IS CHIROPRACTIC TREATMENT BOGUS?

At its core, all chiropractic is based on an unscientific theory of human disease— that all or most disease results from faulty alignment of vertebrae. If chiropractic manipulation appears to solve one’s back pain, it probably wasn’t medically significant to begin with. One of the problems with chiropractic treatment is that evidence for its effectiveness is entirely anecdotal. This is because it is nearly impossible to analyze chiropractic with double blind, placebo controlled studies. If such studies could be done, they would likely prove either that chiropractic was no better than a placebo or that it offered no measurable advantage over a massage. The practice’s founder, D.D. Palmer, created the practice based on the flawed notion that the root of all human illness lies in so-called “misalignments” of the spine (as opposed to things like germs and viruses and genetic anomalies.) Palmer sold his method of “adjustments” to correct these misalignments as a way to “naturally” cure people of problems — He even went so far as to make the dubious claim of curing deafness the first time he ever laid hands on a patient

But at present, chiropractors are hot: According to the Bureau of Labor Statistics, they rake in about $81,210 per year, and their ranks are expected to grow expected to grow 17 percent in the next few years.

And it’s primarily because humans have terrible backs. We just haven’t evolved to keep up with the physical stress of gravity on a straight back, combined with desk jobs that have us crunched over computers for hours on end. A full 80 percent of Americans will deal with back pain at some point in their lives; one in five people reported back pain in the last year alone. About one-third of those folks saw a chiropractor or other alternative practitioner to deal with their back pain in 2016.

But does chiropractic work? The industry is, by definition, an alternative to evidence-based medicine, and aspects of it can be pretty worrying. At the same time, some experts say this treatment has a place.

Even in 2017, chiropractors are full of odd ideas, with many patients reporting being routinely hurt and misled. The Mayo Clinic warns that chiropractic adjustments can cause herniated disks or make already herniated discs worse. Chiropractic patients also often suffer compressed nerves, even strokes. A colleague of mine, a neurosurgeon, informed me that he has personally observed patients who have been rendered quadriplegic (paralyzed from the neck down) following chiropractic manipulation of the neck. The former chiropractor and skeptic Sam Hamola writes that many chiropractors engage in aggressive and scammy behavior to separate patients from their cash.

One of the most disturbing complaints I hear comes from chiropractic patients who have paid thousands of dollars in advance for a course of treatment lasting several months — after succumbing to a high-pressure sales pitch involving scare tactics. These patients have usually opted to discontinue treatment because symptoms have either worsened or disappeared. Most have signed a contract, however, that does not allow a refund, even if the treatment regimen was not completed. Some have used a chiropractic “health care credit card” to borrow the advance payment from a loan company, leaving the patient legally bound to repay the loan.

Edzard Ernst, an expert in pain and its treatments, who has studied the effectiveness of chiropractic medicine, has written columns suggesting that chiropracters often do more harm than good. “You will lose some cash,” he tells a questioner via email of what a typical patient might expect if they see a chiropractor. “You might get some relief in the case of back pain, but not for other conditions …In the worst case, you might be in a wheelchair for the rest of your life.”

But as those numbers above show, chiropractors are doing great financially and patients are flocking to them. There’s about one of them for every two dentists in this country. Wander around any American city or suburb and you’ll likely spot their offices sandwiched between the local FedEx and Panda Express. They’ve even found their way into hospitals, where they work alongside regular doctors and nurses. And here’s where the big BUT comes into play: Some of those doctors actually like it.

Stuart Kahn is a doctor and professor of rehabilitation and physical medicine at Mount Sinai Hospital in New York City. He treats patients with debilitating lower back pain all day. If your back goes out, he’s the guy you want to see. And, every once in a while, he sends patients to chiropractors, stating “The best thing you can do is diagnose what the cause of the back pain is, and then you can try to treat it.” And that’s something only a doctor is qualified to do. When a patient walks into his office with back pain, Kahn’s first task is to rule out cancers, infections, fractures, and other disorders that require specialized treatment. He can also prescribe anti-inflammatory medicines that can reduce swelling and pressure on the spinal cord, saving patients from further pain and damage. But most of Kahn’s patients fall into two baskets: Either they will live with chronic back pain for the rest of their lives, or they have some acute problem, like a slipped disc, that needs to be dealt with. For the latter group, he works on building a treatment regime that can lessen their daily pain and improve their range of motion and quality of life. The most important part of that regime is usually physical therapy. After a period of work, he said, “they’re more flexible, their core is stronger, they have better posture at work, they try to cut out the exercises that trigger the episodes.”

