Complaint to Chiropractic Board of Australia about Light Chiropractic and Wellness

Page 1 of 6

Dr Nahum Shalom Drimer, CHI0000971076, is a chiropractor registered at: GLEBE NSW 2037, who practices at: Shop 1/198-206 St Johns Road Glebe NSW 2037.

He is listed at the Light Chiropractic and Wellness web site (http://lightchiro.com.au/) and presumably is responsible for its content:

We allege that certain claims made by Dr Drimer on his web site breach Section 133 of the National Law that prohibits advertising that:

• is false, misleading or deceptive or is likely to be so; • creates an unreasonable expectation of beneficial treatment, and • encourages the indiscriminate or unnecessary use of health services.

We also believe that the claims documented below are not in accord with the Chiropractic Board of Australia, Code of Conduct, (March 2014):

• s.2.2 (g): providing treatment/care options based on the best available information and practising in an evidence-based context and not being influenced by financial gain or incentives;

• s.2.4 (d): investigating and treating patients on the basis of clinical need and the effectiveness of the proposed investigations or treatment/care, providing necessary services and not providing unnecessary services or encouraging the indiscriminate or unnecessary use of health services, and

• s.9.6 (a): complying with the National Board’s Guidelines on advertising regulated health services, (the Advertising guidelines) and relevant state and territory legislation and Commonwealth law;

• s.9.6 (b) making sure that any information published about services is factual and verifiable.

The details of these allegations follow.

Claim 1: Screenshot 1 (from: http://lightchiro.com.au/chiropractic/what-is-chiropractic/)

Complaint to Chiropractic Board of Australia about Light Chiropractic and Wellness

Page 2 of 6

Comment: In 2005 in an article titled, “Subluxation: dogma or science?” Keating JC, et al,1 said:

“The dogma of subluxation is perhaps the greatest single barrier to professional development for chiropractors. It skews the practice of the art in directions that bring ridicule from the scientific community and uncertainty among the public. Failure to challenge subluxation dogma perpetuates a marketing tradition that inevitably prompts charges of quackery. Subluxation dogma leads to legal and political strategies that may amount to a house of cards and warp the profession's sense of self and of mission. Commitment to this dogma undermines the motivation for scientific investigation of subluxation as hypothesis, and so perpetuates the cycle.”

In May 2010 the General Chiropractic Council, the statutory regulatory body for chiropractors in the United Kingdom, issued guidance for chiropractors stating that the chiropractic vertebral subluxation complex "is an historical concept" and "is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease.2 Chiropractors were also reminded that,

1 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1208927/ 2 http://www.gcc-uk.org/UserFiles/Docs/What%20Can%20I%20Expect/Vertebral%20Subluxation%20Complex.pdf

Complaint to Chiropractic Board of Australia about Light Chiropractic and Wellness

Page 3 of 6

when advertising, claims for chiropractic care “must be based on best research of the highest standard” only. (GCC Guidance on Advertising, March 2010)

In addition, we are unaware of any scientific evidence that supports the statements,

“Subluxations affect the electromagnetic field of the body, as well as neuro-chemistry and neurological function”;

“Integration of the energy stored in a subluxation can result in improved wellbeing in all areas of a person’s life (including their thinking patterns and the way that they feel physically, emotionally and spiritually)”.

“People who enjoy regular chiropractic care experience an improved ability to adapt, self-heal and recover from stress. Their perceptions become clearer and their natural healing ability increases. They find that decision-making processes are easier and that they are able to be more loving. They are able to live in and enjoy the present moment, rather than reacting due to stored experiences from the past”.

“With each adjustment your system becomes better able to adapt, heal and self-correct. Getting adjusted helps you to move toward the flexibility, ease, flow and lightness that you experienced as a child”.

Conclusion Claim 1: we assert that statements above concerning “subluxation” and the alleged benefits from chiropractic “adjustment” lack substantiation and thus are in breach of s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).

