Are chiropractic adjustments evidence-based?

Chiropractic Adjustments: Evidence-Based Assessment

Chiropractic adjustments are not broadly evidence-based and are specifically contraindicated for certain conditions like rheumatoid arthritis, while showing limited effectiveness only for specific conditions such as acute low back pain. 1, 2

Evidence by Condition

Rheumatoid Arthritis

• The American College of Rheumatology (2023) conditionally recommends against using chiropractic therapy for rheumatoid arthritis management due to:
  • Potential cervical spine complications in RA patients
  • Perceived lack of benefit specific to RA
  • Burden and costs associated with treatment 1

Low Back Pain

• For acute/subacute low back pain:

  • Spinal manipulation shows small to moderate short-term benefits 1, 2
  • Differences between spinal manipulation and usual care were modest (approximately 5 points on 100-point scales) 1
  • Benefits diminish over time, with less pronounced effects after 12 months 1
  • One randomized trial found chiropractic more beneficial than placebo in reducing pain 3

• For chronic low back pain:

  • Moderate effectiveness compared to sham manipulation 1
  • No significant differences when compared to:
    • General practitioner care or analgesics
    • Physical therapy or exercises
    • Back school 1, 2

Neck Pain and Headaches

• For cervicogenic headaches:

  • Some evidence suggests spinal manipulation may be beneficial 4

• For migraine:

  • Moderate evidence supports spinal manipulation as part of multimodal interventions 4

• For tension-type headaches:

  • Spinal manipulation cannot be recommended for episodic tension-type headache
  • Insufficient evidence to recommend for or against use in chronic tension-type headache 4

Safety Considerations

• Serious adverse events after spinal manipulation are very rare:

  • Risk estimated at less than 1 per 1 million patient visits 1, 2
  • However, specific populations face higher risks

• Absolute contraindications include:

  • Rheumatoid arthritis with cervical involvement 1, 2
  • Spinal fusion
  • Advanced spinal osteoporosis 2

Clinical Decision Making

When considering chiropractic adjustments:

1. Rule out contraindications first:

   • Rheumatoid arthritis
   • Ankylosing spondylitis with spinal fusion
   • Advanced osteoporosis
   • Suspected vertebral artery issues

2. Consider only for:

   • Acute/subacute low back pain without radiculopathy when other conservative measures have failed
   • Some cases of cervicogenic headache

3. Recognize limitations:

   • Benefits are typically short-term and modest
   • Evidence does not support superiority over many other conservative treatments
   • Effects diminish over time

Evidence Quality Assessment

The overall evidence quality for chiropractic adjustments is moderate to low:

• Most positive findings show only short-term, modest benefits
• Many studies lack adequate control groups or blinding
• The BMJ's umbrella review (2021) noted that many common orthopedic interventions, including manipulative techniques, have limited high-quality evidence 1
• Evidence is strongest for acute low back pain, but even here, benefits are modest and comparable to other interventions

In conclusion, while chiropractic adjustments may provide modest short-term benefits for specific conditions like acute low back pain, they are not broadly evidence-based across all conditions and are specifically contraindicated for patients with rheumatoid arthritis and certain other conditions.