NOTE: Spinal manipulative therapy (SMT) is not unique to chiropractic, it is also offered by qualified medical doctors, physiotherapists and osteopaths.

This page was last updated on 24th June 2013.



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The Meade Report criticism

Review questions spinal manipulative therapy

FEBRUARY 2013: A comprehensive review has concluded that spinal manipulative therapy (SMT) is no more effective for acute low back pain than inert interventions, sham SMT, or as adjunct therapy, and also seems to be no better than other recommended therapies. The reviewers looked at 20 randomised controlled trials with a total of 2,674 participants. The studies varied greatly in quality and contained very little data on recovery, return-to-work, quality of life, and costs of care. [Rubinstein SM and others. Spinal manipulative therapy for acute low back pain: An update of the Cochrane Review. Spine 38:E158-E177, February 2013]  The situation faced by consumers who consult chiropractors is actually much worse than published studies indicate. In the most important studies, patients are appropriately screened for contraindications - often by medical teams - and the treatment is limited by the experimental protocol. However, in the real world, the odds of getting appropriate treatment are much lower because fraud, overtreatment (including "adjustments" to correct "subluxations"), and a wide variety of other unscientific practices are rampant in chiropractic offices.

Spinal manipulation: an update of a systematic review of systematic reviews

“The aim of this update is to critically evaluate the evidence for or against the effectiveness of spinal manipulation in patients with any type of clinical condition…Conclusion: Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition.” Paul Posadzki, Edzard Ernst, New Zealand Medical Journal

Spinal manipulative therapy for chronic low-back pain (Cochrane Review)

“High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority.” Cochrane Systematic Review (16th February 2011)

NOTE: The Cochrane Collaboration is a worldwide network of independent scientists dedicated to systematically summarising the totality of the evidence related to specific medical subjects in a rigorous and transparently impartial fashion.

Combined chiropractic interventions for low-back pain (Cochrane Review)

“Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. Future research is very likely to change the estimate of effect and our confidence in the results.” Walker BF, French SD, Grant W, Green S., Cochrane Database Systematic  Review 2010; 4: CD 005427

Comment on the above review from Professor Edzard Ernst: “The hallmark treatment of chiropractors is spinal manipulation. If critical evaluations of spinal manipulation fail to show what chiropractors had hoped for, defendants may argue that chiropractic typically combines a wide range of modalities in practice, including manipulation, mobilisation, massage, exercise and heat. Thus, it might not be fair to judge the value of chiropractic solely by the effectiveness of spinal manipulation.  This Cochrane review is an attempt to overcome this pitfall. Its results show that, for the most prevalent indication for chiropractic treatment (i.e. LBP), very few studies are available. Those that do exist are often seriously flawed. For acute and subacute LBP, chiropractic seems to be as good or marginally better than conventional treatments. However, I recommend taking this result with a pinch of salt; what is still required is independent replication through high-quality studies, which also account for the risks and costs associated with chiropractic. For chronic LBP, chiropractic does not seem to be any better than conventional treatments.  All in all, this review serves as a poignant reminder that chiropractic may not be as soundly based on evidence as it is often made out to be.” [Subscription to Focus on Alternative and Complementary Therapies required.]

Manipulation or mobilisation for neck pain (Cochrane Review)

Update of Cochrane Database Syst Rev. 2004;(1):CD004249

AUTHORS' CONCLUSIONS: Cervical manipulation and mobilisation produced similar changes. Either may provide immediate - or short-term change; no long-term data are available. Thoracic manipulation may improve pain and function. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Manual therapy for asthma (Cochrane Review)

Concludes "The methodological quality of one of two trials examining chiropractic manipulation was good and neither trial found significant differences between chiropractic spinal manipulation and a sham manoeuvre on any of the outcomes measured."

