Physical therapy+massage+woo=chiropractic

This is a reprint from my old blog that will provide necessary backgroud for an upcoming story. Thanks for your indulgence.
Blogging on Peer-Reviewed ResearchI am often asked my opinion of chiropractic care. My usual answer (based on evidence) is that it can be somewhat helpful in the treatment of low back pain. That's it. Any further claims are complete and utter bullshit. Many chiropractors practice ethically, and recognize the correct scope of their abilities...many do not.

Adapted from RationalWiki
Chiropractic is the theory and practice of correction of "vertebral subluxation processes" to treat and cure disease. It was developed in the late 19th century, just before the development of modern medical education in the United States.
Chiropractors subscribe to the theory of "vertebral subluxation". This differs from the medical definition considerably. An orthopaedic (real) subluxation is a painful partial dislocation of a vertebral body. A "chiropractic subluxation" is an asymptomatic misalignment or a "vertebral subluxation complex" thought to be a cause of disease. The mechanism posited is usually the blocking of nerve impulses from spinal roots, or some such nonsense. Such a subluxation has never been proven to exist.

Lest you think that this unproved hypothesis has died away, in July 1996, the Association of Chiropractic Colleges issued a consensus statement that:

Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.

This hypothesis has never been tested, and ignores significant anatomical reality, such as the fact that much of the nervous system does not pass through "subluxations" in any way. This especially applies to the autonomic nervous system that "influences organ system function".

According to the American Chiropractic Association:

The ACA Master Plan, ratified by the House of Delegates in June 1964 (Amended June 1979, June 1989, July 1994 and September 2000), and will govern future policies of ACA as quoted:
"With regard to the core chiropractic principle, which holds that the relationship between structure and function in the human body is a significant health factor and that such relationships between the spinal column and the nervous system are highly significant because the normal transmission and expression of nerve energy are essential to the restoration and maintenance of health.

That's basically a re-statement of subluxation theory without the "s" word. It's also patent bullshit.

So the chiropractors haven't given up the absurd theory behind their "profession"---but does it work despite the poor theory? After all, outcomes are what count.

For back pain, there is evidence that chiropractic therapy may be as effective back exercises plus anti-inflammatory medications. Chiropractic has also been found to be slightly more effective than simply handing a patient a book about back care. In some studies, chiropractic did cost more overall. Specifically, a study comparing outcomes of acute low back pain treated by orthopedic surgeons, primary care physicians (PCP), and chiropractors found similar outcomes, but less cost from PCPs.

While 50-60% of patients who seek chiropractic care do so for back or neck pain, a significant number are treated for other problems. There is no evidence to support the use of chiropractic outside the realm of minor musculoskeletal complaints. Chiropractors who make any claims beyond low back pain are either dishonest, ignorant, or both. There is some evidence that (rarely) chiropractic care can cause stroke, carotid artery dissection, and other life-threatening problems.

Chiropractic may have a place in the treatment of low back pain---or it may not. Chiropractors are basically glorified massage therapists---except many massage therapists have better training, and know the limits of their profession. Chiropractors who discourage real medical care, vaccinations, and medications, or sell herbs and other potions out of their offices should be ashamed of themselves.

But of course, they have no shame.

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References

  • McDonald W (2003) How Chiropractors Think and Practice: The Survey of North American Chiropractors. Institute for Social Research, Ohio Northern University
  • Samuel Homola, DC,Chiropractic: History and Overview of Theories and Methods, CLINICAL ORTHOPAEDICS AND RELATED RESEARCH, Number 444, pp. 236-242,2006.
  • Shekelle PG, What Role for Chiropractic in Health Care? N Engl J Med 339:1074, October 8, 1998 Editorial
  • Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. The Outcomes and Costs of Care for Acute Low Back Pain among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons, N Engl J Med 333:913, October 5, 1995 Special Article.
  • Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O'Shaughnessy D, Walker C, Goldsmith CH, Duku E, Sears MR A Comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma. N Engl J Med 339:1013, October 8, 1998 Original Article.
  • Hufnagel A, Hammers A, Schonle P-W, Bohm K-D, Leonhardt G. Stroke following chiropractic manipulation of the cervical spine. J Neurol 1999;246:683-688.
  • Vickers A, Zollman C. The manipulative therapies: osteopathy and chiropractic. BMJ 1999;319:1176-1179.
  • Schievink WI, Mokri B, Piepgras D, Parisi J, Silbert P. Cervical artery dissections associated with chiropractic manipulation of the neck: the importance of preexisting arterial disease and injury. J Neurol 1996;243:Suppl 2:S92-S92.
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    The statement you attribute to the Assoc Chiro Colleges (1996) is current as of 2006.
    http://www.chirocolleges.org/paradigm_scopet.html

