A Close Look at Chiropractic Wrongdoing
Stephen Barrett, M.D.Chiropractic is a wide array of practices with emphasis on spinal "adjustments." Chiropractic theory claims that (a) spinal misalignments, which chiropractors refer to as subluxations, impair health by interfering with the integrity of the nervous system and (b) spinal adjustments restore the integrity of the nervous system, enable the body's inherent recuperative power to restore health, and thereby prevent or remedy a wide range of health problems. Chiropractors may help people with certain musculoskeletal ailments, but the problems described in this chapter are widespread and, in some cases, integral to chiropractic philosophy and practice. Thus, even though some of the source materials and opinions cited in this essay originated long ago, they remain relevant to the current marketplace.
Various forms of spinal manipulation have been noted throughout recorded history . The "discovery" of chiropractic was announced in 1895 by Daniel David ("D.D.") Palmer, a grocer, spiritualist, and "magnetic healer" who practiced in Davenport, Iowa. Palmer believed that he had restored the hearing of a deaf janitor by "adjusting" a hump on his spine. Even though the nerve that controls hearing is inside the skull and does not traverse the spine, Palmer concluded that the basic cause of disease was nerve interference caused by displaced vertebrae . He originally declared that such misalignments cause abnormal tension ("tone") in the nearby nerves and that disturbed nerve tone causes 95% of all diseases. Later he elaborated a vitalistic doctrine which held that (a) "Innate Intelligence," or "nerve energy," flows throughout the nervous system and controls every bodily activity not under voluntary control; (b) even slight spinal misalignments hinder this flow, causing people to become ill; and (c) manual manipulation ("adjustment") of the spine is the remedy. He rejected the germ theory and had an aversion to drugs, surgery, and medical diagnosis.
Palmer referred to spinal "misalignments" as "luxations." A few years later a disciple began calling them "subluxations," a term that became central to chiropractic theory and is still used today. The word "chiropractic" was derived from the Greek words cheir (hand) and praktikos (practice).
Soon after his "discovery," Palmer opened a school to teach his methods to others. The basic entrance requirement, as it was in many medical schools around the turn of the century, was the ability to pay tuition . One of the first students was Palmer's son, Bartlett Joshua ("B.J."), who became chiropractic's developer. In 1906 D.D. Palmer was convicted of practicing medicine without a license and spent 23 days in jail. After his release, B.J. denied him access to the school grounds and wound up purchasing D.D.'s interest in the Palmer School of Chiropractic. At that time about 100 chiropractors were practicing in the United States. Today there are about 65,000.
Between 1913 and 1933, 40 states passed laws to license chiropractors; the remaining states gradually followed suit, with Louisiana being the last in 1974. Chiropractors have lobbied successfully in most states for laws that force insurance companies to pay for some of their services. In 1972 Congress legislated coverage under Medicare for "treatment by means of manual manipulation of the spine to correct a subluxation demonstrated by x-rays to exist." The International Chiropractors Association states that passage of this bill was spurred by more than 10 million letters received by members of Congress . The x-ray requirement was eliminated in 2000.
U.S. Census Bureau data indicate that the total reported income for chiropractic offices and clinics rose from $6.57 billion in 1997 to $11.4 billion in 2012. However, other data show that when inflation and other factors are taken into account, the average net income of chiropractors has dropped steadily .
Chiropractic's uniqueness is not in its use of manipulation but in its theoretical basis for doing so. Jarvis describes chiropractic as "a conglomeration of factions in conflict, bound together only by opposition to outside critics."  During the 1960s, Joseph A. Sabatier, M.D., who served for several years as chairman of the American Medical Association's Committee on Quackery, observed that, "Chiropractic is the greatest tribute to the efficacy of technically applied public relations the world has ever known. These people have been delivering a package since 1895, the sale of which depends entirely on the wrapping. The contents are not there." 
Philosophy and treatment methods vary greatly from one chiropractor to another, but there are two main types: "straights" and "mixers." Straights tend to regard "subluxations" as the primary cause of ill health and spinal "adjustments" as the remedy. Some routinely manipulate the neck for complaints in all parts of the body. Many straights disparage medical diagnosis, some even claiming that their sole responsibility is to examine and adjust the spine. Mixers, who are more numerous, acknowledge that germs, hormones, and other factors play a role in disease; however, they tend to regard mechanical disturbances of the nervous system as the underlying cause (through lowered resistance). In addition to spinal manipulation, they may use measures that are standard in physical therapy as well as a wide spectrum of questionable nonmedical approaches. Mixers are more likely to diagnose medical conditions in addition to spinal abnormalities and to refer patients to medical practitioners for treatment.