Spinal Manipulations for Cervicogenic Headaches: A Systematic Review of Randomized Clinical Trials

“The objective of this systematic review was to assess the effectiveness of spinal manipulations as a treatment option for cervicogenic headaches…There are few rigorous RCTs testing the effectiveness of spinal manipulations for treating cervicogenic headaches. The results are mixed and the only trial accounting for placebo effects fails to be positive. Therefore, the therapeutic value of this approach remains uncertain.” Paul Posadzki PhD, MSc, BSc, and Edzard Ernst MD, PhD, FMedSci, FSB, FRCP, FRCPEd, Headache (7th June 2011)

Diagnosis and treatment of acute low back pain

“Although there are numerous treatments for nonspecific acute low back pain, most have little evidence of benefit…Spinal manipulation and chiropractic techniques are no more effective than established medical treatments, and adding them to established treatments does not improve outcomes.” American Family Physician (February 2012)

An independent review of NCCAM-funded studies of chiropractic

Ten studies had tested chiropractic spinal manipulation. Only one had a positive outcome, and all of the studies were poorly designed and/or improperly reported. Because the fundamental concepts of chiropractic are biologically implausible, they recommended that (a) future studies be funded by the chiropractic profession rather than U.S. taxpayers, (b) investigations should aim to test the plausibility of chiropractic's main principles, and (c) measures be taken to ensure that the studies are conducted properly.” Ernst E, Posadzki P. Clinical Rheumatology (30:593-600, 2011)

Chiropractic care: no evidence it provides "clinically meaningful difference in people with lower back pain"

“NICE recently sanctioned chiropractic and osteopathy for recurrent back pain. The positive verdict was subsequently harshly criticised. Two new Cochrane reviews might now re-ignite this debate….Taken together these reviews provide little reason to send back pain patients to chiropractors or osteopaths, particularly if we consider the risks and costs of spinal manipulation.” Professor Edzard Ernst, Pulse (18th March 2011) [Free registration.]

The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralization or peripheralization. A randomized controlled trial

Conclusion. In patients with low back pain for more than six weeks presenting with centralization or peripheralization of symptoms, we found the McKenzie method to be slightly more effective than manipulation when used adjunctive to information and advice.
Spine (Phila Pa 1976) (24th February 2011)

From cradle to grave?

“…the notion that regular chiropractic treatments maintain patients at their optimal level and prevent illness is still a widespread concept in chiropractic. Thousands of websites promote it. Many chiropractors would like to see maintenance care for each patient from the cradle to the grave. This, of course, begs the question whether or not maintenance care is effective. A recent systematic review [1] found only one pilot study addressing this question. In this trial, 29 back pain sufferers were randomised to receiving either nine months of maintenance therapy or to having no such treatment. The results failed to show any differences in pain at follow-up. Since then no further studies have emerged. This means that no conclusive research on the effectiveness of chiropractic maintenance treatment currently exists.” Professor Edzard Ernst, Pulse (22nd November 2010) [Free registration]

An epidemiological examination of the subluxation construct using Hill's criteria of causation

Four scholarly chiropractors have concluded that epidemiologic evidence does not support chiropractic's most fundamental theory. Since its inception, the vast majority of chiropractors have postulated that 'subluxations' (misalignments) are the cause or underlying cause of ill health and can be corrected with spinal 'adjustments'. After searching the scientific literature, the authors concluded: "No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal, this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability." T.A. Mirtz et al, Chiropractic & Osteopathy (2nd December 2009) [pdf]

