Veterinary chiropractic: A friend or foe to your patients?

Chiropractic is primarily the manipulation of bones in the spine in an effort to treat or prevent disease or to reduce discomfort. Though therapeutic manipulation of bones in the spine has a long history, chiropractic—as it is understood today—was invented in the late 19th century by Daniel David Palmer. He conceived the notion that all disease results from vertebrae in the spine being out of place (so-called “subluxations”), and that their forceful manipulation (an “adjustment”) can prevent or treat disease. He gave varying explanations for this idea over time, often claiming nerves carried a spiritual energy called “innate intelligence,” and that obstruction of the flow of this energy by vertebral subluxations caused medical symptoms.1,2 Few chiropractors today still adhere to the notion of a mystical energy such as innate intelligence as the source of disease or the focus of chiropractic treatment. However, there is a split in the field with respect to the subluxation concept.3,4 Most chiropractors still view subluxation, or the vertebral subluxation complex (VSC), as a real entity causing illness and that can be corrected by chiropractic manipulation. These practitioners also sometimes reject modern scientific explanations of illness, such as germ theory, and may recommend their patients avoid accepted medical interventions, such as pharmaceuticals or vaccination.5–7 A minority of chiropractors have rejected the subluxation idea and have tried to find alternative rationales for how spinal manipulation might treat disease. This group tends to be less inclined to reject science-based medical theory and practice generally. However, they have not had great success in influencing the chiropractic profession as a whole, which still tends to focus primarily on the VSC as both the cause of most disorders and the target of chiropractic therapy.4,8 For the most part, the principles and practices of animal chiropractic are extrapolated and adapted from those applied to humans, despite the obvious anatomic differences between bipedal humans and our four-legged veterinary patients. As in human chiropractic, the core concept behind chiropractic for animals is the VSC. For example, the American Veterinary Chiropractic Association (AVCA) criteria for certification include familiarity with “the anatomical, biomechanical and physiological consequences of the vertebral subluxation complex.”9 The British Veterinary Chiropractic Association (BVCA) also identifies the VSC as central to chiropractic treatment of animals.10 Veterinary journal articles about chiropractic often emphasize subluxation “is at the core of chiropractic theory, and its detection and correction are central to chiropractic practice.”11 Technically, in most jurisdictions, chiropractic is defined as treatment of humans, and chiropractors are licensed only to treat humans. However, there are a variety of ways for people to obtain chiropractic treatment for their animals. Some chiropractors will simply treat animals and ignore the fact it isn’t technically legal for them to do so. Alternatively, veterinarians can take one of the many training courses available in animal chiropractic and then employ it as part of their practice of veterinary medicine. There is, however, a tremendous lack of consistency or rigorously scientific content in most of these courses.12 In the U.S., where veterinarians are licensed by the state in which they practice, veterinary practice acts sometimes create legal space for animal chiropractic under another name. In California, for example, the practice of “musculoskeletal manipulation” on animals must meet certain requirements specified in the state veterinary practice act.13 For example: 1) A veterinarian must examine the animal, determine that musculoskeletal manipulation (MSM) is appropriate and safe, and take official responsibility for supervising the treatment. 2) Then the owner is supposed to sign a form: “The veterinarian shall obtain as part of the patient’s permanent record, a signed acknowledgment from the owner of the patient or his or her authorized representative that MSM is considered to be an alternative (nonstandard) veterinary therapy.” 3) Then a licensed chiropractor can examine the pet, determine that MSM is appropriate, and then consult with the supervising veterinarian before performing treatment. I know of many chiropractors treating animals in this state, with and without veterinary supervision, and sadly I have never seen anyone follow all these rules. There is often little oversight of chiropractors who employ their techniques on veterinary patients. There are a number of professional veterinary chiropractic organizations promoting and defending the use of chiropractic in animals. AVCA, for example, offers a certification program that allows either chiropractors or veterinarians to claim to be “board-certified” in animal chiropractic, though this is a bit misleading since the official organization that establishes and regulates veterinary