Can a chiropractor replace your GP?

Chiropractors are increasingly moving into family primary care, taking on the role traditionally filled by GPs.
 
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01 .Introduction

chiropractors

We take a look at the risks and benefits of using chiropractors for routine primary care, as opposed to GPs.

For more information about therapies, see General health.

Chiropractors are increasingly moving into primary health care for the whole family, including babies and children – a move that has a lot of people worried.

Time was when you had a bad back, you might see a chiropractor. Headaches, heartburn or asthma – you’d go to your GP. But now, it seems, you can go to your local chiro for just about any ailment, and by manipulating your spine they reckon they can fix it. Even if you’re not sick, regular manipulations will help keep the bugs at bay.

Chiropractors as alternative health practitioners

Once considered an addition to, rather than replacement of, conventional medicine, chiropractors are increasingly positioning themselves as alternative health practitioners advising on all manner of health problems in a primary healthcare setting. While there is historical precedence for a holistic health approach in chiropractic, the proliferation of chiropractors as de facto GPs has escalated in recent years.

This shift is reflected in the vision statement of the profession’s peak body, the Chiropractors’ Association of Australia (CAA), which positions chiropractic as an alternative health system distinct from the mainstream and aims to “achieve a fundamental paradigm shift in healthcare direction where chiropractic is recognised as the most cost efficient and effective health regime of first choice that is readily accessible to all people”.

As primary healthcare practitioners, then, some chiropractors have moved into family care, including the care of babies and children. It’s this move in particular that has many people worried. The main concerns are that if there's something really wrong with a child, the chiropractor may misdiagnose the problem, miss it altogether and/or not give appropriate treatment; if there's nothing wrong with a child, doing "preventative" manipulations may cause problems; and that by recommending against vaccination, more serious health problems for the child and others in the community may arise.

Safety concerns

One concern is that chiropractors are manipulating babies’, children’s and adolescents’ spines, despite lack of evidence for effectiveness and potential for harm. A recent review of studies looking at the effectiveness of manual therapy for back pain and other musculoskeletal complaints in children and adolescents found no high quality clinical trials had been published.

While chiropractors argue that complications from manipulation are rare and mild, others argue that the possibility is nevertheless real. A 2006 review on paediatric chiropractic that searched all studies in major medical literature databases published up to 2004 identified 14 cases of adverse effects, nine of which were classed as serious, including paraplegia. 

Meanwhile, a number of surveys have found that many adverse events simply aren’t reported in the medical literature. Undoubtedly the percentage of manipulations that ends in tragedy is small, but if there’s little evidence of benefit from chiropractic manipulation, why risk it at all?

Beyond musculoskeletal care

Besides musculoskeletal problems, some chiropractors claim to be able to treat many other health problems in children and adolescents, including colic, hyperactivity and learning disorders, ear infections and glue ear, allergies, asthma, colds and bedwetting. This is based on the innate intelligence and subluxations theory of chiropractic, whereby removing subluxations can help restore the body’s nervous energy flow, allowing the body to heal itself. 

Many parents say their children have benefited from chiropractic treatment for such conditions, and while there is some evidence that chiropractic manipulations are effective for acute back pain, there’s no high-level evidence that it’s effective for anything else. Improvement observed in other conditions may have been due to placebo effect or because the condition may well have improved on its own.

There are also concerns that chiropractors will miss something more serious because they lack the more extensive diagnostic training and experience that GPs and other doctors have. At best this could mean incurring unnecessary expense for ineffective treatment; at worse, increased suffering and poorer long-term prognosis due to delaying appropriate treatment – or not getting it at all.

Anti-vaccination

Another serious concern is that a vocal minority of chiropractors are opposed to vaccination of babies and children. Vaccinations are talked of as “toxic poisons” and blamed for numerous diseases and conditions such as ADHD, autism, diabetes and cancers. With its philosophy of treating people without drugs, chiropractic maintains that keeping the spine free of nerve interference helps promote a healthy body and a normally functioning neurological and immune system. Sometimes, homeopathic vaccines (which don’t work) are recommended.

The CAA doesn’t have a position statement on immunisation, but some of its board members are professional members of the controversial Australian Vaccination Network, an anti-vaccination movement discredited by the Health Care Complaints Commission. The other main member body for chiropractors, the Chiropractic and Osteopathic College of Australasian (COCA), has a position statement in support of immunisation as a “simple, safe and effective way of protecting people against harmful diseases”, and recommends members refer patients to their GP for advice about vaccination.

Health authorities have long acknowledged that while vaccination can sometimes have negative effects, these are extremely rare, while the negative health consequences of the diseases they help prevent are more common and often more serious. Critics from within the profession further point out that risks from manipulation are comparable to, if not greater than from vaccines, so it’s hypocritical of their peers to recommend manipulations while recommending against vaccination on the basis of risk.

The profession’s regulatory body, the Chiropractors Board of Australia, is broadly supportive of vaccination, and if you’re presented with anti-vaccination material or advice by chiropractors, it’s worth reporting them to the board.

Karina Bray is a member of Friends of Science in Medicine (FSM), an organisation committed to promoting the teaching and practice of evidence-based medicine based on scientific principles, while opposing the teaching of non-scientific health courses (eg iridology, homeopathy, reflexology) in universities. CHOICE as an organisation also supports FSM's objectives. Fellow friends include prominent academics, scientists and medical professionals.

 
 

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As any doctor will tell you, an orthopaedic subluxation is a real thing – a painful partial dislocation or misalignment of a vertebra that can be seen on an X-ray image.

Chiropractic has its origins in a quasi-religious system of healing invented by American bonesetter and magnetic healer, Daniel Palmer, in the late 19th century. 

