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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BACK PAIN: A COMMON PROBLEM OFTEN MISUNDERSTOOD AND OVER-TREATED


Almost 80% of our entire population encounters at least one bout of lower back pain during their lifetime. More than 50% of Americans suffer from some type of low-grade chronic back pain. In the majority of cases, standard x-rays show no clear abnormalities to explain the discomfort. Such pains are probably caused by muscle strain and spasm that may be produced or aggravated by emotional tension. Patients over 40 often have minor degenerative changes of the vertebral column in X-ray images, but these rarely produce symptoms. These statistics open wide the door to alternative treatments such as that provided by chiropractors, herbal supplements, and other unconventional measures.

Fortunately, serious spinal disorders are seldom the cause for back pain, which, in the case of recently acquired pain, usually resolves spontaneously within two weeks, regardless what is done. Therefore, in this setting, too many people receive premature high-tech tests, powerful painkiller drugs, or even surgery. Because the pain may be excruciating, most people seek medical help very early, receive aggressive testing and treatment, and, as a result, waste money. Instead of helping, this approach may actually slow one’s recovery.

Not surprisingly, many sufferers from back pain turn to chiropractors, and indeed many large surveys show that patients believe chiropractic works for them. Studies that compare patients’ satisfaction with chiropractic versus conventional medicine in treating low back pain show a preference for chiropractic treatment. The results of a survey of over 14,000 subscribers conducted by Consumer Reports echo those of other studies; 58% of respondents reported that chiropractic treatments “helped a lot.” They also noted that spinal manipulation can be helpful for lower-back pain in the short-term, but Consumers Union, the publisher of Consumer Reports, cautions that manipulations can aggravate structural problems, such as a herniated disk. For chronic back pain lasting more than 12 weeks, however, chiropractic did not appear to be better than general medical care, including physical therapy, exercises, and weight reduction. Chiropractic treatment bears one additional warning: Manipulations extending to the neck carry a slight but definite risk of damage to the spinal cord or proximal blood vessels, both of which can lead to serious—or even fatal—outcomes. Thus elderly patients, especially with preexisting disease of the vertebral column or blood vessels (arteriosclerosis), should be advised to avoid any manipulation of the neck.

So the following comments may help you understand and react to back pain in an appropriate way:

1. In the case of recent onset of pain—even if intense—do not rush to get tests such as X-rays or MRI scans. In most cases the pain will resolve spontaneously, and anything found in such testing will not help in recovery. Moreover, as mentioned, minor abnormalities found in these pictures only contribute to anxiety rather than resolution of pain. Moreover, in the case of X-rays, the radiation exposure produces a small but definite risk of developing cancer later in life.

2. Although recommended for years, try to avoid lying down. Recent studies have shown that after no longer than four days of rest in bed, resuming normal activities results in less pain and earlier recovery. Activities should be low in impact such as stretching and walking, with light exercises that strengthen your abdomen, back and legs. Applying heat to the painful areas may be helpful.

3. Avoid the use of strong drugs such as opiates (OxyContin, Percocet, hydrocodone, etc). Use instead the so-called non-steroidal analgesics such as ibupropren (Advil), naproxen (Anaprox), and others. The opiate drugs are more apt to lead to more disability after several months and may lead to addiction.

4. Some measures that also may be helpful include the following: Tighten your belt, which can help strengthen stomach muscles, a maneuver than can protect the back. Sit forward and straight in chairs, for that relieves strain of the back muscles. Try to sleep on your back or side, and when supine, place a pillow under your knees.  Back massage, which can be done by a physical therapist, may help to relieve muscle spasm and the associated pain.

5. Avoid needless surgery: Back pain often stems from problems that cannot be helped with surgery, such as poor posture, minor arthritis, weak muscles, and others. Even when the pain is caused by conditions such as a herniated disk or spinal stenosis (narrowing of the spinal column), conservative treatment is often enough. Surgery might be considered if you have severe back and leg symptoms clearly linked to a herniated disk or spinal stenosis that hasn’t improved with conservative treatment in three months. But even then, additional measures might first be tried such as local injections with anti-inflammatory agents or analgesics.

We medical practitioners often encounter patients who have undergone one or more surgical procedures without relief, and to me, that represents a real tragedy!



 

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