specialties—the American Board of Veterinary Specialties (ABVS)—does not recognize this certification. The predominant theoretical concept of chiropractic remains the VSC, while the dominant treatment concept is the “chiropractic adjustment.” Generally, this involves locating a VSC, by touch or utilizing X-rays, and applying some kind of force to the area of the spine in which the VSC is found to resolve it and relieve its harmful effects. While the very definition of chiropractic, and the theories and practices the term encompasses, is contested even among those who promote and use these techniques, the predominant theoretical concept remains the VSC, while the dominant treatment concept is the “chiropractic adjustment.” Generally, this involves locating a VSC, by touch or utilizing X-rays, and applying some kind of force to the area of the spine in which the VSC is found to resolve it and relieve its harmful effects. Most often, this force is applied by the hands, utilizing a high-velocity, low-amplitude thrust, meaning a short, hard push or twist of the bones in the spine to cause a small movement of the vertebral bones and joints. Some chiropractors prefer to use a mechanical device to adjust a VSC. Hammers, mallets, and hydraulic devices of various kinds are often employed, especially in large animals such as the horse. It is also quite common for chiropractors to employ a variety of other alternative therapies, including acupuncture, herbal remedies, unusual diets, and more. Most chiropractors tend to focus on treating musculoskeletal problems, such as pain or lameness, or enhancing and maintaining athletic performance. However, some believe the VSC is the cause of a much broader range of health problems, such as allergies, ear infections, colic, seizures, and many others. These practitioners claim that because the nervous system is connected to every organ in the body, and the VSC interferes with normal nervous system function, chiropractic can potentially treat almost any ailment. Chiropractic is one of the most widely used and familiar alternative therapies for humans. Treatment is frequently covered by health insurance, and despite resistance and objections from mainstream medicine, it has become a routine therapy for millions of people. Chiropractic is less commonly used in veterinary patients, and it is more popular among horse owners than among dog and cat owners. Nevertheless, because people are often acquainted with the practice and may feel it has benefited them, they are sometimes interested in the potential benefits of chiropractic treatment for their animal companions. Does it work The vertebral subluxation: The core theoretical construct of the vertebral subluxation complex hasn’t fared well when investigated scientifically. Historically, chiropractors defined subluxation as an interruption in the flow of a spiritual force responsible for normal health. Of course, no scientific evaluation of such a supernatural force is possible. Because the problematic nature of such beliefs is widely recognized, and they tend to carry little weight with health-care professionals and patients, most chiropractors have moved away from this concept. It is now more commonly argued that the misalignment of vertebrae damages health by impinging on nerves leaving the spine. This theory makes some sense when used to explain musculoskeletal pain, though it is less plausible when used to justify chiropractic as a treatment for ear infections, asthma, allergies, or many other complaints. As it turns out, however, chiropractors have not been able to convincingly demonstrate the bones they are adjusting into proper position are actually out of position in the first place.14 It doesn’t seem to be possible to consistently and predictably locate a vertebral subluxation. Chiropractors claim to locate subluxations by feel or using radiographs or other technological methods. Studies of these methods have generally not found very good agreement between different chiropractors in terms of where these lesions are in a given patient.15,16 Unlike a broken bone or dislocated shoulder, a vertebral subluxation cannot be consistently demonstrated on X-rays or other imaging methods. After more than a century of study, the vertebral subluxation has still failed to meet even the basic criteria for determining that it exists and causes disease.14–16 In response to this failure, some chiropractors further modify the definition of the VSC, describing the subluxation not as a misalignment of bones, but a “complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ function and general health.”17 Unfortunately, that’s vague enough to make the concept as unverifiable as any spiritual force. If a VSC cannot be seen, measured, or identified in any way other than the subjective impression of a chiropractor during an examination, is it still an appropriate basis for an entire specialized system of medical treatment? If chiropractic is not the correction of a subluxation but simply the manipulation of bone and muscle tissue, how is it