Both straights and mixers may claim that the nervous system is the master of all body functions, regulating everything from major organs to intricate cellular activities. This statement is untrue. However, charts and other materials relating the spine to the full range of illnesses can still be found in many chiropractic offices and online. Thus, even though nearly all chiropractors manipulate the spine as their primary treatment method, their rationales and techniques vary considerably.
The chart to the right is from a chiropractic brochure. Many chiropractors use such charts to reinforce the idea that spinal problems are a major cause of disease. This one claims that "spinal misalignments" can cause more than 100 health problems, including allergies, amnesia, crossed eyes, deafness, gallbladder conditions, hernias, jaundice, and pneumonia. Other charts showing how nerves connect from the spine to the body's organs are used to persuade patients that regular spinal care is essential for good health.
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The message below is part of a chiropractic newspaper ad from the 1970s that illustrates chiropractic's tendency to overclaim.
Many chiropractors detect "subluxations" in healthy individuals. A small percentage of chiropractors reject the subluxation concept and limit their practice to short-term treatment of musculoskeletal conditions using evidence-based procedures similar to those of physical therapists and osteopaths.
Chiropractors also differ greatly about how treatment should be done. More than 200 "technique systems" have been advocated. In 1996, Thomas F. Bergmann, D.C., who edited the journal Chiropractic Technique, stated:
A challenge for the future is to classify and place all chiropractic techniques into a framework that allows determination as to whether any of them has a basis in fact. . . . Studies designed to compare effectiveness . . . have not been done. . . . No technique system has been demonstrated to be more or less effective than any other for any condition .
In 2011, Bergmann acknowledged that chiropractic research had not yet solved any these problems .
The two largest chiropractic organizations are the American Chiropractic Association (ACA, mixers) and the International Chiropractors Association (ICA, straights). Judging from their income tax returns and dues structures, the ACA appears to have about 8,000 members (not including students) and the ICA has about 2,500. The two groups have considered merging, but they are unable to agree on the definition and scope of chiropractic. The World Chiropractic Alliance, which has about 900 members, states that its mission is "promoting a subluxation-free world."
A small network of faculty members at some of the chiropractic colleges is attempting to place chiropractic on a scientific basis by determining which practices are valid and which are not. In 1995, Magner noted that negative research findings appeared to have little effect on what most chiropractors do . That is still true today.
The Elusive "Subluxation"
Medical doctors and chiropractors use the word "subluxation" differently. The medical meaning is incomplete or partial dislocation—a condition, visible on x-ray films, in which the bony surfaces of a joint no longer face each other exactly but remain partially aligned. Most partial dislocations occur in areas other than the spine and are the result of injury. Spondylolisthesis, a partial dislocation of a spinal bone, usually is congenital and causes no symptoms. Because the ligaments connecting the spinal bones are quite strong, vertebral dislocations rarely occur after birth and are unlikely without severe injury that would require surgical treatment, not chiropractic treatment.
Chiropractors disagree on how their "subluxations" should be defined. Some describe them as "bones out of place" and/or "pinched nerves," some speak of "fixations" and/or loss of joint mobility, some occupy a middle ground that includes any or all of these ideas, and a few renounce chiropractic's subluxation concepts completely. Chiropractors also disagree on whether their "subluxations" are visible on x-ray films. Those who claim that "nerve interference" results in too much or not enough "nerve energy" have never specified how this could be measured by scientific instruments.
|This children's storybook pictured to the right has been used to promote the notion that correcting subluxations promotes general health. After a chiropractor tells a little girl that she had a subluxation, she searches in vain under her bed and in her toybox to find it. She finally learns its location when the chiropractor says it was a bone in her neck that was "not lined up with the other ones." The chiropractor explains: "Subluxations make your body sick. Each time I push on your back, the bones are adjusted closer to their normal position. This opens up the pathways, so that your brain may talk properly with your body. As your subluxations are corrected, you become healthier." The booklet was marketed by a practice-building firm that promoted "chiropractic pediatrics."||The poster to the right has been used in chiropractic offices for more than 25 years to suggest that chiropractic care is necessary. A distributor calls it "the most powerful single visual aid available."|
Chiropractors also differ among themselves about whether specific patients have subluxations and what to do about them. Several investigations in which many chiropractors have examined the same patient have found that the diagnoses and proposed treatments differed greatly from one practitioner to another .
