Chiropractic and the nhs
Chiropractic and the NHS
Use of chiropractic in the NHS is limited. Your GP or practice nurse can tell you more about the availability of NHS chiropractic in your area.
Currently, the National Institute for Health and Care Excellence (NICE) recommends spinal manipulation (as practised by chiropractors) as a treatment option for one condition: persistent lower back pain. Read the 2009 NICE guidelines on low back pain.
Most people who use a chiropractor pay for private treatment. The cost of chiropractic varies and depends on the length of a particular chiropractic session. On average, a 30-minute session will cost £20-£35 and an hour’s session £40-£80.
History of chiropractic
Chiropractic was founded as a health profession in the US in 1895 by a Canadian called Daniel David Palmer, who had no conventional medical training.
Palmer argued that most human disease is caused by misalignments of the spine that apply pressure on surrounding nerves. He called these misalignments “subluxations” (a term also used in conventional medicine, where it has a different meaning) and believed that they blocked the flow of a natural energy, or “life force”, through the body. Correcting these subluxations, he argued, could restore the proper flow of energy, and so restore health. Thus, he saw chiropractic spinal manipulation as a treatment for 95% of all health conditions.
Since its early days, chiropractic has fought for acceptance as a legitimate health profession. In the early 20th century, Palmer came close to declaring chiropractic a religion, at least partly due to difficulties in obtaining legal rights to practise in the US.
More recently, elements within the profession have sought to place chiropractic on a more scientific footing through research to establish an evidence base for its principles and practice.
Today, Palmer’s ideas do not always form the basis on which chiropractors practise, but this varies widely between individual chiropractors. The GCC says that the idea that subluxations are responsible for illness “is not supported by any clinical research evidence” and that this idea should be taught as a historical concept and not a current theoretical model.
Chiropractors, says the GCC, are “concerned with the framework of the muscles and bones that support the body (the musculoskeletal system)” and with treating health conditions by helping the musculoskeletal system to work properly.
Nonetheless, some UK chiropractors continue to claim that they can improve a range of health conditions by correcting subluxations.
According to the General Chiropractic Council, chiropractic is “a health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health”.
Chiropractors (practitioners of chiropractic) use their hands to treat disorders of the bones, muscles and joints. Treatments that involve use of the hands in this way are called “manual therapies”.
Chiropractors use a range of techniques, with an emphasis on manipulation of the spine. They may also offer advice on diet, exercise and lifestyle, and rehabilitation programmes that involve exercises to do in your own time. Some chiropractors may also offer other treatments, such as acupuncture.
Chiropractic is part of complementary and alternative medicine (CAM). This means that chiropractic is different in important ways from treatments that are part of conventional western medicine.
Some uses of chiropractic treatments are based on ideas and an evidence base that are not recognised by the majority of independent scientists.
Many chiropractors only treat conditions related to the spine, such as lower back or neck pain.
Some chiropractors, however, treat a wider range of conditions, including asthma, infant colic, irritable bowel syndrome and many others.
The General Chiropractic Council says that the care provided by chiropractors should be “informed by the best available evidence, the preferences of the patient, and the expertise of practitioners”.
The availability of chiropractic on the NHS is limited (see box, left). Most chiropractic patients pay for private treatment.
Does it work?
Chiropractic is a healthcare profession, and not a single treatment. Evidence about chiropractic generally refers to one or more of the treatments that chiropractors offer.
There is good evidence that spinal manipulation – as practised by chiropractors – can be an effective treatment for persistent lower back pain. Conventional treatments for lower back pain include painkillers, exercise and physiotherapy.
There is some, mostly poor quality, evidence that that spinal manipulation is an effective treatment for some other musculoskeletal conditions involving the bones, joints and soft tissue. The evidence on spinal manipulation is not strong enough in these cases to form the basis of a recommendation to use the treatment.
There is no evidence that treatments offered by chiropractors are effective for other conditions.
There is also no scientific evidence to support the idea that most illness is caused by misalignment of the spine.
How chiropractic is performed
Typically, your first chiropractic session will involve an assessment of your general health and medical history, and a physical examination.
The treatment that follows usually involves hands-on manipulation techniques, which focus on the spine.
You may also be given other treatments and advice on exercise, diet and lifestyle (see below for more).
Sessions typically last between 15 and 30 minutes.
