facial pain and of course headaches & migraines (not to
> mention whiplash).
> Perhaps a better way of explaining chiropractic would be that
> chiropractors look for and feel joint dysfunction or joint
> restrictions. They adjust these restrictions. This would active joint
> mechanoreceptors, muscle spindles and GTO's.(and inhibit
> nociception). If joint dysfunction is removed then the
> motion/position sensors in the joint and musles would send
> proprioceptive information to the brain. When the joints are
> restricted in movement these motion sensors may well be silent? Other
> joints in the body may work harder to overcome this restriction?
> You say the very idea of "adjusting" and "realigning" the spine
> is not supported by
> spinal anatomy or pathology.

I can see that I didn't word that very carefully. I was referring to the idea of bones being out of place, and being pushed back place. Likewise disc herniations being pushed back in place. Believe it or not, these claims are made all the time by many DCs. I've even seen brochures that exploited the expression "slipped disc".

The use of the very inaccurate expression "slipped disc" in ordinary speech, instead of the more accurate "herniated disc", is a good example. Chiropractors have capitalized on this misnomer for years, indoctrinating (brainwashing) their patients into believing that chiropractors could push it back in place again.

Chiropractic patients often believe that when the back is "out of alignment" it is out of joint - the dreaded BOOP (bone out of place). That cannot happen without a fracture or severe joint destruction (and then manipulation/adjustment would be absolutely contraindicated). It is most likely tense and/or cramped muscles that are pulling it "crooked" (temporary scoliosis). If the muscles are treated with warmth, massage and stretching, and often combined with the use of joint mobilization - presto, the back is now "aligned" again. (Not that it ever was out of "alignment.") Thus there is usually little or no need for manipulation/adjustment.


> Yet research now by chiropractor Chris
> Colloca and co are showing the neurological basis behind spinal
> adjusting. New research is supporting manipulation/adjusting,

But not for anything outside the neuromusculoskeletal system.


> .... so much so, that physiotherapist are learning manipulative techniques (as are
> some GP's/medical doctors). The major chiropractic mechanisms are
> neurological.

Even if they were, they are usually very temporary reflex effects.

> [Please cite some of the relevant peer-reviewed references. Incidentally,
> manipulation is by no means new to physiotherapy, since some of the most
> definitive work in manipulation and mobilisation has been carried out for
> many decades by specialists like Maitland. Medics have been doing manipulation
> for as long as any other therapists, especially orthopaedic surgeons who for many
> decades have been doing major manipulations under anaesthesia. The history
> of manipulation among osteopaths may be even longer. Mel Siff]
> I hope this offers a better, more objective (& upto date) evaluation
> of chiropractic science? Perhaps chiropractors should look at the
> research too & level outdated slipped discs, bone out of place
> explanations behind?

I appreciate your comments, Paul (Giles)....great name there! You, like myself, can see that
manipulative therapy does have its place, but that the chiropractic profession has a problem
that needs to be dealt with.

The following excerpt is from the National Association for Chiropractic Medicine (NACM) website.
It is refreshing and the web site is well worth reading in its entirety. It states in no uncertain terms
the core weaknesses in traditional chiropractic and proposes ways to move forward:

"The National Association for Chiropractic Medicine (NACM) was founded in consumer advocacy. Most
professional associations are formed to further the interests of the professional individuals forming the
organization. Members of the NACM believe that the interests of the public must come first over the
interests of the professionals making up the association. Associate members believe that, in serving
the public interest, they will be working toward a better profession, which, ultimately, will further
their professional/personal goals.

"The first and foremost requirement for membership in the NACM is that a Doctor of Chiropractic Medicine
renounce the chiropractic hypothesis and/or philosophy; that is, the tenets upon which their scope of practice
is based. The original chiropractic hypothesis, stated simply, is that "subluxation is the cause of dis-ease."
Modern day chiropractic associations may have expanded and changed this simple statement for the public, but
the reality is that this remains the backbone of chiropractic education and practice to this day. In clarification,
the term "subluxation" has never been defined by the profession in a way as to have universal acceptance within
the chiropractic profession. Chiropractic "subluxation" is not the same as medical subluxation, which represents
a partial dislocation of joint structure and would be a contraindication to "adjusting" or "manipulating" the joint
structures. Chiropractic "subluxation," not having universal definition, and, thereby, not having received
universal scientific status of existence, has evolved into a metaphysical status. Further, the profession has neither
defined nor outlined what disease or "dis-ease" that the correction of the "subluxation" might cure or affect.
Because the hypothesis has found no validity in universally accepted, peer-reviewed, published scientific journals,
belief in the hypothesis, then, is essentially a theosophy. Science has not found any organ system pathology which
"adjustment" or "manipulation" of spinal joint structures has effect; that is, no disease or "dis-ease" process
is affected."