- In 1989 Dr. William M. London visited 23 chiropractors in Ohio and Florida who had advertised free consultations or examinations. Each one espoused subluxation theory either during the consultation or in waiting room literature, and all but two recommended periodic preventive maintenance. Seventeen performed examinations. Of these, three identified subluxations (at differing locations), three said his left leg was shorter than his right leg, and two said his right leg was shorter than his left. Seven recommended treatment, and one treated him with a motorized roller device before examining him.
- In 1994 ABC's "20/20" reported on visits to 17 chiropractors who had made it known through advertising or other means that they treated children. In one segment, an infant named Blake was taken by his mother to 9 chiropractors in the New York metropolitan area, accompanied by a "friend" who was carrying a hidden camera. Blake had experienced recurring ear infections, a problem that a pediatrician said could be managed with antibiotics and would eventually be outgrown. Every chiropractor found a problem, and all said they could help and recommended care ranging from several weeks to a lifetime. The first found "a misalignment between the second and third bones in his neck." The second said it was "on the right side of his neck between the first and second bones." The third, using muscle-testing, found "weakness in the adrenal glands." The fourth said there was a subluxation because one of Blake's legs was shorter than the other. The fifth claimed he could diagnose the boy's problem by pulling on his mother's arm while she touched the boy on the shoulder. The sixth chiropractor did a similar test by pulling on the mother's legs while Blake lay on top of her back. After diagnosing "jamming of the occiput (the back bone of the skull)," the chiropractor said he corrected it by "lifting" Blake's occiput with his thumbs. He also said (a) Blake needed work on his immune system, (b) a learning disorder might be a problem, (c) both mother and son had "eyes that don't team too well," and (d) the cameraman, whom the chiropractor incorrectly assumed was the boy's father, had the same eye problem.
- The same program also reported on visits to eight Wisconsin chiropractors by a 5-year-old boy with chronic ear infections so severe that medical doctors wanted to insert tubes in his ears to drain them. All eight chiropractors found problems, but not usually the same ones. One diagnosed a pinched nerve in the boy's neck. Another said his left leg was shorter than his right. Another said his right leg was shorter than his left. Another diagnosed zinc deficiency. Another chiropractor blamed the boy's ear problems on "food sensitivities" and advised avoiding corn, cow's milk, and white flour. Another gave similar dietary advice but said that the main diagnosis was a "subluxation" in the top vertebra. Another said the boy didn't have an ear problem but had scoliosis—a diagnosis disputed by a pediatrician and a radiologist who reviewed this chiropractor's findings.
- In 2001, a healthy 11-year-old girl was taken by her uncle (a reporter) to five chiropractors in Toronto, Canada, for a checkup. The chiropractors were told the child was generally in good health but suffered from a few earaches, some mild headaches, and a few signs of allergy symptoms. The chiropractors were also told that the girl's mother was worried about the possibility of asthma and had heard from neighbors that chiropractic care could be beneficial for children. Four of the chiropractors found different subluxations and said that the girl needed chiropractic adjustments to get healthy. The methods they used to locate the alleged subluxations included spinal palpation, thermographic scans (looking for heat differences), and surface electromyography (SEMG), which merely measures muscle electrical activity. Among other things, the chiropractors said the child had one shoulder lower than the other, one leg longer than the other, one hip higher than the other, one ear lower than the other, something called "anterior head carriage," scoliosis, early osteoarthritis, and numerous subluxations, all of which could cause earaches, headaches, allergies, asthma, arthritis, learning problems, and more serious problems later in life, including digestive and reproductive problems.
- In 2004 a team of high school students contacted chiropractic offices in metropolitan Portland, Oregon, and found evidence of unscientific practice in every one. Following a script, they posed as a prospective patient and telephoned 42 local offices. All questions were answered by a member of the chiropractor's office staff, who sometimes consulted with the chiropractor. The students reported that all routinely or usually took x-rays during the first visit, 40 said they treated "subluxations," 41 recommended "maintenance" adjustments, 38 offered craniosacral therapy, 37 recommended treatment for newborn infants, 29 treated newborns, and at least 28 did not recommend routine vaccination for children.
Some physical therapists, athletic trainers, osteopathic physicians, and medical doctors use manipulative techniques. However, their intent is never to correct subluxations; it is to relieve pain and secondary muscle spasm by restoring the mobility of joints that have a mechanical malfunction.