Claim 2: Screenshot 2 (from: http://lightchiro.com.au/chiropractic/pregnancy-and-pediatrics/)

Comment: The claim that regular chiropractic care in pregnancy can lead to a reduction in labour time is attributed (on some other chiropractic web sites) to:

• Fallon J DC. Chiropractic and Pregnancy, a partnership of the future. ICA Review Nov/Dec 1990. (pg. 39-42) attached

We quote,

"Statistics from the author's case files were tabulated and a comparison of average labor time made. Twenty-seven primagravida and 31 multiparous women were compared as to their mean duration of labor. The results can be seen in Fig. 2. We can see by these statistics what with all else being equal, the mean labor times were reduced by 25 percent in the primagravida women, and by 31 percent in the multiparous women”. This in no way represents a controlled study..."

A search of http://www.ncbi.nlm.nih.gov/pmc/?term=(Fallon+J%5BAuthor%5D)+AND+Pregnancy) found no relevant entries.

Complaint to Chiropractic Board of Australia about Light Chiropractic and Wellness

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A broader search: http://www.ncbi.nlm.nih.gov/pmc/?term=Chiropractic+pregnancy also found no relevant entries.

In our opinion, the results of this uncontrolled (and unreplicated) 1990 case series reported by one author does not justify its widespread citation by chiropractic manipulation as to the benefits of chiropractic in reducing the time of labor.

Conclusion Claim 2: The claim that regular chiropractic care in pregnancy can lead to a reduction in labour by up to five hours lacks good evidence to substantiate it and thus is in breach of s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).

Claim 3: Screenshot 2 (from: http://lightchiro.com.au/chiropractic/pregnancy-and-pediatrics/)

Complaint to Chiropractic Board of Australia about Light Chiropractic and Wellness

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Comment: Dr Drimer makes numerous claims for the benefits of chiropractic care for children. With the exception of “improve spinal posture” we were unable to find good scientific evidence to substantiate these claims. Other reviews3, of the literature have noted that,

“in children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation”.

Conclusion Claim 3: The majority of the numerous claims made by Dr Drimer for the benefits of chiropractic care for children lack good evidence to substantiate them and thus are in breach of s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).

In summary, we believe that Dr Drimer makes a number of therapeutic claims on his web site that are not supported by sound evidence. We agree with Ernst and Gilbey (article appended) that such unsubstantiated claims constitute both an ethical and public health issue.

We ask the Chiropractic Board of Australia to determine if the above claims made by Dr Drimer have breached both the Chiropractic Board of Australia Code of Conduct and the National Law:

• AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014), s.6.2 & the • Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), s.2.4 (d) and s.9.6

(a) & (b)

If so, we ask that Dr Drimer be ordered to retract the offending claims and the determinations made in this case be published as a deterrent to others.

3 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841070/

Complaint to Chiropractic Board of Australia about Light Chiropractic and Wellness

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Yours sincerely,

Dr Ken Harvey 35a Mary St Hawthorn VIC 3122 M: 0419 181910 W: www.medreach.com.au E: k.harvey@medreach.com.au

Mal Vickers 2/45 Banff St Reservoir VIC 3073 malv@melbpc.org.au

Cc Mr Scott Gregson Executive General Manager, Consumer Enforcement Australian Competition & Consumer Commission Level 3, 23 Marcus Clarke St, Canberra, ACT, 2601 23 August 2015

BY JOAN M. FALLON, DC

"During pregnancy the pelvic joints and ligaments are relaxed and capable . of more extensive movements. This relationship renders the locking mecha- .. nism of the sacro-iliajoint less restrictive and permits greater rotation. This change allows alterations in the diameter of the pelvis at childbirth. The less the locking mechanism the more the strain of weight-bearing falls on the ligaments leading to frequent occurrence of sacro-iliac strain after preg­nancy. After childbirth the ligaments become tightened up but in some cases the locking may occur in the position of rotation of the hip bones adopted during pregnancy. This so-called subluxation of the sacro-ilia joint causes pain by the unusual tension which it imposes on the ligaments and the reduction by forcible manipulation may be attempted."

T he tremendous changes that take place in the pregnant woman bear special signifi­

cance to the chiropractor. Gray's Anatomy clearly gives the justification for adjustments during pregnancy and the post-partum period. It is important for the chiropractor to understand the physiological changes that take place which bring about alterations in the musculoskeletal system as well as in every system in the body. In this article we will explore those changes with respect to the biomechancis of the spine

Gray's Anatomy 36th British Edition

and the effects on the mother.

