Probably one of the most widely used and trusted of the alternative medicines are manipulative therapies such as osteopathic and chiropractic interventions. More than 30,000 people visit an osteopath every day, with complaints ranging from back and neck pain to headaches and even asthma. Both practices come with an expensive qualification and official licensing, and many people I have spoken to have simply assumed that these treatments are part of the scientifically proven body of treatments we know as ‘modern medicine’. But both chiropractors and osteopaths in fact practise alternative medicine.

What is Osteopathic and Chiropractic?

In addition to the confusion over the evidence base of chiropractic and osteopathic care, for many people the exact definition of the two is rather hazy. So I tried to find out exactly what is chiropractic care and how is it different from osteopathic care, massage, sports massage and physiotherapy. As it turns out, even the professionals are a little fuzzy on the specifics.

Chiropractic care is concerned with treating the neuromusculoskeletal system, and traditionally assumes that vertebral subluxation interferes with the body’s ‘innate intelligence’. Some modern chiropractors recognise that this vitalistic concept of innate intelligence is misguided, and affirm that chiropractic care should not be applied as a cure-all, but directed specifically to conditions that actually involve the musculoskeletal system.

Osteopathy, on the other hand, claims to treat and prevent health problems using movement, stretching and massage, based on the concept that the well-being of an individual is dependent upon the harmonious alignment and functioning of bones, muscles, ligaments and connective tissue. Using massage, physical manipulation, stretching and massage, osteopaths claim to increase joint mobility, relieve muscle tension and increase blood flow to tissues to enhance the body’s own healing mechanisms.

So, chiropractors and osteopaths both agree that proper alignment and function of the bones, muscles and tendons is really important to health. However, chiropractors generally focus on spinal manipulation techniques, while osteopaths include soft tissue massage and movement in addition to the ‘clicking’ joint manipulation (known as “high velocity thrust” or HVT) employed by chiropractors. Osteopaths are also concerned with joints and bones across the entire body, including the bones in the skull; chiropractors only focus on the spine.

This article will specifically review the evidence for these two alternative medicines. I will not cover reflexology, massage, sports massage, physiotherapy or any other treatments. How do they differ? Well, reflexology is based upon the concept that there are reflexes in the feet, hands and ears which refer to every part of the body, some suggest through their connections via the nervous system. Reflexology therefore attempts to relieve pain by stimulating these reflexes or pressure points. Physiotherapy, which is widely available on the NHS and is not generally considered an alternative medicine, employs a range of techniques including movement and exercise, as well as some of the same techniques applied by chiropractors. The term physiotherapist, like chiropractor and osteopath, is a protected term, whereas reflexologist, masseuse and massage therapist are not. Massage includes a broad range of therapies that involve the rubbing and kneading of muscles and joints to relieve tension and pain. Some consider massage to be an alternative medicine, whereas others view it simply as a therapeutic experience without any specific medicinal claims.

Although most people associate chiropractic and osteopathic treatment with back and neck pain, these manipulative therapies have also been applied to an astonishingly long list of ailments including digestive conditions, headaches, asthma and insomnia.

How Does it Work?

Ask an osteopath how their treatment works and you’ll likely get an explanation something like this: “misalignments in the vertebrae and other parts of the musculoskeletal system can irritate or compress nerves, and tension in muscles or joints can starve organs and tissues of blood and nerve connections, both of which can cause pain or other health problems. Manipulative therapy on the muscles, bones, joints and spine can serve to realign the musculoskeletal system, relieve tension and restore blood flow.” Chiropractors claim that spinal manipulation can remove vertebral subluxations, which restores balance to the innate intelligence and heals the person. This sounds fairly scientific, but does it actually make any sense? Well, subluxation is a well-defined medical term, which refer to bones out of place (e.g. partial or complete dislocation), and subluxations like these are clearly visible on x-rays. Recently, chiropractors have had to redefine their subluxations (which don’t show up on x-rays) to be “a complex of functional and / or structural and / or pathological articular changes that compromise neural integrity and may influence organ system and general health”. In other words, we don’t currently really understand what chiropractors are doing when they manipulate bones and joints. The changes are not visible through modern scanning techniques and at present we have no way to quantify them.