The length of a course of treatment will depend on the type and severity of symptoms. In the case of persistent lower back pain, NICE recommends that treatment should include up to nine sessions over the course of 12 weeks.
As part of this assessment, a chiropractor should:
ask about your symptoms
ask about your general state of health and previous health conditions
carry out a physical examination that may involve an examination of your spine and posture, and where relevant an attempt to find the source of your discomfort or pain
They may also take X-rays of your spine.
If your chiropractor discovers or suspects that you have a serious health condition, they should advise you to see your GP. Do not use a visit to a chiropractor as a substitute for a visit to a GP.
Once this assessment has been carried out, you should be given a care plan. This describes the chiropractor’s diagnosis and outlines the suggested treatment.
Initial assessments typically last between 45 and 60 minutes.
Your chiropractor will advise you on treatments intended to address your health condition, and help you to manage or avoid it in the future.
This may involve manipulation of your muscles, bones and joints, often in the spine. This kind of treatment is sometimes called “manual treatment”.
It may also involve massage or manipulation of soft tissue. Additionally, it may also involve advice on diet, exercise and lifestyle, and a rehabilitation programme for you to follow in your own time.
The main technique used in chiropractic is spinal manipulation. The chiropractor uses their hands to apply force to the muscles, bones and joints in and around your spine.
During the session, you will be asked to sit or lie down. You will usually be asked to remove your upper body clothing so the chiropractor can access your spine. If you are asked to undress, you should be offered a gown.
Chiropractors use a wide range of manual techniques, including:
short, sharp thrusts applied to the spine (intended to remove joint restrictions and improve the range of movement)
gradually moving joints through a range of different positions (intended to reduce tension within a joint)
pulling or stretching muscles in a certain direction (intended to strengthen the muscle and improve its range of movement)
Usually, chiropractic treatment is not painful. If the chiropractor is treating an injury that is painful or inflamed, there may be some minor pain or discomfort. If you experience any pain or significant discomfort while having chiropractic treatment, tell your chiropractor immediately.
During spinal manipulation, you may experience a popping sensation in your joints and hear a popping or cracking sound. It is thought this is caused by gas bubbles in the fluids that surround your joints. It is a normal part of spinal manipulation and other manual treatments.
Other elements of treatment
Some chiropractors can make other treatments available, as well as manual therapy.
These can include advice on exercise, diet and nutrition, which is intended to help improve, manage or avoid the recurrence of your health condition, and to improve your general health.
They can also include rehabilitation programmes in which you are taught exercises that are intended to help you recover from your health condition, and prevent it recurring.
Some chiropractors may also offer other complementary and alternative treatments, such as acupuncture.
Conditions commonly treated by chiropractors
Chiropractic treatments are often used for musculoskeletal conditions (affecting the muscles, bones and joints).
These conditions include:
lower back pain
shoulder pain and problems
leg pain and sciatica
pain or problems with hip, knee, ankle and foot joints
pain or problems with elbow, wrist and hand joints
Some chiropractors treat a wide range of conditions that are unrelated to muscles, bones and joints, such as:
headache and migraine
high blood pressure
mental health conditions, such as depression, phobias or anxiety disorders
gastrointestinal disorders (of the stomach and bowel)
They may also use chiropractic treatments to maintain overall good health.
Guidance from the General Chiropractic Council
The General Chiropractic Council says that treatment provided by chiropractors should:
be informed by the best available evidence, the preferences of the patient and the expertise of practitioners
be appropriate to the patient’s current state of health and health needs
minimise risks to that patient
NICE recommended uses
The National Institute for Health and Care Excellence (NICE) provides guidelines to the NHS on use of treatments and care of patients. Currently, NICE recommends that spinal manipulation – as practised by chiropractors – be considered as a treatment option for one condition:
persistent low back pain (that has lasted longer than six weeks, and less than one year)
Safety and regulation of chiropractic
There is statutory regulation of chiropractic in the UK.
Chiropractic is one of two complementary and alternative medicines (CAMs) that operate under statutory regulation. The other is osteopathy.
Statutory regulation of chiropractic works in the same way as regulation for conventional medical doctors.
This means it is illegal to practise as a chiropractor or call yourself a chiropractor unless you are registered with the General Chiropractic Council (GCC).
The GCC only accepts registration from practitioners who have certain qualifications in chiropractic and who agree to comply with its code of practice.