Physiological changes The physiological changes that occur in the mother during pregnancy can be broken down into two categories:

1. Hormonal 2. Biomechanical

While the biomechancial changes are seemingly most important to the chi­ropractor, the hormonal changes which are truly profound, overlap into the musculoskeletal system and thus af­fect the biomechanics of the spine.

Many of the neurological conditions seen during pregnancy have their ori­gins in the hormonally induced changes in the pregnant woman. We will therefore begin our discussion with the hormones of pregnancy.

Hormones of pregnancy Progesterone and estrogen are the most important hormones which affect pregnancy. Progesterone which climbs as high as 250mg/day creates vast changes which result in an overall de­crease in tonality thereby creating a

!CA INTERNATIONAL REVIEW OF CHIROPRACTIC NOVEMBER/DECEMBER 1990 39

stasis of activity. Some of progesterone's effects are as follows: a decrease in smooth muscle and vascular tone, and an increase in fat storage and tem­perature. Progesterone also acts with estrogen to increase development of the breasts for nursing.

Estrogen, which reaches a peak of 40mg!day during pregnancy, creates significant alterations in the connec­tive tissue. This alteration results in an increase in joint mobility. As we will see later, this will have a significant effect on the "subluxation complex of pregnancy." In addition, estrogen has an important effect on the uterus and its control and function as well as on the growth and regulation of the fetus.

Cortisol, aldosterone, Human Cho­rionic Gonadotropin (HCG), Human Chorionic Somatomammotrophin (HCS), relaxin and prolactin also play an integral role in the changes during pregnancy.

These hormones all enter into com­bination which alter and control the various organ systems of the body. 'The respiratory system, GI system, cardiovascular system, renal system and again the musculoskeletal systems all are profoundly affected by the hor­mones of pregnancy. Reduction of cardiac workload, augmentation of the inspiratory and expiratory volume of the lungs, increased absorption time for food, and strict regulation of uri­nary output and water retention are just a few of the effects that the hor­mones have on the body.

Bio mechanical considerations of pregnancy In addition to the alteration of sup­porting structures by the hormones, there is another significant change which occurs in the pregnant woman that alters her biomechanics. This is the large increase in weight gain over a relatively short period of time. The customary weight gain for the pregnant woman varies between 25 to 35 lbs. However, a weight gain of 40+ lbs. is not uncommon. This gain is a result of the weight of the fetus and maternal organs, an increase in the volume of blood and interstitial fluid as well as an

40

increase in protein and fat storage.

Subluxation complex of pregnancy In 1947, Drs.Janse, Houser and Wells, in their definitive work "Chiropractic Principles and Technic" proposed a model of lordotic subluxation which we shall apply to pregnancy. In their model they state: "If the head and chest are thrown too far backward and the weight is thrown upon the articular processes, the inferior articular pro­cesses will have a tendency to slide backward on the superior articular process of the vertebra below, and in this way will force the latter forward into the intervertebral foramen (Fig. 1). Such a condition which might be termed 'physiological lordosis' is seen very commonly in fleshy people who in order to maintain their balance lean backward and by doing so throw the lumbar portion of the spine forward. This model of lordotic subluxation proves to be extremely useful when looking at pregnancy. When one speaks of the "pride of pregnancy" we are looking at the extreme exaggeration of the lumbar lordosis and the flattening of the kyphotic curve of the dorsal spine.

Neurological conditions associated with subluxation in pregnancy There are many conditions that are associated with subluxations in preg­nancy and they include the following:

Meralgia paresthetica - compres­sion of the lateral femoral cutaneous nerve as it passes beneath the inguinal ligament. Pain and most often pares­thesia are seen in the lateral aspect of the upper thigh.

Brachial neuralgia - compression of the brachial plexus characterized by tingling and numbness of the shoulder and arm.

Intercostal neuralgia - compres­sion of the intercostal nerves resulting in radiating pain in the thorax in be­tween the ribs.

Sciatic neuralgia- compression of the lumbar plexus resulting in pain in the pelvic region and/or pain radiating

Figure 1

down the leg. Coccydynia-pain at the site of the

coccyx due directly to subluxation. Often seen during delivery but also seen during the last trimester.

