5X5 Episode 93

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5X5 Episode 93
Chiropractic 3
13th August 2010
5X5 92	5X5 94
Skeptical Rogues
S: Steven Novella
R: Rebecca Watson
B: Bob Novella
J: Jay Novella
E: Evan Bernstein
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Chiropractic - Part 3

Voice-over: You're listening to the Skeptics' Guide 5x5, five minutes with five skeptics, with Steve, Jay, Rebecca, Bob and Evan.

S: This is the SGU 5X5 and this is the third in our series on chiropractic. Tonight we're talking about the current evidence for the effectiveness of chiropractic manipulation, if any, for any particular indication. There has been quite a bit of research into the use of chiropractic manipulation for various medical conditions, including back pain, and medical situations such as asthma or ear pain or headaches, things that are not directly related to mechanical back pain. Now, the evidence for the effectiveness of manipulation for back pain is the one area where it's in fact a little positive - there is some evidence for some effectiveness, right Evan?

E: That's right. So there is some evidence to support, and understand this is a really narrow indication of spinal manipulation, for the symptomatic management of acute uncomplicated lower back strain. The evidence outside of that narrow indication, it gets much sketchier at that point. Perhaps one of the most important facts concerning lower back pain is this: most acute lower back pain will go away on its own. And better still, there are many cases of even chronic back pain that have resolved itself. This is without manipulations, doctors, drugs or medical procedures. Simple rest, applying heat or cold or moisture - these can have as effective an impact on relieving your pain as any spinal manipulation can offer. Chiropractic is by no means the only option patients with acute lower back pain. Patients can see an osteopath, physical therapist, an orthopedist, to seek treatments for temporary relief. But manipulation is most readily available from chiropractors. In a report issued by the Rand Corporation in the 1990s stated that 94% of all such manipulation in the United States is done by chiropractors. For this reason many people who have back pain will visit a chiropractic office where they will experience spinal manipulation for the first time. But understand, manipulation is no more effective and is often more expensive than other forms of treatment such as best medical management or simple physical therapy with good home back care.

S: And Evan, that Rand report is a little out-dated in that physical therapists in the last 10 and 20 years have been increasingly using manipulation very similar to chiropractic manipulation for acute uncomplicated lower back pain. So they are another professional that you can go to for that kind of treatment. And in fact there are those who recommend that physical therapists are a better choice because they are more evidence-based and they are not still mired in a lot of the pseudo-scientific roots of chiropractic. So for most people, if just usual back hygiene and the kind of things you can do at home are not sufficient, a physical therapist might be a better first choice than a chiropractor. It's really difficult to find a strictly science-based chiropractor these days.

R: When it comes to neck pain, that's another really common one that's treated by chiropractors. There's really not much evidence to suggest that it's at all effective. There've been some small studies to suggest that it may improve range of motion, but these have been pretty flawed and too small to realyl make a call on. Which is a shame because neck pain seems to be one of the most dangerous things you can treat with chiropractic. There have been numerous documented cases of people having strokes after having neck manipulation. There is also a study of 377 members of British and Scottish chiropractic associations and more than 1900 of their patients, asking about complications following neck manipulation, and though no one reported any strokes there, they did find that 3.9% of cases reported headache, 1.3% reported numbness or tingling of the arms and 1.1% reported fainting, dizziness and light-headedness. 400 of the patients discontinued the treatment and couldn't be reached for follow-up. So, you know, there's a disturbing trend that shows a lot of negative side-effects of chiropractic treatment on the neck, and very little evidence to back up using it at all.

S: Yeah, in fact there's a movement in the United States to push for informed consent for neck manipulation for chiropractors, essentially advocating regulation to force them to inform their patients that there are reported cases of vertebral dissection and stroke following neck manipulation. If you do a risk versus benefit analysis, basically there's no real evidence for benefit but there is evidence for a small risk, so it's just not worth it.

J: Ok, so a very common question that we get is "can chiropractic cure disease?" So, quickly let me give a definition of what disease is. Disease is a pathological condition of a part organ or system of an organism, resulting from various causes such as infection, genetic defect or environmental stress, and characterized by identifiable group of signs or symptoms. So going back in history in chiropractic, B.J. Palmer, the son of chiropractic's founder, wrote in 1906 in his book The Science of Chiropractic: Its Principles and Adjustments, he wrote a list of what I like to call "the list of everything," which is basically a list of every disease that you can think of off the top of your head. I'm going to read the first 9 of this list of 84 that he had in his book, so he said "abscesses, apoplexy, asthma, appendicitis, Bright's Disease [now called nephritis], brain fever, bladder trouble, bronchitis, cancer," and in parenthesis "(any part of body)," so he's basically saying any kind of cancer. And at the end of this list of 84 diseases he writes "if your disease is not on this list, bear in mind that this chapter is not as large as a medical dictionary." That's pathetic. So over the years some chiropractors have come to accept the germ theory and the effect of poor lifestyle choices like drinking and smoking, but sadly many of them still believe that at its core disease is caused by the misalignment of the spine which inhibits the flow of life force energy.

S: Yeah, that's really what separates the so-called straight chiropractors from those that try to be more evidence-based or at least restrict their scope of practice to mechanical back pain, is the notion of the subluxation theory. And basically 100 years of chiropractic there is zero evidence that the chiropractic subluxation complex exists. So just the very basic concept of using chiropractic manipulation to treat disease does not exist in science, anatomy, physiology, biology. And of course there's also no evidence to support the use of chiropractic for any specific medical condition at all.

B: When chiropractic groups do actually offer studies to back up their claims, they may provide a list of studies but the list becomes quickly unimpressive-looking when you take a good look at them. In terms of supporting chiropractic pediatrics, the list [pdf] famously offered by the British Chiropractic Association during the Simon Singh case, was a great example. Not only was the sheer number of supporting studies feeble but so was the quality of the individual studies, even with the cherry-picking. For example, the support offered for chiropractic treatments for colic consisted of 8 studies but the 4 best were either unblinded, single-blinded or even uncontrolled. None were double-blinded and placebo-controlled, meaning it was all low-grade stuff, nothing to hang your hat on. There was a study done by Olafsdottir et al that had a superior design but it was not on the list. It concluded "chiropractic spinal manipulation is no more effective than placebo in the treatment of infantile colic."

Now a similar story unfolds for childhood asthma. Only a few weak studies are presented by the BCA while the most definitive study to date is not even mentioned. This large randomized controlled trial study from the New England Journal of Medicine concluded "in children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit."

As bad as the evidence is for colic and asthma, it's arguably even worse for conditions like otitis media, which is middle ear infection, and nocturnal enuresis which is bedwetting. You'd think by now if there were any clinical effects for the chiropractic treatment of common pediatric illnesses, there'd be many or even one well-designed study that showed it.

S: So the bottom line of all of this evidence that has accumulated over the last few decades is that chiropractic manipulation is effective for acute uncomplicated lower back pain but not much else. In essence the strict evidence- or science-based chiropractor is a glorified physical therapist, which is fine to be a specialist in the non-drug therapy of back pain, and that's what chiropractic should evolve into if it really did endeavor to be part of the science-based healthcare system. But far too many chiropractors still cling to their pseudo-scientific roots and make therapeutic claims that the evidence shows are not theoretically plausible and simply do not work.

S: SGU 5x5 is a companion podcast to the Skeptics' Guide to the Universe, a weekly science podcast brought to you by the New England Skeptical Society in association with skepchick.org. For more information on this and other episodes, visit our website at www.theskepticsguide.org. Music is provided by Jake Wilson.