The notion that nerve interference is a major cause of disease clashes with established anatomic facts. During the early 1970s Dr. Edmund Crelin, a prominent anatomist at Yale University, subjected subluxation theory to an actual test . After collecting the spines of six people who had died a few hours earlier, he twisted them with instruments and observed the spaces between the vertebrae through which the spinal nerves passed. No nerve compression occurred, regardless of the force applied. In a later memorandum he commented further:
Only 24 of the 43 pairs of nerves that pass from the brain and spinal cord to various parts of the body could ever be impinged upon in the [vertebral openings] by the excessive displacement of vertebrae. Why these 24 pairs should be causing disease, exclusive of all the others, defies a rational explanation. . . .
Complete severance of spinal nerves to the heart, glands (salivary, thyroid, liver, pancreas, etc.) and smooth muscles of the lungs, stomach, intestines, etc., has only transient effects. The gland cells and smooth and cardiac muscles not only survive, but function normally. They surely do not become diseased .
Despite the unscientific nature of the subluxation concept, a cross-sectional survey of North American chiropractors conducted in 2002 found that (a) 88.1% thought that the term vertebral subluxation should be retained, (b) 89.8% thought that spinal adjustment should not be limited to treating musculoskeletal conditions, and (c) 62.1% rated the subluxation as a significant contributing factor in visceral conditions (diseases of the internal organs), and (d) 76.5% taught patients about a relationship between subluxations and visceral health .
Mainstream chiropractic organizations are also strongly tied to the subluxation concept. In 2000, the ACA House of Delegates reaffirmed its core principle of subluxation by passing this resolution:
The ACA will strive to reiterate this principle and further state that the core treatment of chiropractic is manual manipulation/adjustment of the articulations, both spinal and extra-spinal, to reduce subluxations, when called upon in relation to Federal legislative efforts, in addition to full scope of practice as allowed by state law. References to subluxation and chiropractic adjustments/manipulation should be made in ACA releases, whenever possible.
In 1996, in an attempt to unify the profession, the Association of Chiropractic Colleges (ACC) adopted a subluxation-based "chiropractic paradigm" statement that contains this definition:
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. A subluxation is evaluated, diagnosed and managed through the use of chiropractic procedures based on the best available rational and empirical evidence .
In 2005, the World Federation of Chiropractic, an association of chiropractic organizations in 85 countries, adopted an "identity statement" based on a survey in which thousands of chiropractors were asked how the public should perceive them. The survey found that 65% of respondents said that the phrase "management of vertebral subluxation and its impact on general health" fits chiropractic "perfectly" or almost perfectly .
Subluxation theory is not only entrenched in the practices of chiropractors; it is also embodied in all 50 of the state laws that govern chiropractic regulation. Twenty-states authorize chiropractors to treat subluxations, 25 authorize them to treat purported vertebral malpositions that interfere with nerve flow (or similar wording), and five authorize the use of whatever is taught at chiropractic colleges . As a result, all states permit chiropractors to treat all or most diseases by adjusting subluxations to improve nerve flow.
In 1973 the U.S. Office of Education approved the Council on Chiropractic Education (CCE) to accredit chiropractic schools. In 2018, the requirements for admission to a CCE-accredited school included 90 credit hours (about 3 years) of prechiropractic college education with at least a 3.0 (out of 4.0) grade-point average . To receive the doctor of chiropractic (D.C.) degree, students must complete at least 4,200 hours of study over a 4-year period. Courses include anatomy, biochemistry, microbiology, pathology, public health, diagnosis and x-ray examination, related health sciences, and chiropractic principles and practice. Seventeen chiropractic programs in the United States have CCE accreditation.
In 1968 a comprehensive study by the U.S. Department of Health, Education, and Welfare concluded that chiropractic education did not prepare its practitioners to make an adequate diagnosis and provide appropriate treatment . Chiropractic colleges have improved considerably since that time. However, all still discuss subluxations in their philosophy courses, some consider subluxations to be real entities, and a few still encourage students to treat "subluxations" rather than diseases or "conditions."  The ACC paradigm statement says, "Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation."  The statement was signed by all of the U.S. chiropractic college presidents in 1996 and is still considered current.