different from massage or conventional physical therapy? Research on chiropractic treatment: Without a plausible physiologic rationale behind a therapy, clinical trial testing is likely to be more misleading than illuminating. Applying a treatment to patients without any reasonable hypothesis for how it might work is a recipe for false results. Nevertheless, because chiropractic has long been a popular treatment, there have been quite a few clinical studies of the effects of chiropractic manipulation on human patients despite the lack of validation of the VSC. As always, good-quality scientific studies require randomization, effective blinding of investigators, patients, and caregivers, and robust placebo or positive control interventions. Ideally, other methods to control bias and error are also employed, including a priori fixing of primary outcome measures, registration and pre-study publication of protocols, insulation against funding bias, and others. Very few studies of chiropractic in human medicine achieve this level of quality, and none in veterinary patients do so. As a result, there are often studies that appear to provide positive results, but this is rarely replicated or consistent. When the best quality studies (i.e. those with reasonable numbers of subjects and good controls for bias) are reviewed, they find spinal manipulation to be ineffective for almost all conditions in which it has been tested. It is at least clear that claims chiropractic is an effective treatment for non-musculoskeletal disorders are untrue. There is some evidence spinal manipulation provides mild relief for back pain, but this evidence is weak and inconsistent.18–24 The best we can say for spinal manipulation in humans, then, is that it might have a small, short-term impact on back pain, though possibly not enough to matter to many patients and no better than conventional therapy.19,20,24 After more than a hundred years of research since chiropractic was invented, this is not a particularly impressive showing. As is too often the case, there is no high-quality research on chiropractic in animals. Only anecdotal evidence and studies with significant limitations and a high risk of bias have been published.11,25–31 Rigorous scientific evidence is lacking in veterinary patients, and most applications of chiropractic to animals rely on anecdotal evidence or extrapolate from the research in humans. Horses are one of the species most commonly treated with spinal manipulation, and chiropractors have claimed to be able to effectively treat even much larger creatures, such as elephants and giraffes. But can the force applied by hand or with other instruments impact the large and robust bones and muscles of these animals? A major problem with this, of course, is there are significant anatomical differences between humans and other mammals. A therapy useful only for lower back pain in humans is unlikely to be relevant to many other problems in our four-legged veterinary patients. And there is reason to question how effective the mainstay of chiropractic treatment—the low-velocity, high-amplitude thrust—is in larger animals. Horses are one of the species most commonly treated with spinal manipulation, and chiropractors have claimed to be able to effectively treat even much larger creatures, such as elephants and giraffes. But can the force applied by hand or with other instruments impact the large and robust bones and muscles of these animals? Or conversely, could the forces applied to the human spine be more likely to cause injury in smaller and more delicate species? This leads us to the crucial question of safety. Is it safe? Though adverse effects of chiropractic treatment are probably under-reported,32 there is still strong evidence that both minor and serious harm can occur with chiropractic manipulation.33,34,43,44,35–42 Mild side effects, such as headache, soreness, dizziness, and numbness, occur in roughly half of human chiropractic patients. Much less common, but also much more serious events have been reported. Tears in vertebral arteries can occur following manipulation of the neck, and these have led to stroke and permanent disability or death in some patients. Fractures of the vertebrae and rupture of intervertebral disks have also been reported. Because evidence of benefits in people is so tenuous, vigorous neck adjustments should be avoided. Many chiropractors make extensive use of X-rays, despite the lack of evidence that such imaging methods can identify subluxations or other lesions amenable to chiropractic treatment. Repeated X-rays can increase cancer risk, and use of radiography to guide chiropractic treatment is not justified when there is no evidence such imaging can localize real, treatable lesions. No reliable research exists on the safety of chiropractic treatment for veterinary patients. Anecdotally, injuries to horses from chiropractic manipulations have occasionally been reported. It is likely the risk of vertebral artery tears would be lower in this species given the differences in spine anatomy. The