Chiropractic for fibromyalgia: a tale of two systematic reviews

“Within only a few months, two systematic reviews on the above subject were published [Schneider M, Vernon H, Ko G et al. Chiropractic management of fibromyalgia syndrome: a systematic review of the literature. J Manipulative Physiol Ther 2009; 32: 25–40, and Ernst E. Chiropractic treatment for fibromyalgia: a systematic review. Clin Rheumatol 2009; 28: 1175–78.] …The curious thing about these two articles is that their conclusions are quite different...Of course, it is as legitimate to evaluate one specific modality, e.g. spinal manipulation, as it is to assess a whole treatment package provided by chiropractors, e.g. ‘chiropractic management’. In the latter case, one would expect to see only trials included that were conducted by chiropractors in a chiropractic setting. This was the approach of my review but not of that by Schneider et al. For example, Schneider et al. included trials of acupuncture or exercise, which had nothing to do with chiropractic. Moreover, they included only some of the relevant trials while others were omitted. Their review was thus neither systematic nor was it specific to chiropractic. To publish reviews of that nature, is, in my view, misleading…In conclusion, several recent systematic reviews of ‘chiropractic management’ have drawn positive conclusions. Yet the hallmark therapy of chiropractors, spinal manipulation, is not supported by good evidence in the respective conditions. In my view, these reviews are therefore likely to mislead.”  Edzard Ernst, Focus Alternative and Complementary Therapies [FACT] (December 2009)

Spinal manipulation 'has no benefit for back pain'

"Controversy over the inclusion of spinal manipulation in NICE guidelines on back pain intensified this week after a study showed no benefit when it was added to standard care with painkillers…The study adds to mounting criticism over NICE guidelines on back pain. The controversy has already led to the British Pain Society ousting their president, Professor Paul Watson, a member of the guideline development group." Nigel Praities, Pulse (21st September 2009)

Chiropractic spinal manipulation for infant colic: a systematic review of randomised clinical trials

"Some chiropractors claim that spinal manipulation is an effective treatment for infant colic. This systematic review was aimed at evaluating the evidence for this claim. Four databases were searched and three randomised clinical trials met all the inclusion criteria. The totality of this evidence fails to demonstrate the effectiveness of this treatment. It is concluded that the above claim is not based on convincing data from rigorous clinical trials." Ernst, E. Int J Clin Pract. (September 2009) [pdf]

Chiropractic for otitis?

"Previous research has shown that professional chiropractic organisations 'make claims for the clinical art of chiropractic that are not currently available scientific evidence…'. The claim to effectively treat otitis seems to be one of them. It is time now, I think, that chiropractors either produce the evidence or abandon the claim." Edzard Ernst in a letter to the International Journal of Clinical Practice (September 2009)

Spinal manipulation for asthma: A systematic review of randomised clinical trials

"None of the studies showed that real manipulation was more effective than sham-manipulation in improving lung function or subjective symptoms. It is concluded that, according to the evidence of the most rigorous studies available to date, spinal manipulation is not an effective treatment for asthma." Ernst, E. Respir Med. (29th July 2009)

Chiropractic manipulation, with a deliberate “double entendre”

“…the best evidence available to date fails to demonstrate clinically relevant benefits of chiropractic for paediatric patients, and some evidence even suggests that chiropractors can cause serious harm to children. In the interest of vulnerable children, we should not be manipulated by misleading statements to the contrary.” Edzard Ernst, Archives of Disease in Childhood ( 2009) [PDF]

A randomised controlled trial of spinal manipulative therapy in acute low back pain [Full Text]

This trial compared standard care with standard care plus spinal manipulative therapy (SMT). Conclusions: SMT is unlikely to result in relevant early pain reduction in patients with acute low back pain. Bernhard, H-R Ziswiler, M Dähler, S Reichenbach and P M Villiger P Jüni, M Battaglia, E Nüesch, G Hämmerle, P Eser, R van Beers, D Vils, J, Ann Rheum Dis 2009;68;1420-1427 (originally published online 5th September 2008) [pdf]

Maintenance care in chiropractic — what do we know?