In 2018, researchers who investigated 46 chiropractic programs (18 in the United States and 28 elsewhere) found that among the U.S. programs, the average number of mentions of "subluxation" in course titles and descriptions was 7. Those with the most mentions were Life University (25), Sherman College of Chiropractic (17), and the Palmer College of Chiropractic—Florida (16). "Subluxation" was mentioned by only a few the 18 non-U.S. programs. The research team concluded:
Unscientific terms and concepts should have no place in modern health care education, except perhaps in discussions with historical context. Unless these outdated concepts are rejected, the chiropractic profession and individual chiropractors will likely continue to face difficulties integrating with established health care systems and attaining cultural authority as experts in conservative neuromusculoskeletal health care 
Chiropractic colleges do not provide the depth of diagnostic and therapeutic training that physicians receive. Whereas most medical school faculties are large and contain experts in every aspect of medical practice, chiropractic colleges have few or no physicians on their faculty. Whereas the patients studied by medical students encompass the full range of disease, the vast majority seen by chiropractic students seek help for musculoskeletal problems. Although many of their courses are based on standard medical textbooks, chiropractic students lack much of the experience needed to make the information meaningful .
Some chiropractors try to downplay their lack of clinical experience by claiming that they spend more hours than medical students do in one subject or another. These claims are misleading because nearly all medical doctors undergo at least 3 additional years of full-time clinical training before going into practice, whereas nearly all chiropractors enter practice directly after graduation from their 4-year program. Moreover, in chiropractic colleges, instruction in many subjects, including pediatrics, obstetrics, and gynecology, is confined to the classroom, with little or no actual patient contact and no experience with hospitalized patients . A team of research-oriented chiropractors recently stated:
There is a tremendous void in how chiropractic graduates develop any meaningful hands-on clinical experience with real patients in real life situations. The chiropractic profession has an obligation to actively divorce itself from metaphysical explanations of health and disease as well as to actively regulate itself in refusing to tolerate fraud, abuse and quackery, which are more rampant in chiropractic than in other healthcare professions." 
Critics also note that because much of chiropractic is based on a false premise, neither length of study nor accreditation of its schools can ensure that those who graduate will practice competently.
After graduation many chiropractors take courses to help build their practices. These courses teach efficient office management, but some have taught unethical methods of recruiting and retaining patients. For example, one practice-building manual advised that "Every action the chiropractor does should have the one purpose to slowly but surely direct the patient's attention to the fact that chiropractic is capable of correcting the 'condition' that is 'causing' the patient's ill health" and provided detailed instructions for persuading all comers to have monthly spinal examinations . Another suggested telling patients that "the best health insurance you'll ever buy is regular adjustments of your spine, releasing nerve pressures."  Both of these books were authored by chiropractic college presidents and widely used for more than 30 years. Although neither book is still published, most current practice-builders teach the same techniques and thousands of chiropractors use them.
A 1986 report by the Office of the Inspector General (OIG) concluded that "practice-building courses, popular with many chiropractors, advocate advertising techniques which suggest the universal efficacy of chiropractic treatment for every ailment known to humans." It also concluded that despite evidence of an increased emphasis on science and professionalism in the training and practice of chiropractors, "there also exist patterns of activity and practice which at best appear as overly aggressive marketing—and, in some cases, seem deliberately aimed at misleading patients and the public regarding chiropractic care." 
A 1989 OIG report noted that the two most common reasons for disciplinary actions by state chiropractic boards were billing abuses (relating to utilization or fees) and advertising abuses .
Many chiropractors use messages that reinforce the idea of a special bond between themselves and their patients. The bumper sticker shown below was distributed by the American Chiropractic Association. The heart sticker is from a company that sells novelty items to chiropractors. Several companies sell birthday cards and other greeting cards with chiropractic themes.
Many studies have examined whether spinal manipulation can relieve back pain. Relatively few studies have looked at whether manipulation could help other problems. In properly selected cases, manipulation may relieve low-back pain of musculoskeletal origin. However, there is little evidence that it is effective for other musculoskeletal conditions and no evidence that it is effective for nonmusculoskeletal conditions. Homola has noted that "chiropractic research has yet to pinpoint what chiropractors do that is beneficial." 
During the early 1990s, manipulation received considerable publicity after reviews by the RAND Corporation  and the Agency for Health Care Policy and Research (AHCPR)  concluded that manipulation was effective for acute low-back pain in patients with no signs of lower-limb nerve root involvement.
Although chiropractors promoted these reports as endorsements of chiropractic, they were not. They merely supported the use of manipulation in carefully selected patients. Only a few of the studies on which their conclusions were based involved manipulation by chiropractors; most were done by medical doctors and physical therapists whose practices were not identical to those of chiropractors .
Since that time, there have been many more studies and many more reviews. In 2003, a team that included RAND's project leader concluded: "There is no evidence that spinal manipulation is superior to other standard treatments for patients with acute or chronic low back pain." 