Regulation aims to protect patient safety, by setting and monitoring standards of training, practice and conduct. It doesn’t mean that there is scientific evidence that the treatment provided is effective.
Chiropractors in the UK must adhere to standards of practice laid down by the GCC. If you use a chiropractor and they do not adhere to this standard of practice you can complain to the GCC, which has a duty to investigate the complaint.
You can read more about the qualifications required of chiropractors and the code of practice they must adhere to at the General Chiropractic Council website. You can also use this website to find a registered practitioner.
Never use an unregistered practitioner.
Around 50% of patients report experiencing adverse effects after spinal manipulation. The most commonly reported adverse effects are:
stiffness or soreness
temporarily increased pain
These effects are usually minor or moderate, develop within four hours of a session and typically resolve themselves within one or two days.
Serious complications that have been linked to spinal manipulation include:
tearing of an artery wall, leading to stroke
injury to the spinal column, leading to paralysis
build-up of blood between the skull and the outer layers of the brain, which can result in coma or death
These events usually occurred after spinal manipulation involving the neck. Some may have occurred due to a pre-existing health condition, and not the spinal manipulation itself.
These more serious complications of spinal manipulation are probably rare. Estimates of the rates of serious complications range widely, from one in tens of thousands to one in millions of treatments.
The use of manual treatments as practised by chiropractors is not recommended in cases where there is an increased risk of damage to the spine or other bones, or the nerves.
This means that people with certain health conditions may not be able to have chiropractic. They include people with:
primary cancer of the bone or a secondary cancer that has spread to the bone
poorly controlled arthritis or gout
poorly controlled diabetic neuropathy
compression of the nerves in the spinal cord
Chiropractic treatment is also not recommended if you are taking blood-thinning medicines, such as warfarin.
In some cases, where manipulation of bones, joints and soft tissue is not recommended, a chiropractor may be able to offer other treatments along with diet, exercise and lifestyle advice.
If you have any of these health conditions, or you are unsure whether chiropractic is safe for you, speak to your GP first.
Evidence for its effectiveness
To be able to judge whether any health treatment is safe and effective, we need evidence.
Evidence on a treatment is gathered by conducting fair scientific tests of the treatment.
Chiropractic is a health profession, and not a single treatment. Evidence about chiropractic generally refers to one or more of the treatments that chiropracors can offer.
Studies that examine health treatments, including treatments offered by chiropractors, can reach different conclusions on whether the treatments are safe and effective. This can happen for various reasons, including differences in the design of the study, bias or simply chance. When this happens, more high quality research is needed to determine whether the treatment is effective and safe.
When we use a treatment and feel better, this can be because of phenomena such as the placebo effect and not because of the treatment itself.
There is good evidence available that chiropractic is an effective treatment for persistent lower back pain.
This means that scientific trials conducted to investigate the effect of chiropractic on lower back pain found that it did have a beneficial effect.
A 2011 Cochrane review of studies of chiropractic intervention – treatments offered by chiropractors, including spinal manipulation – found that it is not possible to confirm or refute that chiropractic treatments are any more effective than conventional treatments for persistent lower back pain. Conventional treatments include painkillers, exercise and physiotherapy.
Some positive evidence
There is some, mostly poor quality, evidence that manipulation of bones, joints and soft tissue, as practised by chiropractors, may be an effective treatment for some other musculoskeletal problems. These include:
acute (new-onset) back pain,
acute and sub-acute neck pain
chronic neck pain when combined with exercise
shoulder girdle pain
tennis elbow, when treatment is combined with exericse
knee osteoarthritis, some kinds of knee pain and some kinds of heel pain
migraine and headache originating from problems in the neck
This evidence is not conclusive, and therefore isn’t strong enough to form the basis of a recommendation to use the treatment for these conditions.
More high-quality research is needed to determine whether manual treatments are effective for these health conditions.
There is some evidence that chiropractic treatments are not an effective treatment for:
carpel tunnel syndrome
This means that scientific trials found that chiropractic treatments had no beneficial effect on these conditions.
Inconclusive or no evidence
Despite being used by some practitioners, there is a lack of good-quality evidence on the effectiveness of chiropractic treatments for other conditions, including:
high blood pressure
mental health conditions, such as depression, phobias or anxiety disorders
This means that fair tests into the effectiveness of chiropractic treatments for these conditions have not been conducted.