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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.
Conclusions: "SMT [Spinal Manipulative Therapy] is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies.” (12th September 2012)
“…the therapeutic value of this approach for athletes remains uncertain.” Edzard Ernst and Paul Posadzki, Focus on Alternative and Complementary Therapies [FACT] (March 2012)
“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)
Critical comments on the study conducted by Gert Bronfort (DC), Roni Evans (DC), Alfred V. Anderson (DC), Kenneth H. Svendsen, Yiscah Bracha, and Richard H. Grimm (Ann Intern Med January 3, 2012 156:1-10;)
“…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]
Results showed that preventative spinal manipulation was no better than regularly discussing the neck problem. BMC Musculoskeletal Disorders (February 2011)
“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
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)
“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)
Conclusions: Current evidence does not support the use of spinal manipulations for the treatment for migraine headaches. Posadzki P, Ernst E. Cephalalgia. (21st April 2011)
“We conclude that high-quality systematic reviews with a clear focus are required before the value of SM for headaches can be defined.” Posadzki P, Ernst E. Headache. (31st March 2011)
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)
“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.]
“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 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.]
Conclusion: “There is no supportive evidence that chiropractic is an effective treatment for gastrointestinal disorders.” Edzard Ernst, Canadian Journal of Gastroenterology (January 2011)
“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)
“…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  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]
CONCLUSIONS: Neck manipulation is not appreciably more effective than mobilization. The use of neck manipulation therefore cannot be justified on the basis of superior effectiveness. Arch Phys Med Rehabil. (September 2010)