In 2005, after looking at 19 reviews related to back pain, Canter and Ernst concluded that "those authored by chiropractors tended to generate positive results, whereas the others failed to demonstrate effectiveness."  In 2006, Ernst and Canter reported on 16 systematic reviews of clinical trials of spinal manipulation published between 2000 and May 2005 on back pain, neck pain, headache, non-spinal pain, menstrual pain, infantile colic, asthma, allergy, neck-related dizziness, and medical problems in general. They concluded:
These reviews were largely negative, except for back pain where spinal manipulation was considered superior to sham manipulation but not better than conventional treatments. . . . Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment .
A 2010 Cochrane review examined the effect of manipulation plus other modalities on low-back pain. The other modalities were heat and cold therapy, electrotherapy, mechanical devices, exercise, nutritional advice, orthotics, lifestyle modification, and patient education. The reviewers concluded that although combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low-back pain, "there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain."  A 2011 review drew similar conclusions for chronic low-back pain . Although a 2019 Cochrane Review was slightly more favorable , Ernst concluded that the analysis was severely flawed and::
- The lead author and second author of the review team were chiropractors who had significant conflicts of interest,
- The review actually produced no good evidence that spinal manipulation has effects beyond placebo.
- Spinal manipulative therapy is still not supported by convincing evidence for back (or other) problems and does not qualify as the treatment of choice .
Little has been written about the fact that studies of manipulation in research settings may not reflect what takes place in typical chiropractic offices. Patients in research studies are likely to be better screened for appropriateness and are highly unlikely to face the many things that chiropractors do wrong in their offices. So even if manipulation is proven useful for carefully selected patients, consulting chiropractors outside of research settings may still be problematic.
PROBLEMS FOR CONSUMERS
Although some research on the use of spinal manipulation is favorable, the situation faced by consumers is actually worse than these studies might seem to indicate. Most research on spinal manipulation is done in studies where the patients are appropriately screened and the treatment is limited by the experimental protocol. In the real world, however, the odds of getting appropriate treatment are much lower because the following problems are widespread. I have also noted that chiropractors seldom react constructively to criticism. When specific wrongdoings are exposed, they typically claim that the criticized practices are not representative, or that the critic is biased, or they attack the medical profession .
Many chiropractors exaggerate what they can achieve. Tedd Koren, D.C., publishes many brochures and other practice-building supplies, one of which states:
Nearly every condition to which the flesh is heir has responded to chiropractic, including ear infections, asthma, allergies, colic, bedwetting, hearing problems, skin conditions, digestive and menstrual problems, infertility, spine and nerve pain, colds and flu, headache, sciatica, emotional and neurological conditions and many others .
Koren also advised chiropractors they could double their practice "practically overnight" by having patients read one of his lists of conditions treated and asking: "Do you know of any children, perhaps your own, or those of relatives or friends, that have any of the problems in this list?" 
A recent survey found that unsubstantiated claims are very common among chiropractic Web sites. In the fall of 2008, the researchers looked at the sites of 200 chiropractors and 9 chiropractic associations in Australia, Canada, New Zealand, the United Kingdom, and the United States. Each site was examined for claims which suggested that chiropractic treatment was appropriate for asthma, colic, ear infection/earache/otitis media, neck pain, whiplash, headache/migraine, and lower back pain. The study found that 95% of the surveyed sites made unsubstantiated claims for at least one of these conditions and 38% made unsubstantiated claims for all of them. The authors concluded:
The majority of chiropractors and their associations in the English speaking world seem to make therapeutic claims that are not supported by sound evidence, while only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue .
Patients who rely on exaggerated chiropractic claims may delay obtaining more appropriate care. Modde highlighted this problem when he said that "malpractice is an inevitable result of chiropractic philosophy and training." 
Many chiropractors claim that treating subluxations improves general health and is important throughout life. For example, in 1995 an ACA board member stated: "I treat my patients as if each spinal adjustment has a virtually unlimited potential in improving their health. My father adjusted me on the day that I came home from the hospital, and I did the same with my children." 
Many chiropractors suggest unnecessary "spinal adjustments" for "preventative maintenance" or for treating nonexistent conditions. Maintenance care is typically promoted with claims that undetected subluxations pose a serious health threat. A 2009 Koren pamphlet, for example, states: "Subluxations are sometimes referred to as 'silent killers' because they can slowly eat away at your health and vitality for years without your knowing it."  Figure 9-4 shows a poster used to reinforce this idea.