"For these reasons, members of the NACM renounce the chiropractic hypothesis as a basis for their scope of practice.
NACM members accept the scientific fact that "manipulative procedures" ("adjusting" spinal segments) has scientific
validity simply for affecting joint dysfunctional disorders. NACM members confine their scope of practice to the
treatment of joint dysfunctional disorders, which include the biomechanics of the human frame, posture, weight
bearing and gait, and the pain or discomfort concomitant with this dysfunction which may result in excessive "wear"
of these joint structures. NACM members do not consider themselves to be an "alternative" to scientific medical care
and attempt to work closely with medical/osteopathic professionals. NACM members do not consider themselves to be
"primary care" practitioners, as this would necessitate the training and ability to therapeutically impact any health
care need of the consumer. NACM does not believe chiropractic education nor license to practice encompasses this
scope of practice. NACM membership practitioners are "portal of entry" doctors, in that the consumer does not
need referral from any other type of health care professional." (All emphasis original in the HTML version
on the web site.)


I'll leave you all with these well-written words from a sensible chiropractor:

Dr. G. Douglas Andersen, DC, DACBSP, CCN

Last fall I read an article that blasted the Research Agenda Conference IV (RAC IV) because Dr. Ian Coulter recommended
that our profession abandon the antiquated subluxation theory. The article said that 90% of those in attendance agreed
with Dr. Coulter. I was very disappointed I missed the conference. It made me happy to know that there are those in
leadership positions who realize that our profession's survival in the next century must be based on science.

Even though people like Don Petersen plead for chiropractors to work together, the differences may be too great for one
profession. Our profession is so diametrically opposed in so many areas that a split may benefit both camps. Imagine how
hard it is for a wellness chiropractor to convince a new patient that they need 20 treatments a year when that patient's
previous DC had a "treat and release" practice.

Conversely, how many thousands of people have been turned off by those who practice with a "philosophy" geared toward
overutilization driven by greed? Where is the literature to support the "catastrophic effects" the vast majority of the
people on this planet supposedly suffer because they are not receiving regular manipulations? Where are the insurance
studies to prove that people who go to the chiropractor 15 or 20 times a year, whether they have pain or not, have fewer
injuries, less illness, longer lives, or lower health care costs?

When I consult a new patient, I have to waste valuable time to inform them what kind of chiropractor I am. I have to
tell them that :

- I don't take x-rays unless a history and examination indicates they be performed.

- If I do take x-rays, they will not be used as a marketing tool.

- I will not manipulate their asymptomatic neck to relieve the symptoms in their lower back.

- I do not diagnose nutritional deficiencies by having them hold a vitamin while pulling their arm.

- I will do everything indicated, including numerous types of soft tissue therapy and modalities, to eliminate their
discomfort as soon as possible.

- I will not try to brainwash them to bring in their asymptomatic family members.

- I will try to educate them about diet, lifestyle and exercise to prevent a recurrence of their problem.

- I will inform them that if I cannot help them, I will find a health care professional who can.

I understand there are many who feel that a "real" chiropractor would not practice this way. Fine. If being a real
DC means wellness care, asymptomatic care, excessive x-rays, poor working relationships with MDs, rejection of
scientific data, bizarre techniques, outrageous claims, and the same treatment each visit regardless of the problem,
then I don't want to be a "real" DC.

The only thing "real" DCs and I agree upon is that we would both like the public to look at our title and have an idea of what we do. Maybe all DCs would benefit if those of us who reject pseudoscientific subluxation-based philosophical chirobabble (designed to addict the world to manipulation) had a different title. I would proudly introduce myself as a medipractor, a treatipractor, a physical medicine therapist, a doctor of chiropractic medicine, or whatever it would take to inform the public there is a basic difference.

In any profession, there will be differences in how one approaches various conditions. Generally speaking, healthy scientific debate benefits both patients and clinicians. However, I fail to see any common ground between those who try to see each patient as many times as possible, regardless of symptoms, and those who see each patient as few times as possible to eliminate symptoms. Maybe the best way for both sides to flourish in the new millennium is with a formal division.

G. Douglas Andersen, DC, DACBSP, CCN, writes for Dynamic Chiropractic magazine, with a column on nutritional advice for DCs.


Needless to say, this is just the tip of an iceberg. There's plenty of debate and information on this subject. It doesn't always stop there. Lives do get threatened and attempts do get made. The danger isn't from normal chiros, even though misguided, but from rabid chiros who feel that their biotheological religion is getting threatened by the existence of these brave chiros who expose the fundamentally false teachings and practices in their profession. It's sad.



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