risks in smaller animals or animals with ruptured intervertebral disks, fractures, tumors, or other serious spinal problems may well be higher, but unfortunately this has not been studied. While direct risks, other than possibly for neck manipulation in people, appear to be small, there are indirect risks of chiropractic therapy that come from some of the views often held by chiropractors. Those treating humans, for example, sometimes recommend against vaccination,7,45–47 and it is not uncommon for them to employ a variety of therapies besides musculoskeletal manipulation, including colon cleansing, untested herbal remedies, homeopathy, and so on. Chiropractors also frequently make claims about their treatments that are not supported by scientific evidence.48 Chiropractors practicing on animals have also been known to stir up irrational fear of vaccination, claim toxins in pet food are common causes of cancer, and otherwise express disdain for science-based veterinary medicine. Even a small true benefit from manual treatment may not be worth it if the practitioner discourages safe and effective conventional treatment for the patient. I have worked with many patients receiving care from chiropractors, and while most of these practitioners are kind and well-intentioned, their approach is often disturbingly unscientific. As an example, I was once asked to examine a rabbit that had come to my hospital to be treated by a chiropractor, at the advice of a veterinarian who had seen the patient elsewhere. The rabbit had been anesthetized for treatment of dental disease earlier in the day, and upon waking it was paralyzed in its hind legs. Anyone familiar with rabbits would immediately be concerned about a self-induced vertebral fracture, which can occur when a frightened or dysphoric rabbit kicks its hind legs. In this case, the rabbit had the typical findings associated with a such an injury; a normal neurologic exam to the level of the seventh lumbar vertebrae with hyperreflexia, absence of voluntary motor movement, and deep pain distal to this location. The chiropractor, however, examined the rabbit and concluded it had a subluxation in its neck. He recommended giving a chiropractic adjustment to the neck and sending the pet home, with additional adjustments likely necessary in the following days or weeks. When I asked how he reconciled his diagnosis with the symptoms and history, which best fit the pattern associated with an acute spinal cord injury in the lumbar spine, the chiropractor informed me he was familiar with conventional neurology theory and training, but had chosen not to employ them because they were not consistent with his daily experience in practice. He felt localizing and treating vertebral subluxations was more effective in his veterinary and human patients. This is an example of a truly alternative approach to medicine, in which even well-established scientific knowledge is ignored in favor of unproven alternative theories and personal experience and belief. While there are chiropractors who genuinely try to adhere to scientific principles and practices, this sort of preference for private belief over scientific fact is all too common in the profession. The client permitted me to take a radiograph of the rabbit, which confirmed a traumatic lumbar vertebral fracture and severe spinal cord trauma. The patient was humanely euthanized in light of the severe symptoms and poor prognosis. Though this was sad for the owner, I consider it a better outcome for the animal than having its neck manipulated and being sent home paralyzed and with a fractured spine but without any pain control. Of course, this anecdote proves nothing about the safety or efficacy of chiropractic treatment in veterinary patients. However, it is illustrative of the risks of substituting a belief system for science-based medicine, which is still all too common among those who employ chiropractic in animals. Bottom line Traditional chiropractic is based on the idea of fixing an imaginary problem: the vertebral subluxation. A minority of chiropractors are trying to move beyond this concept, as well as the vitalism and resistance to mainstream science that still dominates the profession. So far, however, there is no cogent physiologic explanation for how chiropractic might be helpful, whether to animals or people. There is also very little good research evidence to show chiropractic actually is helpful, despite many studies over decades. The best that can be said in humans is it might provide some relief to people with back pain and other musculoskeletal complaints, similar to physical therapy and other manual treatments. Even this has not been shown in veterinary species, and the little research that exists does not convincingly show chiropractic to be beneficial. In humans, the most serious direct risks of chiropractic come from forceful manipulations of the neck in adults or of any part of the body in infants and children. Major harm appears to be uncommon, while minor discomfort occurs more frequently in people. The