At its core was the belief that the body possessed an innate intelligence, defined as an energy or vital force that enabled the body to heal itself, but whose functioning could be impeded by subluxations (displacements). The chiropractor’s remit, then, was to detect and correct these subluxations.

As any doctor will tell you, an orthopaedic subluxation is a real thing – a painful partial dislocation or misalignment of a vertebra that can be seen on an X-ray image. 

They rarely affect nerves and don’t cause disease. But a chiropractic subluxation refers to a functional entity, and can’t necessarily be detected via X-ray or modern medical imaging. According to neurophysiology professor, Marcello Costa, “The elusive ‘subluxation’, the one chiropractors postulate as causing diseases, simply does not exist.” Even chiropractors themselves have never successfully proven subluxations actually exist, let alone cause myriad health problems.

Yet to a large extent it’s the belief in subluxations and innate intelligence that distinguishes members of the chiropractic profession. Many practitioners have rejected these theoretical constructs and focus on the physical aspects of musculoskeletal therapy, yet there are still so-called fundamentalists who adhere to these beliefs, including the profession’s peak body, the Chiropractors Association of Australia (CAA), which has about 2600 members.

The CAA’s core values include the recognition that there’s “an innate intelligence within a living organism that strives to preserve life and, if uninhibited, will express optimal wellbeing”. Furthermore, “subluxations compromise the expression of innate intelligence, and … prevention and removal of subluxations will facilitate the expression of optimal health”.

The other main member body for chiropractors, the Chiropractic and Osteopathic College of Australasian (COCA), which has more than 1000 members, rejects the notion of subluxations and proposes to adopt the position of the General Chiropractic Council in the UK, which states: “The chiropractic vertebral subluxation complex is an historical concept but it remains a theoretical model. It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.”

In some respects, chiropractic has come a long way since its quasi-religious beginnings. Qualification now involves intensive study of anatomy, physiology and biomechanics, particularly as these relate to the spine. It’s taught in four Australian universities, and graduates of the four- or five-year courses are considered allied health professionals – they can even title themselves “doctor” – who are funded by Medicare and most private health insurers. 

Practitioners are required to register with the Chiropractic Board of Australia, which regulates professional practice and currently has more than 4000 practising members.

Those in chiropractic who prefer an evidence-based approach lament the lack of well-conducted clinical trials, but also point out that not all practices in conventional medicine are evidence-based. Mainstream medical practitioners by and large acknowledge the system’s failings, but also argue they are conscientiously self-critical and continually evaluating and striving to improve the state of evidence in medicine. They also point out that conventional therapies that haven’t been strictly subjected to randomised, placebo-controlled trials are at least biologically plausible – unlike many alternative medicine therapies.

But not all chiropractors believe any shortcomings in conventional medicine let them off the hook in their own profession. Indeed, some of the profession’s harshest critics come from within. Having invested many years and (particularly in some countries) a lot of money obtaining their qualifications, they understandably want to be recognised as highly qualified, scientifically trained health practitioners who can make a legitimate and valuable contribution to people’s health and wellbeing – and they’re concerned references to theories and practices not based on sound scientific principles reflect negatively on the profession as a whole.

The scoliosis dilemma

Scoliosis is a condition where the spine has an abnormal sideways curve. The most common type is adolescent idiopathic (which means it has no known cause) scoliosis, which occurs mostly in girls. While most cases are mild and don’t require treatment, the most common treatment when necessary and appropriate – depending on the degree of the curve, the age of the patient and evidence of progression – is to wear a back brace. Because adolescents’ bones are still growing, the brace helps control the curve so it doesn’t get worse – but it doesn’t cure scoliosis. In extreme cases, surgery to fuse the vertebrae in a more normal alignment may be required.

Because it involves the spine, many chiropractors feel they have something to offer in the treatment and management of scoliosis, and while chiropractic may be helpful for pain relief, it’s the treatment aspect that has orthopaedic specialists concerned. They argue there is no evidence that chiropractic manipulation, exercise programs, electrical stimulation or dietary advice can successfully halt the progression of the curve.

The risk, then, is that people miss out on effective management or delay seeking help while visiting a chiropractor, and by the time they turn to conventional medicine the window of opportunity for obtaining the best results may have passed – either the curve is too large or the growth phase has finished.

For more information about identifying and managing scoliosis, talk to your doctor or visit Scoliosis Australia.

The doctors that CHOICE spoke to are quick to point out that there are some great chiropractors out there, and they happily refer patients to them for musculoskeletal problems. 

So if you develop a bad back, the first step is to ask your family doctor or GP to recommend one. However, if they can’t help you, there are some indicators to help you choose a good one.

  • Look for a chiropractor whose practice is limited to conservative treatment of back pain and other musculoskeletal problems. Avoid chiropractors who insist that they are primary care doctors.
  • Science-based chiropractors commonly use heat or ice packs and recommend a home exercise program in addition to manual manipulation or stretching or massage of tight muscles or joints. They don’t use applied kinesiology, live blood analysis, surface electromyography, thermography, an Insight Subluxation Station or an activator (“the stick that goes click”). See our article on Dodgy Diagnostics for more on these.
  • You should see significant improvements after a few visits. Don’t get caught into signing up for a long-term treatment program or “contract of care” where you agree to have regular, frequent visits for many months – some even ask for payment in advance.
  • Avoid chiropractors who claim to prevent or treat diseases, infections and health conditions other than musculoskeletal ones; who claim to detect and treat subluxations; or who prescribe and sell dietary supplements or homeopathic remedies.
  • Avoid chiropractors who advise you not to have your children immunised.
  • The chiropractor should explain that chiropractic neck manipulation can cause serious injuries, including stroke. Ideally, they should ask you to give informed written consent.
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