    You wrote For back pain, there is evidence that chiropractic therapy may be as effective ... I distinctly recall that, in more recent writing, you noted that such therapy provided by chiros was simply massage and manipulation; which can be had from masseurs or medical professionals, and is not really chiro. In reality, no truly chiro treatment is known to be effective for anything.

    There is a new post on the dangers of chiro http://www.sciencebasedmedicine.org/?p=94

    May I add, this is a link to a 42 min. video emphasizing the difference between manipulation by a chiro and a professional. This can be lisstened to without watching it, for people who like to knit ... http://ph-ms.ouhsc.edu/ah/rehab/kinsinger.wmv

    Well, I guess Harriet beat me to it---that was to be the topic of the follow up post. All that pubmed time gone to waste. Well, I'll just finish it and reference her excellent article.

    These whackos have a grip on my dad. They gave him some sort of "neck stretching" device recently. He ended up getting nose bleeds and having a spike in blood pressure. Go figure. I bet he goes back for more "treatment."

    Funny thing is my dad works in the medical field. He should know better, but instead yells at my mom for trying to control her diabetes via meds and a good diet (oddly enough she's doing very well). Apparently his chiropractor can CURE diabetes. I guess he's too busy doing good to call Time magazine and collect his prize for curing one of the most common diseases to affect mankind.

    "There is some evidence that (rarely) chiropractic care can cause stroke, carotid artery dissection, and other life-threatening problems."

    My gf's brother got both a dissection and the follow up stroke from an overly enthusiastic adjustment.

    By quasinonymous (not verified) on 29 Apr 2008 #permalink

    Before I get into the examples I want to present it is important to state that I read this blog, Pharyngula, Arac, and many others daily and am big fan, consider myself a rational skeptic and despise woo, new ageism, alt medicine, etc. I also know there are many dishonest chiropractors who are vendors of woo like the best of them.

    That said, I must relate 2 experiences with chiropractors that I find hard dismiss. The first appears below and will present the second in a following post.

    When I was still at the university one night I became nauseous and wretched so hard that I ended up on the floor in spasms. I was taken to the hospital in severe pain and was told I had torn the collagen fibers of a rib, it had slipped and it was pinching a nerve somewhere. The doctors told me to wear a support to keep my back straight and that I would be in pain for some time. They wouldn't give me any more of the Darvon they shot me up with the first night and I spent the next month in uncomfortable pain unable to lie down. I felt like there was a vise around my chest. I could not raise my arms even with my shoulders.

    It turns out a casual friend I had met that year had just recently finished chiropractic school and offered to take a look. I was hesitant but agreed because I was so discouraged by the pain and constant discomfort. I went to his office and he had me stand against a wall facing it. He felt around my ribs, announced he had found it and placed a 6" long U shaped instrument so that the U ends rested on either side of my spine. He told me to relax and exhale. He then pushed the instrument firmly into my back. I felt a definite jolt and snap, the pain was literally gone and I was standing straight again. I mean it was like something out of a movie and I stood for a moment in disbelief. But when I turned my upper torso to look back the pain returned as before. He repeated the same process and the pain was again gone.

    His explanation was that he had pushed the rib back in place but that the torn fibers allowed it to slip out because there was nothing to hold it in. He did something to the back support I was wearing so that it seemed to give more support where he claims the rib was out. He had me visit daily for him to check and readjust if I had more pain. At the end of 6 weeks it had apparently healed and I never had any more problems.

    He never charged me, never tried to get me back for other adjustments or gave me any other claims about chiropracty.

    Now I am perfectly willing to accept that it would have healed of its own accord in the same time period, but the relief from the pain was dramatic and repeatable. After he had pushed the rib back in the first few times I could literally feel it move when he did it and the pain ceased every time..

    Any thoughts or observations I may have missed? I am not trying to convince anyone of anything and felt compelled to relate my experience because I have no other explanation.