But the former group consists of a narrow subset of those patients who require management not only for pain, but for accompanying stress and emotion, and this is the group that he thinks might be helped by chiropractic management. In these cases, improvement is likely attributed largely to the so-called “placebo effect,” i.e. the emotional lift that can make a useless “treatment” actually suppress physical pain. As I have described in detail¥, the placebo effect can be quite powerful, especially when accompanied by an attentive and sympathetic therapist combined with physical contact (“laying on of hands”). There is none better positioned to fulfill these criteria than a chiropractor. Thus there does seem to be some people who a few chiropractors can help, but truly physical benefit is questionable. In any case, however, those adjustments should be part of a course of treatment recommended by a medical expert, not the bloke hawking $10,000 neck twists next to Denny’s.

CONCLUSION: If your back hurts, see a doctor (MD type), and then let him/her decide whether you should consider a chiropractor. My preference, however, is to stick with a licensed physical therapist and forgo chiropractic entirely.

 

 

¥ Tavel, ME, “Snake Oil is Alive and Well: The Clash between Myths and Reality. “Reflections of a Physician”. Brighton Press, Inc. Chandler, Arizona, 2012

Tavel ME. The Placebo Effect: The Good, The Bad, and The Ugly. The American Journal of Medicine. 2014; 127(6):484–488

 

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FALSE CURES: DON’T BE A SUCKER!

       As of 2007, about 40% of Americans opted for questionable treatments that range from those simply unproven to those that are outright frauds. These diverse methods encompass practitioners of alternative medicine (employing herbs and dietary supplements and others), spinal manipulation, acupuncture, and “energy healing”. Not only are we being duped, but many states actually sanction these dubious practices.  At this time, seventeen states, the District of Columbia, Puerto Rico and the Virgin Islands license naturopaths. Forty states license acupuncturists. Chiropractors are licensed in all 50 states. The Affordable Care Act mandates coverage of “state licensed alternative medicine practitioners” including “wellness” clinics that can employ “energy” healers and herbalists.

     So after over a century of painstaking rigorous scientific advances, we preserve a mishmash of unproven methods that offer dubious “cures”. The federal government has fostered this situation by forming an ill-advised Office of Alternative Medicine at the National Institutes of Health, and under this department, the National Center for Complementary Medicine (NCCAM). Defying modern concepts of scientific investigation, these departments have funded non-evidence-based practices such as naturopathy, oriental medicine, and chiropractic treatments. Between 1992 and 1998 they doled out $4 million to chiropractic, $2 million to naturopathic, with a total funding reaching $110 million by 2000, and it continues to the present day. This department has been awarding grants for training and career development for alternative medicine practitioners, as well as supporting research that would presumably test whether or not these methods are beneficial. Despite such funding, however, a published result for such a trial is rare indeed, and whenever this does occur, the “researchers” seldom provide precise statements. The protocols are usually poorly designed, non-evidenced based trials. Despite these obvious deficiencies, NCCAM continues to funnel taxpayer funds into dubious research on unproven—even disproven—alternative medicine protocols. One study§ tracked $2 billion in research grants to test the success of these methods, and it yielded no positive result that would alter current evidenced-based medical practice. Moreover, from 2000 to 2012, over $76 million was awarded to medical and alternative medicine schools to initiate or enhance efforts for teaching alternative methods.  

   In order to understand why we have been so terribly misguided, we need to examine briefly the modern criteria required to prove the benefit of any method of treatment:

    First, we usually form a hypothesis based upon biologic plausibility. This depends upon fundamental knowledge of biology, which is usually supported by preliminary observations. For instance, long ago a fungus, later called penicillin, was found to be capable of killing disease-producing microbes in the laboratory. This then led to numerous trials in humans to see if various infections could respond to this antibiotic and yet be free of any toxic effect from the penicillin itself. Needless to say, we all know how this turned out!

    In most cases, repeated study from varying sites and researchers is required to confirm that a proposed new treatment is really effective. This laborious process usually involves many volunteer human subjects with a given malady that are divided into two groups—treated and untreated (control group)—to ascertain whether the new method really accounts for improvement. Ideally, neither the patients nor the dispensers of the new treatment are aware of which ones are actually receiving the new, presumably active, agent. This process is termed “double blinding”.  Statistical methods are used to determine the numerical validity of the resulting responses.  In some cases, as in the case of surgical or manipulative procedures, blinding is not feasible, but comparison with some type of control group is necessary. These controls may consist of no treatment or competing methods. When possible, sham methods can be used as controls, as in the case of acupuncture (small pointed objects such as toothpicks are applied to non-acupuncture sites). The results from the latter protocols uniformly show no significant difference between those treated and the sham controls. Any study lacking double blinding is considered less robust, and in most cases, repeated research employing differing methods and study groups is necessary in order to confirm the validity of the initial results.

    As soon as the “alternative” medical treatments cited above are subjected to these same rigorous standards demanded by modern science, we will never know if any of them is real and which of them is merely designed to extract money from the pockets of gullible, unsuspecting people. Maybe even worse, the taxpayers are being ripped off. Thus, buyers beware!



§ Mielczarek E. and Engler BD. Measuring mythology: Startling concepts in NCCAM grants. Skeptical Inquirer 36(1):35-43,. 2012.

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