Separation of the syrnphsis pubis -When the symphysis pubis separates more than one cm it is characterized as a subluxation. This subluxation will cause pain at the syrnphysis pubis and at the SI joint.

Carpal tunnel syndrome - com­pression of the median nerve under the flexor retinaculum resulting in pain at the wrist joint.

Bell's Palsy - compression of CN VII within the temporal bone. Paraly­sis of the facial muscles is seen. This condition most often occurs during the third trimester but is also seen one week to 10 days after delivery.

Traumatic neuritis - motor and sensory deficits ofL5, SI, and S2 nerve roots after labor. It may be a result of one or more of the following:

-disc protrusion at IVF -traction of lumbosacral trunk

(forceps) -compression of lumbosacral

trunk by fetal head -compression of popliteal nerve

due to positioning

Effects of chiropractic care on labor Statistics from the author's case files

!CA INTERNATIONAL REVIEW OF CHIROPRACTIC NOVEMBER/DECEMBER 1990

were tabulated and a comparison of average labor time made. Twenty-seven primagravida and 31 multiparous women were compared as to their mean duration of labor. Only woman who were first seen from the first to tenth week of pregnancy were used for comparison purposes. The term "labor" was defined as the time rhythmic contractions could be discerned and followed by timing. The results can be seen in Fig. 2.

We can see by these statistics what with all else being equal, the mean labor times were reduced by 25 per­cent in the primagravida women, and by 31 percent in the multiparous women. This in no way represents a controlled study, but does reflect con­cise accurate records which are kept by the author with respect to nearly every aspect of the pregnancy of each patient seen.

Conclusion In conclusion, it is easy to see how significantly a woman's body is affected by the hormonal changes that occur during pregnancy, and how these changes profoundly affect the muscu­loskeletal system. Subluxation is an inherent part of pregnancy and thus the chiropractor's role is defined. The success of the chiropractor-obstetrician

24

22

20

18

16

H 14

0

u 12

R

s 10

8

6

4

2

0

Without Chiropractic

Care

With Chiropractic

Care

Primigravida

Figure 2

!CA INTERNATIONAL REVIEW OF CHIROPRACTIC NOVEMBER/DECEMBER 1990

Without Chiropractic

Care

With Chiropractic

Care

Multiparous

41

TREATMENT PROTOCOL

RULE OF THUMB-Women who have a history of back problems especially sciatica will usually benefit from the hormonal influences of "relaxation" during pregnancy. Those women who generally have "healthy" backs will suffer from the hormonal influences which feel as though there is a lack of support.

In the author's office a combination of manual manipulation and soft­tissue techniques are employed on a hi-lo with the fall away thoracic/ abdominal section. Any number of chiropractic techniques can be employed with excellent results. Fig. 3 shows the case management protocol used in the author's office.

Frequency of Visits

1 XWeek

2 Xmonth 2 Xmonth

1 Xmonth 1 Xmonth

--------------- - - - - - - - - - -1 20 40

GESTATION POST-PARTUM

WEEKS

Figure 3

relationship rests on the chiropractor's ability to constructively contribute to the care and education of the pregnant woman. With the increasing awareness of environmental effects on the fetus and the increased stress on the pregnant woman, chiropractic's natural and ef­fective methods are quickly coming into the mainstream of care of the pregnant woman.

Bibliography Carpenter,M.B. HumanAnatomy. 7th Ed.; Williams and Wilkins 1976.

Janse, Howser, Wells. Chiropractic Prin­ciples and Technic; 2nd Ed 1978 (1948); National College of Chiropractic.

Gary Govan et al. Obstetrics Illustrated; 3rd Ed.; Churchill Livingstone 1980.

Haldeman, Scott. Modern Developments in the Principles and Practice of Chiroprac­tic; Appleton, Century, Croft 1980.

McMullen, Maxine. Unpublished notes 1982.

Sutherland, S. Meningeal Neural Relations in the Intervertebral Foramen; ]. Neurosurgery 1974; 40:756

Fulton, J.F. Physiology of the Nervous System; 3rd Ed., Oxford University Press 1949

Tedeschi, CG. Neuropathology: Methods and Diagnosis; Little and Brown 1970.