Many chiropractors offer free evaluations with the hope that takers will contract for long-term care. These offers may be communicated through mall exhibits, free dinners, newspaper advertising, and various other channels. Figure 6 provides an example.
|Figure 6. This "danger signal" ad from a telephone directory is misleading because (a) most of the listed symptoms are unlikely to be caused by pinched nerves, (b) most cases involving these symptoms are not serious, and (c) some of the symptoms (such as difficult breathing) are far more likely to be appropriate for medical rather than chiropractic evaluation. Contour analysis has no diagnostic value.|
The in-office sales pitch typically includes a recommendation for 50 to 100 visits over a 6- to 12-month period to promote wellness and/or prevent spinal degeneration. To increase compliance and discourage patients from stopping if their initial symptoms resolve, patients are offered a discount is they pay in advance for a specified number of treatments. As illustrated by the following case, such arrangments are usually a bad idea:
In 2008, in response to an advertisement, Gertrude West, a 76-year-old retired attorney, sought help from a chiropractor for knee pain. The chiropractor performed a cursory examination, some diagnostic tests, and an x-ray examination and advised West that she had "subluxation degeneration" that would worsen without intensive chiropractic care. The chiropractor's written report of findings called for 100 visits at a total cost of $7080, but if she signed a contract and paid in advance the price would be discounted (15%) to $6,354. After 49 visits over a 4-month period, West concluded that she was not being helped and asked that payment for the unused visits be refunded. When the chiropractor refused, she sued him in small claims court. The contract GlimWest signed said that if she stopped before the 100 visits were completed, she would be charged at a nondiscounted rate for the visits she had and an additional 10% "administrative fee." However, the judge ruled that the penalty clause was "unconscionable" and that West had been misled and was entitled to a full refund. A small claims appeal judge reduced the award to $4,589 but agreed that the contract was unreasonable. Chiropractors who offer "discount" plans should be avoided because such plans are a sign of overselling. Even when chiropractic treatment can be helpful, it is not possible to know in advance that a large specified number of visits will be needed.
Some patient-recruitment programs have been packaged as an opportunity to participate in research. In 2008, for example, several chiropractic Web sites began advertising for "research volunteers" who would be evaluated free of charge. After the evaluation, they would then be invited—as paying patients—to "commit to a 24-visit cycle, and continue coming until they reach their maximum potential." The ads are part of a practice-building program offered by Research & Clinical Science (RCS), which promised chiropractors that it would tabulate data that would ultimately pinpoint "exactly what impact subluxations have on the body, and what benefits chiropractic might offer to people of various ages and health levels." RCS also promised that its program would generate between 10 and 25 new patients a month and promote long-term wellness and compliance among existing patients. To join the program, chiropractors would pay $7384 in advance or up to $8384 for an installment plan. In return, RCS provided the training, research technology, wall plaque, brochures, and other materials needed to represent themselves as "RCS Authorized Clinical Investigators." 
Opposition to Immunization
Many chiropractors say that vaccinations are ineffective and do not recommend them to their patients. In 1992, 36% of 178 chiropractors who responded to a survey agreed that "there is no scientific proof that immunization prevents infectious disease" and 23% said they were uncertain. In the same survey, 41% agreed that "immunization campaigns have not substantially changed the incidence of any infectious diseases in the 20th century" and 29% said they were unsure . A more recent study looked at vaccination rates obtained from insurance data compiled in the state of Washington from 2000 to 2003. The researchers found that vaccination rates were much lower among children who saw chiropractors and naturopaths than among those who relied only on medical doctors .
The ACA, ICA, WCA, and International Chiropractic Pediatric Association oppose compulsory vaccination, and all but the ACA distribute anti-vaccination publications 
Dubious Practices and Procedures
- Many chiropractors use leg-length measurement, thermography, surface electromyography, or other dubious methods to detect alleged subluxations. The Chirobase Web site (www.chirobase.org) has detailed reports on these methods.
- Many chiropractors use applied kinesiology muscle-testing, hair analysis, or other dubious methods as a basis for prescribing unnecessary vitamins, irrational "dietary supplement" formulations, herbs, and/or homeopathic products, most of which are sold to patients at two or three times their wholesale cost.
- Many chiropractors x-ray most or all of their patients to look for "subluxations." About 10% of chiropractors still obtain 14 x 36-inch full-spine x-ray films, which yield little or no diagnostic information and involve relatively high levels of radiation.
- A 2003 survey by the National Board of Chiropractic Examiners found that 89% of 2167 full-time practitioners who responded said they had used "nutritional counseling, therapy or supplements" within the previous year and that 46.4% said they had prescribed homeopathic remedies .