    FTR I do not regulary see a chiropractor. In fact the last one I saw was him for that injury and have long since lost track of him.

    By mayhempix (not verified) on 29 Apr 2008 #permalink

    Well here's one person you've convinced - no more neck adjustments for me.

    I've gone to 5 or 6 different chiropractors with little to no relief from anything they did. I have neck and low back problems.

    The reason I keep trying is that once a chiro really fixed me. I had 6 weeks of constant sharp pain in my middle back that came on very abruptly. I had been to my family doctor and he just told me to wait until it healed itself.

    The chiropractor examined me, told me I had a rib out of place, pushed it back where it belonged, and the pain was gone instantly, never to return.

    I'm a skeptical person and I never did and still don't believe in the theory of chiropractic, but this was one case where what was required was for someone to put his hands on me and poke around. My MD never touched me.

    I think Denise's comment sums it up: if you've got something like a rib out of a place, or lower back pain, etc., a readjustment can help - and it should help almost immediately (although I tend to follow up with applying heat to the affected area for 15 minutes or so to relax the muscles as they adjust to the adjustment).

    It need not be a chiropractor who does this. I have a recurring displacement from years of martial arts training; every 6 months to a year or so, I have to get it popped back into place. And every time I move I have to start the long search to find an osteopath or physical therapist or chiropractor skilled enough to do so correctly, without feeding me a bunch of New Age woo in the process.

    It can be done -- such people do exist -- but it's a challenge! Generally, I look for those who specialize in sports medicine/physical therapy who have chiropractic training as only part of their arsenal of skills...

    if you've got something like a rib out of a place

    Anatomically, there really is no such thing.

    Actually "rib out of place" is an alternative diagnosis for alternative practitioners (like "feldspar deficiency" or "leaky aura").

    This post is flatus from someone who is ignorant and does not seem to want to take the time to look at the research -- medical research, not just osteopathic and chiropractic.

    On the basis of dealing with back and neck problems, ribs and the like, every study the AMA or MDs did starting in the 1950s showed Chiropractic more effective than and type of "medical" treatment. Enough said on that subject.

    If you look at the research by neurosurgeons on Adult Tethered Cord Syndrome (Yamada 2000 and current) and the works of neurosurgeons like Alf Breig starting in the 1960s it has been shown beyond doubt that stretching of a nerve stops its function and can cause all sorts of neurologic signs and symtoms. Depending upon what method is used, realignment of the skeleton can take the stretch off the tissues and immediately start making fact of the claims of chiropractors.

    The problems come because chiros have little understanding of engineering and have not found the basic factor they need to handled in structural correction. Therefore the results have been inconsistent and unpredictable.

    If you want to criticize chiropractors there is plenty to criticize in the way they do research. They talk about "Chiropractic Manipulation" but do not specify the method of manipulation and treat it all as though it is the same. This is silly beyond belief. Private researchers have been working on this.

    The basic reason structural correction works when it does (and does not when it does not) has been found and if you do not have cancer, infections, diabetes, fractures or the like, there is no longer any reason to hurt or have problems. www.AdvBioStructualCorr.com anyone can learn it.

    More things are mechanical than anyone thinks. Take a look at Straight Back Syndrome and heart disease. More mechanical than anyone thinks but, until recently, there has been no method of structural correction that consistently changed chest shape. Now there is and many people with heart problems and asthma and more are finding their bodies corrected and lives back to what is normal and healthy.

    Personally, I had severe stomach problems, including ulcers found on imaging. Since the first time they did something to take the tension off my brain stem and the vagus nerve, I have had none of it unless I do something to pull the thing out of place. I get it corrected and the viceral effects disappear. There is research confiming this in plenty of others too.

    Anyone can learn to do it.

    Dr. Jutkowitz AdvBioStructualCorr.com

    if you've got something like a rib out of a place
    Anatomically, there really is no such thing.

    Posted by: PalMD | April 30, 2008 9:37 AM

    I have no reason to doubt your statement. I have no medical background and I have no agenda including the need to defend chiropractors. But my experience with immediate cessation of pain was real.

    If I did not have some sort of dislocated rib, which I am perfectly willing to accept, all I can I say is that whatever the practitioner did, it clearly stopped the pain.