Gray's Anatomy; Williams and Wilkins; 36th British Ed.

Palmer, M.H. Chiropractic Anatomy; 5th Ed., Palmer College of Chiropractic 1923

Leach, Robert H. The Chiropractic Theories: A Synopsis of Scientific Research; 2nd Ed., Williams and Wilkins 1986. II

JoanM. Fallon, DC is a graduate of Palmer College of Chiropractic. Dr. Fallon has a private practice in Bronx­ville, New York, where she special­

izes in obstetrics and pediatrics. She also serves as assistant professor at Yeshiva University in the department of natural sciences and mathematics. Dr. Fallon has been interviewed on TV in the NYC metropolitan area on children and chiro­practic care and pregnancy. She recently presented a paper on biomechanics and pregnancy at the 1990 Annual Conven­tion and Symposium of the American Public Health Association.

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42 !CA INTERNATIONAL REVIEW OF CHIROPRACTIC NOVEMBERJDECEMBER 1990

THE NEW ZEALAND MEDICAL JOURNAL

Journal of the New Zealand Medical Association

NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 36

URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA

Chiropractic claims in the English-speaking world

Edzard Ernst, Andrew Gilbey

Abstract

Background Some chiropractors and their associations claim that chiropractic is

effective for conditions that lack sound supporting evidence or scientific rationale.

This study therefore sought to determine the frequency of World Wide Web claims of

chiropractors and their associations to treat, asthma, headache/migraine, infant colic,

colic, ear infection/earache/otitis media, neck pain, whiplash (not supported by sound

evidence), and lower back pain (supported by some evidence).

Methods A review of 200 chiropractor websites and 9 chiropractic associations’

World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom,

and the United States was conducted between 1 October 2008 and 26 November

2008. The outcome measure was claims (either direct or indirect) regarding the eight

reviewed conditions, made in the context of chiropractic treatment.

Results We found evidence that 190 (95%) chiropractor websites made

unsubstantiated claims regarding at least one of the conditions. When colic and infant

colic data were collapsed into one heading, there was evidence that 76 (38%)

chiropractor websites made unsubstantiated claims about all the conditions not

supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%)

associations made claims about lower back pain, whereas 179 (90%) websites and all

9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated

claims were made about asthma, ear infection/earache/otitis media, neck pain,

whiplash in at least half of all chiropractor websites.

Conclusions The majority of chiropractors and their associations in the English-

speaking world seem to make therapeutic claims that are not supported by sound

evidence, whilst 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.

The raison d'être of chiropractic “is to enhance the natural healing abilities of the

body by correcting a malfunction of the spine called a vertebral subluxation through

adjustment”.1 Chiropractic is advocated as being “much more than a way of seeking

relief from back pain”,1 “the third largest healthcare profession in the world”,

2 and

“entering the healthcare mainstream”.3

The relationship between chiropractic and mainstream medicine has, at times, been

somewhat uneasy. For example, Chiropractic’s founder, DD Palmer, was once

imprisoned for practising medicine without a licence in America4—and, in New

Zealand in the 1970s, the medical profession argued that chiropractic is “an unproven

treatment directed at an unlimited range of disorders”.5 More recently, in a survey of

chiropractic brochures provided by 9 national organisations in the United States and

NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 37

URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA

Canada, all were found to have made “claims for chiropractic services that have not

been scientifically validated”.6

Similarly, a survey of World Wide Web claims of chiropractic colleges in the United

States and Canada found that 8 out of 16 made “unsubstantiated claims for the value

of chiropractic clinical care”.7 In response to a fictitious email enquiry sent to 13 New

Zealand chiropractors, purportedly from a concerned parent about their child’s asthma

and recurrent ear infection (conditions for which there is no sound evidence to support

chiropractic interventions), 12 encouraged a consultation, 9 suggested that they could

treat asthma, and 8 that they could treat ear infection.8

In a small pilot study of chiropractors’ claims in their World Wide Web websites, 9 of