- Although not qualified by training to understand the use of prescription drugs, many chiropractors discourage their use.
Consumer Reports has advised people to be suspicious of any chiropractor who does the following:
- Takes full-spine or repeated x-rays
- Fails to take a comprehensive history and perform a clinical examination to determine the cause of your trouble
- Claims that the treatment will improve immune function, benefit organ systems, or cure disease
- Offers to sell you vitamin cures, nutritional remedies, or homeopathic remedies
- Solicits children or other family members
- Advises against the immunization of children
- Wants you to sign a contract for long-term care
- Promises to prevent disease through regular checkups and spinal adjustments 
Adverse Effects of Spinal Manipulation
Most chiropractors manipulate the vast majority of patients who visit their office; some use techniques that have not been studied scientifically, and many emphasize a technique that is more vigorous (and therefore potentially less safe) than the controlled manipulation used by other practitioners.
Manipulation, particularly of the neck, can be dangerous. In 1992 researchers at the Stanford Stroke Center asked 486 California members of the American Academy of Neurology how many patients they had seen during the previous 2 years who had suffered a stroke within 24 hours of neck manipulation by a chiropractor. The survey was sponsored by the American Heart Association. The 176 neurologists who responded said that they had treated 56 such patients, all between the ages of 21 and 60. One patient had died, and 48 were left with permanent neurologic deficits such as slurred speech, inability to arrange words properly, and vertigo (severe dizziness). The neurologists also reported treating 46 cases of nerve or muscle injury . Although the percentage of chiropractic patients who are seriously injured is small, injury caused by an unnecessary manipulation is inexcusable.
In 1995, Assendelft and colleagues reviewed 295 published reports of complications and concluded (a) it is difficult to estimate the incidence of complications of spinal manipulation because they are underreported in the scientific literature, (b) information about the risk of stroke should be included in an informed consent procedure for neck manipulation that involves thrusting, and (c) practitioners using rotatory manipulation should be avoided .
In 2008, Ernst reported that seven prospective studies had found that about half of the patients who received spinal manipulation experienced mild-to-moderate, transient adverse effects . Local or radiating pain, headache, and tiredness occurred most often. Spinal manipulation can also result in serious injury to nerves, disc herniation, and, with neck manipulation, dissection of the vertebral artery followed by stroke . Severe injuries are uncommon, but their actual incidence is unknown .
Excessive Use of X-Ray Examinations
A receint review concluded that (a) in the vast majority of cases who present to chiropractors, the potential benefit from spinal X-rays does not outweigh the potential harms and (b) spinal x-rays should not be performed as a routine part of chiropractic practice .
A Plea for Reform
In 2016, Bruce F. Walker, D.C., Dr.P.H., who heads the chiropractic program at Murdoch University (Australia), urged chiropractors to adopt a 10-point plan for "a new chiropractic" that would achieve full acceptance for his "troubled profession." His report includes a list of "bad" practices that continue to cause significant reputational damage to the profession:
- Adherence to a flawed chiropractic ideology centering on "innate intelligence" and vitalism
- Anti-vaccination propaganda
- Anti-physiotherapy sentiments
- Over-servicing, including unnecessary treatment of babies
- Use of the term "subluxation" as a valid diagnosis
- Biologically implausible diagnostic tests and therapies without supporting evidence
- Lifetime chiropractic care in the name of "wellness"
- Claims of cures for visceral and other non-musculoskeletal conditions
- Anti-drug and anti-medicine propaganda
- Misleading and deceptive advertising
- Unscrupulous contracts of care
- Obligatory full-spine x-rays
- Unfounded claims of decreased immunity from "subluxation" and increased immunity from chiropractic treatment
- An unhealthy disregard of clinical research, evidence based practice, and non-specific treatment effects including natural history and the placebo effect
Walker's proposed plan included "marginalization of the nonsensical elements within the profession," unequivocal support of proven public health measures, increased research, and unambiguous statements from chiropractic organizations that support science and evidence . His suggestions are excellent, but there is little reason to believe that most chiropractors will follow them.
SOME FINAL THOUGHTS
The terms "chiropractic" and "chiropractic treatment" are ambiguous and are not synonymous with "spinal manipulation." Chiropractic is both a philosophy and a treatment approach. Chiropractic treatment may include a wide variety of dubious measures in addition to appropriate or inappropriate manipulation. Thus, the potential usefulness of spinal manipulation may not counterbalance the unscientific philosophy or methods commonly embraced by chiropractors.
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This article was revised on March 21, 2019.