lack of good quality research makes it impossible to accurately assess the direct risks of chiropractic treatment in animals. However, when used in small animals, patients with intervertebral disk disease, and those susceptible to serious injury from forceful manipulation of the spine, it is likely there is significant risk to such treatment. As is true for many alternative therapies, the most serious danger of chiropractic is the delay or avoidance of truly safe and effective medical treatment. To the extent some chiropractors discourage science-based treatment and offer unproven alternative therapies besides musculoskeletal manipulation, they can do significant harm to their animal patients, even when their ministrations are not causing any direct injury. Anyone seeking chiropractic care for their animals should certainly consult with a veterinarian and make sure such care is gentle and appropriate, and does not interfere with other, more science-based treatments. Brennen McKenzie, MA, MSc, VMD, cVMA, discovered evidence-based veterinary medicine after attending the University of Pennsylvania School of Veterinary Medicine and working as a small animal general practice veterinarian. He has served as president of the Evidence-Based Veterinary Medicine Association and reaches out to the public through his SkeptVet blog, the Science-Based Medicine blog, and more. He is certified in medical acupuncture for veterinarians. 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Review of chiropractic veterinary science: An emerging profession with somatic and somatovisceral anecdotal histories. Chiropr J Aust. 2011;41(4):127-139. Haussler KK, Manchon PT, Donnell JR, Frisbie DD. Effects of Low-Level Laser Therapy and Chiropractic Care on Back Pain in Quarter Horses. J equine Vet Sci. 2020;86:102891. doi:10.1016/j.jevs.2019.102891 Gorrell LM, Engel RM, Brown B, Lystad RP. The reporting of adverse events following spinal manipulation in randomized clinical trials—a systematic review. Spine J. 2016;16(9):1143-1151. doi:10.1016/j.spinee.2016.05.018 Nielsen SM, Tarp S, Christensen R, Bliddal H, Klokker L, Henriksen M. The risk associated with spinal manipulation: an overview of reviews. Syst Rev. 2017;6(1):64. doi:10.1186/s13643-017-0458-y Stevinson C, Ernst E. Risks associated with spinal manipulation. Am J Med. 2002;112(7):566-571. http://www.ncbi.nlm.nih.gov/pubmed/12015249. Accessed November 18, 2018. Ernst E. Chiropractic: A Critical Evaluation. J Pain Symptom Manage. 2008;35(5):544-562. doi:10.1016/j.jpainsymman.2007.07.004 Ernst E. Deaths after chiropractic: a review of published cases. Int J Clin Pract. 2010;64(8):1162-1165. doi:10.1111/j.1742-1241.2010.02352.x Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med. 2007;100(7):330-338. doi:10.1177/014107680710000716 Ernst E. Prospective investigations into the safety of spinal manipulation. J Pain Symptom Manage. 2001;21(3):238-242. http://www.ncbi.nlm.nih.gov/pubmed/11239743. Accessed November 18, 2018. Puentedura EJ, O’Grady WH. Safety of thrust joint manipulation in the thoracic spine: a systematic review. J Man Manip Ther. 2015;23(3):154-161. doi:10.1179/2042618615Y.0000000012 Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Therap. 2017;25(1):37. doi:10.1186/s12998-017-0168-5 Todd AJ, Carroll MT, Robinson A, Mitchell EKL. Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the Literature. J Manipulative Physiol Ther. 2015;38(9):699-712. doi:10.1016/j.jmpt.2014.09.008 Gouveia LO, Castanho P, Ferreira JJ. Safety of Chiropractic Interventions. Spine (Phila Pa 1976). 2009;34(11):E405-E413. doi:10.1097/BRS.0b013e3181a16d63 Wynd S, Westaway M, Vohra S, Kawchuk G. The quality of reports on cervical arterial dissection following cervical spinal manipulation. PLoS One. 2013;8(3):e59170. doi:10.1371/journal.pone.0059170 Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic Review. Pediatrics. 2007;119(1):e275-e283. doi:10.1542/peds.2006-1392 Gleberzon B, Lameris M, Schmidt C, Ogrady J. On Vaccination &amp; Chiropractic: when ideology, history, perception, politics and jurisprudence collide. J Can Chiropr Assoc. 2013;57(3):205-213. http://www.ncbi.nlm.nih.gov/pubmed/23997246. Accessed November 18, 2018. Campbell JB, Busse JW, Injeyan HS. Chiropractors and vaccination: A historical perspective. Pediatrics. 2000;105(4):E43. http://www.ncbi.nlm.nih.gov/pubmed/10742364. Accessed November 18, 2018. Busse JW, Wilson K, Campbell JB. Attitudes towards vaccination among chiropractic and naturopathic students. Vaccine. 2008;26(49):6237-6243. doi:10.1016/j.vaccine.2008.07.020 Ernst E, Gilbey A. Chiropractic Claims in the English-Speaking World. Vol 123.; 2010. http://www.dcscience.net/Ernst-Gilbey-Chiropractic-claims-NZMJ.pdf. Accessed November 18, 2018.

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Veterinary chiropractic: A friend or foe to your patients?

Despite obvious anatomic differences, the principles and practices of animal chiropractic are extrapolated and adapted from those applied to humans

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