10 United Kingdom clinics were found to have made unsubstantiated claims about the

effectiveness of chiropractic.9

Criticisms regarding unsubstantiated claims have been raised even by Doctors of

Chiropractic, two of whom suggested that those outside the chiropractic profession

may interpret widespread unsubstantiated claims of effectiveness as “evidence of a

lack of professionalism and of quackery” that have evolved within a “tradition of

dogma, fallacious reasoning, and unconventional attitudes about research and

science”.6

Contrarily, many chiropractic associations and practitioners believe chiropractic is

essentially based in scientific principles and supported by research, the same as is

orthodox medicine.10,11

This debate may be of esoteric interest only, as chiropractic is

clearly thriving irrespective of criticism.3,12

Although there is evidence that some chiropractic brochures, colleges, and phone

advice make claims not supported by evidence,6,7,8

apart from a small pilot-study of

10 UK chiropractors,9 no studies have so far tested claims made or implied on

chiropractors’ Websites, from which potential first-time users of chiropractic may

seek information.

The purpose of the current study was therefore to investigate the websites of

chiropractic associations and practitioners, in Australia, Canada, New Zealand, the

United Kingdom, and the United States, regarding direct or indirect claims to treat

seven conditions that are not supported by sound evidence from well-designed

controlled trials: asthma, headache/migraine, infant colic, colic, ear

infection/ache/otitis media, neck pain, and whiplash (Table 1). These conditions were

chosen for investigation as from experience we were aware that they frequently

appear in chiropractic literature, despite a lack of sound supporting evidence.

We accept that some studies purportedly demonstrate the effectiveness of

chiropractic. However, when case studies, non-controlled, non-randomised, or non-

peer reviewed studies were excluded, as they do not constitute quality evidence in any

hierarchy of which we are aware, and systematic reviews or randomised control trials

(if systematic reviews were not available) were consulted instead, we could find no

evidence of chiropractic effectiveness for the seven conditions. Claims regarding

lower back pain were also reviewed as evidence suggests it may respond to

chiropractic spinal manipulations13

and thus might reasonably be expected to be

robustly promoted in chiropractors’ websites.

NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 38

URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA

Table 1. The best current evidence for conditions commonly referred to by

chiropractors

Condition Type of evidence (ref) Conclusions

Asthma Cochrane review 14

There is insufficient evidence to support the use

of manual therapies for patients with asthma*

Back pain (lower) Cochrane review13

No evidence that spinal manipulation is superior

to other standard treatments for acute or chronic

low back pain*

Colic None found No evidence

Infant Colic Health Technology Report 15

No convincing evidence*

Ear infection/ache/otitis media Only a feasibility study is

available16

No sound evidence

Headache/migraine Systematic review 17

…no rigorous evidence…*

Neck pain Cochrane review 18

…evidence did not favour spinal

manipulation/mobilisation done alone…*

Whiplash Systematic review19

No controlled clinical trials…* *Verbatim.

Method

A search for chiropractors’ websites and chiropractic associations on the World Wide Web was carried

out between 1 October 2008 and 26 November 2008, using the internet search engine Google, with the

appropriate domain extension for Australia, Canada, New Zealand, the United Kingdom, and the

United States. The keywords, were ‘chiropract*’AND ‘association’, ‘chiropract*’AND ‘organisation’,

‘chiropract*’AND ‘society’, and ‘chiropractor’.

All international and national associations and the first 40 chiropractors’ websites returned for each

country would form the sample for review. Sponsored links were not included, as these may be high

profile practices with little in common with the average practice.

Our convenience sample was limited to 40 websites for each country as most chiropractors were clearly

using one of two common templates for their websites and further data collection would therefore

contribute little. We believe that a convenience sample is the best strategy for the current study as it

would replicate the results of a World Wide Web based search by a member of the public seeking

information about chiropractic; had we randomly sampled from a register of practitioners in each

country, then we may have found websites not readily returned on a member of the public’s search of

the World Wide Web.

In the first 300 New Zealand search results, using the keyword ‘chiropractor’, 32 chiropractor websites

were returned. To increase the New Zealand sample size, a second search using the keyword

‘chiropractic’ was conducted; as a result, 8 further chiropractor websites were returned. All reviewed

materials were saved in both electronic and hard copy.

The material thus located was systematically checked by one author (AG) for evidence of claims

regarding any of the above-named conditions. The criterion deemed sufficient to conclude evidence of

a claim was that the condition would be mentioned by name on the website. Evidence would thus

include direct claims (e.g. chiropractic may help with headaches) or indirect claims (e.g. conditions for

which people consult chiropractors include headache).