This review concludes that there is no evidence-based definition of maintenance care and the indications for and nature of its use remains to be clearly stated. The prevalence with which maintenance care is used has not been established. Efficacy and cost-effectiveness of maintenance care for various types of conditions are unknown. This conclusion is identical to that of a similar review published in 1996, namely that maintenance care is not well researched and that it needs to be investigated from several angles before the method is subjected to a multi-centre trial. Charlotte Leboeuf-Yde and Lise Hestbaek, Chiropractic and Osteopathy (8th May 2008)

Chiropractic: A Critical Evaluation

"Currently, there are two types of chiropractors: those religiously adhering to the gospel of its founding fathers and those open to change. The core concepts of chiropractic, subluxation, and spinal manipulation, are not based on sound science. Back and neck pain are the domains of chiropractic but many chiropractors treat conditions other than musculoskeletal problems. With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition. Manipulation is associated with frequent mild adverse effects and with serious complications of unknown incidence. Its cost-effectiveness has not been demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt." Edzard Ernst, Journal of Pain and Symptom Management (February 2008)  [FULL TEXT] [pdf]


Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial [FULL TEXT]

Interpretation: "Patients with acute low back pain receiving recommended first-line care do not recover more quickly with the addition of diclofenac or spinal manipulative therapy….These results are important because both diclofenac and spinal manipulative therapy have potential risks and additional cost for patients. If patients have high rates of recovery with baseline care and no clinically worthwhile benefit from the addition of diclofenac or spinal manipulative therapy, then GPs can manage patients confidently without exposing them to increased risks and costs associated with NSAIDs or spinal manipulative therapy." Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, O Day R, et al., The Lancet 2007; 370:1638-1643 (November 2007) [pdf] [An accompanying editorial noted: (1) Systematic reviews had concluded that NSAIDS and spinal manipulation were more effective than placebos. However, the patients in the reviewed studies did not have optimum first-line care, and the apparent benefit was not large, and (2) Advice to remain active and prescription of paracetamol will be sufficient for most patients with acute low back pain. (Koes BW. Evidence-based management of acute low back pain. Lancet 370:1595-1596 2007)]

Chiropractic manipulation and acute neck pain: a review of the evidence

"…there has only been one randomized clinical trial published in the English language that specifically dealt with the treatment of acute neck pain by manipulation… There has been scant investigative research into the treatment of acute neck pain with chiropractic manipulation." Dept. of Research, Palmer College of Chiropractic West (USA), Journal of Manipulative and Physiological Therapeutics (September 2005)

Cost-effectiveness of Combined Manipulation, Stabilizing Exercises, and Physician Consultation Compared to Physician Consultation alone for Chronic Low Back Pain: A Prospective Randomized Trial With 2-Year Follow-up

Concludes: "Physician consultation alone was more cost-effective for both health care use and work absenteeism, and led to equal improvement in disability and health-related quality of life. It seems obvious that encouraging information and advice are major elements for the treatment of patients with cLBP". Spine (15th May 2005)

The value of chiropractic

Edzard Ernst, MD,PhD, FRCP, FRCPEd, Focus on Alternative and Complementary Therapies [FACT] (June 2005)

[NOTE: In a letter to the Editor of the Health Service Journal on 26th July 2004, Margaret Coats, Chief Executive and Registrar of the UK General Chiropractic Council, claimed that there was a "wealth of research evidence that demonstrates the cost-effectiveness and efficacy of chiropractic". The letter may be viewed by visiting the Press Releases archive found in Publications section of the GCC's website:]

Sources of bias in reviews of spinal manipulation for back pain

"The effectiveness of spinal manipulation as a treatment for back pain remains uncertain and controversial. This is because of methodological weakness in many of the published clinical trials and also because of markedly opposing interpretations of the primary data by different reviewers… We conclude that the outcomes of reviews of this subject are strongly influenced by both scientific rigour and profession of authors. The effectiveness of spinal manipulation for back pain is less certain than many reviews suggest; most high quality reviews reach negative conclusions." Canter PH, Ernst E. Wiener Klinische Wochenschrift (The Middle European Journal of Medicine) (May 2005)


Effectiveness of physical treatments for back pain in primary care. Abstract and Rapid Responses. British Medical Journal (November 2004)  [Full text available via free registration]

Chiropractic care in asthma and allergy

Concludes that there is currently no evidence to support the use of chiropractic SMT (spinal manipulative therapy) as a primary treatment for asthma or allergy. Balon J W, Mior S A, Dept. of Graduate Studies and Research, Canadian Memorial Chiropractic College, Annals of Allergy, Asthma, & Immunology (August 2004) NOTE: Chiropractic services have recently been delisted by the governments of British Columbia, Ontario, and Alberta.]