Lots of explanations of how manipulative therapies work include mention of restricting the flow of nerves and blood or other fluids in the body (I assume they’re talking about lymphatic fluid). It isn’t clear exactly how this might occur – moving muscles and tendons may allow trapped nerves to become untrapped, or restore blood flow that was previously constricted, perhaps. However, there is no hard evidence, and so far science has been unable to provide a robust explanation for how chiropractic manipulations might work, assuming that they do.

Hard Science

8 (12) studies on chiropractic techniques, 10 meta-analyses
No. Reporting Significant Results: 9 (6 are for back / neck pain)
6 (7) studies on osteopathic techniques, 1 meta-analysis
No. Reporting Significant Results: 3 (2 are for back / neck pain)

Ok, time for the hard scientific evidence. I was able to find more studies on chiropractic therapy than any other manipulative therapy. Still, in total I was able to download 36 academic papers, of which 30 described randomised, placebo-controlled studies (or meta-analyses of). Of these, roughly half considered back or neck pain, with the other studies covering a wide range of ailments including infant colic, high blood pressure, asthma, headaches and menstrual cramps.

Overall the best evidence for the efficacy of chiropractors and osteopaths comes from studies on lower back pain. Two randomised, but uncontrolled trials showed a significant benefit of chiropractic intervention for back pain. That’s great, but without a placebo control it doesn’t tell us very much. However, a third, randomised, blind, placebo-controlled study by Hoirillis and colleagues (2004) backed up this result, finding that chiropractic treatment did in fact perform better than the placebo in reducing pain.

These were short-term effects, however – Hoirillis followed up with patients two weeks after treatment, at which point patients how had received chiropractic treatment did report a significant improvement in the severity of their symptoms. But look to the long term, and the verdict is much poorer. Several studies have showed that chiropractors provide only a short-term relief of pain, with the positive effects disappearing just weeks or months after treatment.

The picture is similar for osteopathic treatment. One study on treatment for lumbar disc herniation showed that osteopathic treatment was as effective as the alternative, , although the former was considerably cheaper. This effect persisted, with patients reporting similar reductions in pain after 12 months for both traditional treatment (chemonucleolysis) and osteopathic treatment.

Several other studies showed support for the use of chiropractic or osteopathic treatment for back pain, but they were plagued with methodological issues – small sample sizes, inadequate controls, lack of randomisation – an ongoing problem with studies on alternative medicine.

Across the literature I was able to find, there was no convincing (read large well-balanced, randomised controlled trial with a suitable placebo) support for any benefit of chiropractic treatment on asthma, headaches, arthritis, menstrual cramps or PMS. In fact, one study even found a negative effect – Licciardone et al (2004) report a lower rehabilitation rate for patients with knee and hip arthiritis who received oestopathic treatment compared to a placebo.

I found that about half of all studies on manipulative therapies claimed to show a significant benefit. However, as with many other alternative therapies, the overwhelming complaint in meta-analyses was that the methodological quality was extremely poor, with small sample sizes and poor controls. The average sample size of studies I looked at was similar for studies reporting significant and non-significant results, although the average for significant studies was substantially increased by a single very large study on back pain in over 700 participants – remove this and the average sample size for significant studies dropped to half that of the non-significant studies. This trend is supported by meta-analyses that tended to find a significant effect in smaller, poorer quality studies. For example, in one meta-analysis reviewing six studies of osteopathic treatment for lower back pain, the largest positive effect reported was for the smallest study (12 participants), and the next two largest effects were for studies lacking a proper control.