If an association or advertisement mentioned a condition of interest as not suitable for chiropractic

treatment (e.g. a person suspecting they had condition X should consult their general medical

practitioner), then it would not be interpreted as an unsubstantiated claim. Whenever the phraseology

used in the reviewed materials was ambiguous about a particular condition, we (EE & AG) classified

the website or association as not making an unsubstantiated claim. Evidence of claims for other

conditions was also noted in a non-systematic fashion if they seemed sufficiently extraordinary to be

noted.

NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 39

URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA

Results

Two international and 7 national chiropractic associations were identified (see note 1

to Table 2 for names/countries of the associations). Chiropractic associations and

chiropractors’ claims (direct or indirect) about the 8 conditions are shown in Table 2.

Table 2. Chiropractic association and chiropractor website claims regarding the

eight conditions

There was evidence that 190 (95%) chiropractor websites make unsubstantiated

claims regarding at least one of the conditions. Only 56 (28%) chiropractor websites

and 4 of the 9 (44%) associations appeared to explicitly mention lower back pain,

although tentative evidence suggests it may respond to chiropractic manipulation,13

whilst 179 (90%) websites and all 9 associations mentioned headache/migraine,

which is not supported by sound evidence. When claims for colic and infant colic

were collapsed into a single heading, 76 (38%) of chiropractor websites were found to

make unsubstantiated claims about all the conditions for which there is a lack of

sound supporting evidence.

NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 40

URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA

There was evidence that some chiropractic associations make unsubstantiated claims

about conditions outside the scope of this survey; for example, allergies, arthritis,

immune system, longevity, osteoarthritis. There was also evidence that some

chiropractor websites make unsubstantiated claims regarding conditions outside the

scope of this survey; for example, attention deficit hyperactivity disorder, cancer,

epilepsy, immune function, infertility. In the case of infertility, one chiropractor’s

website printed what we believe is the extraordinary claim of research showing that

14 of 15 women unable to conceive, some for up to 10 years, had given birth after

beginning regular chiropractic care.

Discussion

Our results provide evidence that the professional chiropractic organisations of

Australia, Canada, New Zealand, the United Kingdom, and the United States make or

imply therapeutic claims that are not backed up by sound scientific evidence. Perhaps

as a consequence, many chiropractor websites of these countries follow suit.

Most healthcare professionals associate chiropractic with musculoskeletal problems.

Yet, several of the conditions claimed to respond to treatment are clearly not

musculoskeletal by nature (e.g., asthma, otitis, colic). One way to understand this

finding is to consider it within the wider context of chiropractic history.

The birthday of chiropractic is said to be September 18, 1895. On this day, D. D.

Palmer manipulated the spine of a deaf janitor allegedly curing him of his deafness.20

Palmer’s second patient, a man suffering from heart disease, was also claimed to be

cured.21

Following these early successes, Palmer articulated his theory of chiropractic,

coining the term “innate intelligence” (or “innate”) for the “energy” or “vital force”

he believed to be the essence of life. The “innate” is said to regulate all body

functions. The presence of a “vertebral subluxation” inhibits, according to Palmer, its

flow. Chiropractic is “a system of healing based on the premise that the body requires

unobstructed flow through the nervous system of…innate intelligence”.22

Based upon this notion, chiropractors use spinal manipulations to correct subluxations

to treat a very broad range of conditions: “95% of all diseases are caused by displaced

vertebrae, the remainder by luxations of other joints”.23

Broadly similar to our

findings, early chiropractic pamphlets hardly mention back pain or neck pain, but

assert that, “chiropractic could address ailments such as insanity, sexual dysfunction,

measles and influenza”.24

More recently the chiropractic profession split into those aligned to Palmer’s original

teachings (the “straights”) and those who also used treatments other than spinal

manipulation and focussed on musculoskeletal problems (the “mixers”). For many

years it seemed that the mixers dominated and chiropractors tended to fashion

themselves as back pain specialists using many forms of non-pharmacological

treatments. Now there is evidence that this process might be reversing. In 1991,

hardly any UK chiropractors admitted treating conditions other than spinal

problems.25

In 2003, 69% of all UK chiropractors felt confident to treat

visceral/organic conditions,26

currently this figure stands at 74%.27

In the US, “nearly 80% of chiropractors teach a relationship between subluxation and

