Pain in the Neck

Snap. Crackle. Pop.

That's the sound of the man, working on your back pain. Every year, some 20 million Americans undergo chiropractic treatment, receiving a series of specialized (and distinctly audible) adjustments to their spinal columns. Studies have also shown that chiropractors are extremely popular with patients. But, at the same time, some doctors and researchers have made legitimate claims against the safety and effectiveness of the treatment. So what’s a consumer to do?

What’s In a Name?

Before you can make health decisions about chiropractic you need to understand what it is and what it’s meant to treat. Essentially, chiropractic is a series of specialized manual techniques that are usually applied to the joints of the spine.

The basic ideas of chiropractic date back to a late 1890s faith healer named Daniel David Palmer, who believed that all people carried a life force that flowed through the body and aided natural healing. To Palmer, misalignments called “subluxations” in the spine blocked the flow of this force and made people sick.

Today, though few chiropractors would promote the idea of a healing life force, most still attribute health problems to chiropractic subluxations. These are different from medical subluxations, which, according to the World Health Organization, are dislocations of the spinal joints so severe that they can be seen by X-ray. They don't happen terribly often. Chiropractic subluxations, on the other hand, are the main thing chiropractors treat. In 1996 the Association of Chiropractic Colleges declared that a subluxation puts your nervous system at risk of damage and can affect how your organs function—and how healthy you are overall.

But not all chiropractors work the same way. Dr. Richard Cooper, a professor of medicine at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, has researched and written extensively on chiropractic treatment and practice. He splits chiropractors into two groups: “Straights,” who believe chiropractic subluxations are responsible for almost all illnesses and that chiropractic treatment alone can heal; and “Mixers,” who usually make less broad claims about what causes disease and who mix traditional chiropractic with other methods like massage or vitamins. 

Making the Right Choice

Does chiropractic work? That's a complicated question.

Despite the differences in approach, not all studies of chiropractic distinguish between the approaches of mixers and straights. In addition, as Dr. William Lauretti, spokesperson for the American Chiropractic Association, points out, it's almost impossible to do a properly scientific double-blind study on chiropractic the way you would compare the effects of a prescription drug versus a sugar pill. Even if subjects don't know whether they're getting a chiropractic adjustment, the person giving the treatment has to know in order to do it correctly.

However, there are several studies that are generally recognized as legit. One of the most prominent is a report released in 1995 by the federal Agency for Healthcare Research and Quality, which analyzed existing research at the time and synthesized the results. From this paper, we know that there is some evidence that chiropractic treatment might be effective for certain types of lower back pain in adults, within the first month of symptoms. There was no evidence supporting the treatment for other problems. In fact, one common claim—that chiropractic can treat childhood asthma—actually has evidence against it.

The safety of chiropractic is equally complicated.

Dr. Edzard Ernst, chair of Complementary Medicine at the University of Essex in England, studies the effectiveness and safety of alternative treatments. He says there's a lot of evidence that as many as 50 percent of all chiropractic patients experience mild, temporary pain following treatment—a statistic Lauretti says is overblown and largely irrelevant.

More alarming—and equally controversial—are a series of statistics showing a connection between chiropractic treatment and stroke. At least 700 people have died from strokes caused by internal damage to the arteries in their necks. Although a cause-and-effect link hasn't been proven, the people were all chiropractic patients who died in the days or weeks following a visit.

The Bottom Line

Chiropractic advocates, like Lauretti, say the treatment is perfectly safe and comes with plenty of anecdotal evidence proving effectiveness. Ernst, Cooper and other skeptics argue that concerns about safety outweigh any possible use and chiropractic should never be used.

But there are opinions outside these black and white terms. Dr. Stephan Barrett and Dr. Samuel Homola run a Web site called Chirobase, which provides scientific analysis and facts about chiropractic. They discount both Straights and Mixers as ineffective, saying that even Mixers use un-proven, un-scientific methods and give chiropractic too broad a role in health. Instead, they say responsible chiropractors are those who only use chiropractic to treat specific problems in the muscular-skeletal system, particularly in the lower back.

Barrett and Homola believe that chiropractic should only be used rarely—after a patient has first consulted with a medical physician. In addition, they say, patients should never continue chiropractic “maintenance” once symptoms have cleared up and should avoid having any treatment applied to their necks. They also say that it’s vitally important that you trust your back to only reputable chiropractors.

Unfortunately, that last part is more difficult than it sounds. According to Barrett and Homola, scientific, responsible chiropractors are few and far between. But they say there are several signs that will help you weed out the bad ones.

First, avoid the chiropractors who advertise excessively and who lure patients into their offices with free consultation specials. Trust your doctor’s recommendation—not the phone book—to find a good chiropractor.

Second, ask questions. Make sure that your prospective chiropractor doesn’t claim to treat anything outside the muscular-skeletal system, doesn’t prescribe unscientific treatments, doesn’t subscribe to the unproven theory of chiropractic subluxations and doesn’t work on children. Dr. Barrett and Dr. Homola (as well as Drs. Ernst and Cooper) say that chiropractic can damage immature cartilage growth centers and cause serious, lifelong neurological complications when used on people under the age of 10 or 12. Dr. Homola also says that backache isn't common in kids under 10 or 12 and, when it appears, can be a symptom of serious health problems that can't be diagnosed or treated by chiropractors. If you take a young child to a chiropractor for a backache you could end up with big problems that aren't being treated or noticed.

Finally, Barrett and Homola suggest avoiding any chiropractor who wants to take a series of X-rays—or worse, a full spine X-ray—as a standard up-front procedure. They say this isn’t something every patient needs, particularly if they’ve been previously diagnosed and referred by a medical doctor. Extra X-rays taken at the chiropractor’s office needlessly expose you to radiation and are frequently a pretense for diagnosing chiropractic subluxations and prescribing an unnecessarily high number of treatments or ongoing, expensive maintenance procedures.

Maggie Koerth-Baker’s work has appeared in AARP magazine, The Associated Press and Health magazine.