The Verdict

I have to say that the jury is still out on whether manipulative therapies such as chiropractic and osteopathic care can be effective in treating back pain. Overall, the studies conducted to date are of such poor quality that it is impossible to say for certain. The evidence is strongest for a positive effect on lower back pain, however this may well only be short-term. Longer-term effects are more commonly reported for osteopathic treatment, although this is still far from conclusive. Even when positive effects have been reported, they are often small and not clinically relevant. It seems unlikely that these techniques can be effective for treating other health problems, and future research should focus on identifying the mechanisms underlying the reported benefits of chiropractic and osteopathic care for lower back pain.

The Dangers

I’m all for harmless placebos – why take a drug with side effects when you can take a sugar pill with the same benefits? The problem is that many forms of alternative medicine come with risks. In the case of chiropractic and osteopathic care, and manual and manipulative therapies in so far as they involve high velocity thrusts to the spine and other joints, have been linked to strokes. A stroke can be triggered through spinal or neck manipulation when an artery leading to the brain ruptures, or becomes blocked as a result of stretching, commonly caused through extreme rotation of the head.

One study reviewed hospital records for nearly 600 patients and found that stroke victims were five times more likely to have visited a chiropractor in the previous week. Further, two independent controlled studies of stroke patients found that they were three times more likely to have seen a chiropractor or received spinal manipulation prior to the event. Together, these studies suggest there may be serious risks associated with osteopathic and chiropractic treatment. And just as doctors are legally obliged to provide patients with all the available information about the possible side effects of treatments, I believe patients considering visiting an osteopath or a chiropractor should have be informed about the possible side effects. Especially when those side effects could be lethal.

I’m not suggesting that we abandon manipulative therapies entirely. Although the underlying premise that the alignment of the skeleton somehow holds the cure to all ailments is rather naïve, it certainly seems reasonable that it might be important in back and neck conditions. Further, modern medicine struggles to cure back problems, and there are often few traditional treatment options available. With tentative evidence that osteopaths may be able to reduce pain for sufferers of back and neck pain, the next step is to improve our understanding of how this process works. Understanding this may enable us to develop new techniques that make the most of the beneficial effect of chiropractic treatment whilst reducing the risk of side effects such as stroke.

Articles in this Series:

• Introduction: The Truth and Lies Behind Alternative Medicine
• Part One: The Ultimate Dilute – Homeopathy
• Part Two: Body Manipulation – Osteopathy and Chiropractic Care
• Part Three: Poking Holes in Things – Acupuncture
• Part Four: Mental Manipulation – Hypnosis
• Part Five: Good Vibrations – Reiki and Crystal Healing

Want to Know More?

• Licciardone et al (2010) Osteopathic manipulative treatment of back pain and related symptoms during pregnancy: a randomized controlled trial American Journal of Obstetrics and Gynaecology
• Walker, French, Grant and Green (2010) Combined chiropractic interventions for low-back pain The Cochrane Collaboration
• Cassidy et al (2008) Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study Eur Spine J
• Licciardone, Brimhall and King (2005) Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials BMC Musculoskeletal Disorders
• Licciardone et al (2004) A Randomized Controlled Trial of Osteopathic Manipulative Treatment Following Knee or Hip Arthroplasty JAOA
• Hoiriis et al (2004) A randomized clinical trail comparing chiropractic adjustments to muscle relaxants for subacute low back pain Journal of Manipulative and Physiological Therapeutics
• Williams et al (2003) Randomized osteopathic manipulation study (ROMANS): pragmatic trial for spinal pain in primary care Family Practice
• Rothwell, Bondy and Williams (2001) Chiropractic Manipulation and Stroke : A Population-Based Case-Control Study Stroke
• Burton, Tillotson and Cleary (2000) Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation Eur Spine J
• Ernst (2000) Does Spinal Manipulation Have Specific Treatment Effects Family Practice
• Fabio (1992) Efficacy of Manual Therapy Physical Therapy
• Rubinstein, van Middelkoop, Assendelft, de Boer and van Tulder (2011) Spinal manipulative therapy for chronic low-back pain The Cochrane Collaboration
• Meade, Dyer, Browne, Townsend and Frank (1990) Low back pain of mechanical origin: randomised comparison of
  chiropractic and hospital outpatient treatment BMJ