internal health”,28

88% of US chiropractors believe that subluxation contributes to

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over 60 % of all visceral ailments and 90% feel that chiropractic treatments should not

be limited to musculoskeletal conditions.29

The American Chiropractic Association

stresses that chiropractic care is not limited to back pain, neck pain or other

musculoskeletal disorders,30

and most chiropractic texts discuss spinal manipulation

as a treatment for “visceral disorders”e.g.31,32,33,34

Based on the data presented here, the

situation seems to be similar in the other English-speaking countries.

Unsubstantiated claims of the nature described above may put patients at risk and are

simply at odds with the notion that chiropractic is in any way scientific. As evidence

of these claims is so widespread, we suggest this amounts to a public health issue. If,

for instance, a child suffering from severe asthma is treated with ineffective spinal

manipulation instead of effective drug therapy, there is an increased chance that this

patient’s life might be lost. In this context, one must, of course, also consider the

direct risks of spinal manipulation, which evidence suggests may be

considerable35,36,37

(although it is noted that orthodox medicine is by no means free of

risk38

).

A survey of UK chiropractors shows that 90% of them believe they support evidence-

based practice principles,39

and their code of ethics states that “chiropractor’s

provisions of care must be evidence-based...”.40

The data summarized above suggest

that chiropractors fail to abide by their own rules, although we suspect this is not

intentionally but due to the paucity of science in their curriculum.

The same code of ethics also regulates chiropractor’s advertising and provides that

“the information used must be factual and verifiable. The information must not be

misleading or inaccurate in any way.”40

The ethical guidelines in Canada, New

Zealand, and the United States are similar, but the Chiropractors’ Association of

Australia does not appear to prescribe guidelines for advertisements. Claims such as

those disclosed here in chiropractors’ websites, in our view, violate the most

fundamental rules of medical ethics: beneficence, non-maleficence and autonomy.41

This has further important practical implications; for instance, informed consent is not

a realistic possibility if it is given based on misleading information.42

Our analyses have some important limitations. Web-based information can only

generate an indirect picture of what might happen in actual clinical practice, even

although it may be the first place that potential patients may use. However, more

direct ways to ascertain such information seem to confirm the bleak impression

gained by our surveys: direct questioning of chiropractors, for instance, revealed that

the advice issued by them is frequently not responsible. New Zealand and UK

chiropractors have been shown to recommend chiropractic for childhood asthma,8,43

Canadian chiropractors have recommended treatment for an 11 year old female

assessed as healthy by an experienced paediatric orthopaedic surgeon,37

and many UK

chiropractors advise parents against immunisation of their children.43

Future research in this area should seek to explore differences in the degree to which

the practices of “mixers” and “straights” are successful; that is, does claiming to treat

conditions that are clearly not of musculoskeletal origin lead to a more successful

practice; for example, in number of consultations and financial remuneration. The

extent to which chiropractor websites make unsubstantiated claims could also be

explored in relation to length of time since graduating in chiropractic, as new

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graduates are more likely to believe their scope of practice extends beyond the

treatment of back, head, and neck pain.37

Finally, the healthcare community at large might investigate ways of minimizing the

risk to patients caused by unsubstantiated claims, particularly insofar as patients may

delay or fail to seek out orthodox care.

In conclusion, we have presented evidence that many of the direct or indirect claims

made by chiropractors and their organisations around the world are not supported by

current sound evidence. This, we feel, raises important issues and may even put lives

at risk. We therefore urge the chiropractic community to address this situation

adequately and urgently.

Competing interests: None known.

Author information: Edzard Ernst, Director, Complementary Medicine, Peninsula

Medical School, University of Exeter, Exeter, England; Andrew Gilbey, Lecturer,

College of Business, Massey University (Turitea Campus), Palmerston North,

New Zealand

Correspondence: Andrew Gilbey, College of Business, Massey University,

Private Bag 11 222, Palmerston North, New Zealand. Email:

a.p.gilbey@massey.ac.nz

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