    I find myself in a damned if I do, damned if I don't position on this. The last thing I want to do is come across as a crank or woo apologist. As I stated in my first post, I sit squarely in the rationalost pro real science camp and never pass chance to challenge friends and family when they wander off into woo land. But at the same time I had a clear and repeatable experience that I cannot pass off as coincidence. To ignore that makes me feel hypocritical.

    I don't expect a direct response but I do wish to not be lumped into the same group as some of the other commentators. I do not believe "adjustments" can prevent disease, cure heart problems, etc.

    Keep up the good work and my sincere congrats to the Hoofnagles on their first year anniversary.

    By mayhempix (not verified) on 30 Apr 2008 #permalink

    @arthritis...guy "chiropractic is not really an exact science."

    It is not a science at all. It is a cult that still believes that grocer DD Palmer cured deafness by slapping a guy on the back in 1895 (a feat that has never been replicated).

    Did you have a point?

    "Dr." Jutkowitz says:

    "On the basis of dealing with back and neck problems, ribs and the like, every study the AMA or MDs did starting in the 1950s showed Chiropractic more effective than and type of "medical" treatment. Enough said on that subject."

    I'm afraid that isn't enough said. Don't you feel compelled to provide some evidence to back up that ludicrous claim? Maybe fifty years of references from the AMA or "MDs". Your fantasies are not proof.

    Scare quotes around medical, grandiose claims without evidence... both good signs of a quack. Hmm... let's check the website.

    Yikes. Multiple fonts and colors, and photos of people standing offered as "PROOF!".

    It is one thing for one doctor to be able to create changes like this. It is another thing for a doctor who has just taken the home seminar and never personally been trained otherwise to create these changes immediately.

    Seriously? People with a home seminar are claiming to be qualified to do spinal realignment?

    One of my favorites is what Galileo was reported to have said as they took him away after the inquisition into his writings found him guilty of heresy -- it was something like, That doesn't change anything, the earth still goes around the sun.

    There we have it! The Galileo Gambit! Definitely a quack.

    As far as the rib or whatever the chiropractor fixed, I had something very similar with my big toe ball joint once. It very abruptly start hurting while I was walking. For 10 days it felt highly inflamed and I couldn't put any weight on it. Then I took a step and felt something like a little pop and the pain was instantly gone. Completely gone, from one step to the next.

    Clearly - or at least to me - something was out of place and popped back. It felt very similar to what happened in my back. If it happened again I would definitely try to manipulate it myself. For those who say joints don't "go out", do you have an explanation?

    mayhempix, PalMD -

    I posted to the other "Chiro is woo" scienceblogs article today - They (Chiropractic Medicine) rejects the germ theory of disease, and nobody knows what the hell a subluxation is, anyway - not even them. And of course I've been told "If your spine was misaligned, you'd be paralyzed." That may be true; like mayhempix, I'm no doctor, surgeon, or anatomist.

    However, I have had a couple of problems in my 45 years. I worked through them with "real" doctors a couple of times. "Here, take this flexeril, relax, take a week off work, stay horizontal, and the pain should go away in a month or so." And they were right. The most repeatable event is something goes 'thump' between my shoulderblades, and suddenly I'm in excruciating pain. It hurts to breath, turn my head, bend over, you name it.

    After losing a few time of losing a month to standard treatment, I went to a Chiro - much like mayhempix, frustrated with the pain and ready to try almost anything. He "adjusted" my back, and the pain was just gone. vanished. Since then, when it happens, I go to a chiro, he fixes me, and we part ways for another year or two. Call it what you want, it worked.

    Frankly, I think that the "theories" of chiro came AFTER the manipulation techniques, and are woo explanations for a technique that was useful in some instances.

    Just a small addendum... in re the pain I experienced, "real" doctors shrug, mumble something about 'soft tissue injury', and write me a scrip for flexeril. There are enough anecdotes for repeatable chiropractic relief of specific pains that I would like to see studies not based on generic 'back pain', but specifically identified problems. Do an MRI of something like my problem before and after and see if anything actually changes, physically. I suspect that manipulation is able to relieve pain in the instance of very specific instances that just haven't been sorted out. With before and after pictures, real doctors might be able to see what actually happens and explain it with something rational. AFAIK, no explanation whatsoever has been offered for the fact that chiro was effective at reducing lower back pain; I certainly would like to know why, because I don't buy the subluxation stuff at all.