Management of chronic low back pain (Clinical Update)

"Manipulative therapy was found in the latest meta-analysis to be slightly more effective than sham therapy (by 4 points on a 100-point scale), but not more effective than other forms of care, including care by a general practitioner, physiotherapy or exercises, 'back school', or therapies known to be ineffective. A contemporary review echoes these findings." Nikolai Bogduk, The Medical Journal of Australia (January 2004)

Spinal Manipulative Therapy for Low Back Pain

No evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain. Annals of Internal Medicine (June 2003) The definitive meta-analysis of spinal manipulation for back pain. "This is the most thorough and thoughtful analysis of this subject ever published…. According to a recent cost evaluation chiropractic care for back pain is about twice as expensive as medical care and we also know of serious and rare complications associated with spinal manipulation. Thus, spinal manipulation is an unlikely candidate for the treatment of choice for back pain….. Among other things, (this meta-analysis) should prompt those experts that are responsible for writing guidelines on therapy for back pain to check carefully whether their recommendations regarding spinal manipulation are truly evidence-based." E. Ernst, Focus on Alternative and Complementary Therapies (FACT), December 2003]

Chiropractic manipulation for non-spinal pain — a systematic review

The claim that this approach is effective for such conditions (fibromyalgia, carpal tunnel syndrome, infantile colic, otitis media, dysmenorrhoea and chronic pelvic pain) is not based on data from rigorous clinical trials. Edzard Ernst, New Zealand Medical Journal (August 2003)

Diagnosing and Treating Acute Mechanical Back Pain

"Almost all of the commonly used diagnostic procedures and passive modalities utilized by chiropractors are not supported in the available literature. Spinal manipulation has mild support in the treatment of acute low back pain, only being equal to or slightly superior to a placebo. The manipulable lesion appears to be hypothetical." Preston Long, PhD., Skeptic Report. Article originally published in the Journal of Quality Health Care (December 2002)

The effectiveness of spinal manipulation for the treatment of headache disorders: a systematic review of randomized clinical trials

"Despite claims that spinal manipulation is an effective treatment for headache, the data available to date do not support such definitive conclusions. It is unclear to what extent the observed treatment effects can be explained by manipulation or by nonspecific factors (e.g. of personal attention, patient expectation)." J. A. Astin & E. Ernst Cephalalgia (October 2002)

Low Back Pain

"We found conflicting evidence on the effects of spinal manipulation in acute and chronic low back pain." American Family Physician (March 2002)

Does spinal manipulative therapy help people with chronic low back pain?

Concludes that spinal manipulation does not produce clinically worthwhile decreases in pain compared with sham treatment, and does not produce clinically worthwhile reductions in disability compared with NSAIDs for patients with chronic low back pain. Ferreira M L, Ferreira P H, Latimer J, Herbert R, and Maher C G, Australian Journal of Physiotherapy (2002)

Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease

“The proper differential diagnosis of somatic vs. visceral dysfunction represents a challenge for both the medical and chiropractic physician. The afferent convergence mechanisms, which can create signs and symptoms that are virtually indistinguishable with respect to their somatic vs. visceral etiologies, need to be appreciated by all portal-of-entry health care providers, to insure timely referral of patients to the health specialist appropriate to their condition. Furthermore, it is not unreasonable that this somatic visceral-disease mimicry could very well account for the "cures" of presumed organ disease that have been observed over the years in response to various somatic therapies (e.g., spinal manipulation, acupuncture, Rolfing, Qi Gong, etc.) and may represent a common phenomenon that has led to ‘holistic’ health care claims on the part of such clinical disciplines.” Nansel D, Szlazak M. J Manipulative Physiol Ther. (1995)