Lecture 3: Chiropractic

[Music] welcome back I'm Dr Harriet Hall and this is lecture three in a series of 10 lectures on science-based medicine in the last lecture I talked about cam in general and now let's look at some specifics of all the things in alternative medicine Chiropractic is probably the most widely accepted 30% of Americans have visited a chiropractor in their life time it's not so popular in other parts of the world there are 50,000 chiropractors in the United States but about half the countries in the world have no chiropractors at all chiropractors are not medical doctors they can say they're doctors because because they hold the DC degree doctor of Chiropractic if a chiropractor calls himself Dr Jones and doesn't explain his patients may assume that he's a medical doctor some people don't even know there's a differ they think chiropractors are just MDS who specialize in the back most customers go to chiropractors for treatment of back pain but some people go to chiropractors for all their health needs and for health maintenance and prevention that's a mistake these claims were made by a chiropractor in the comments on the science-based medicine blog they are all false Chiropractic is not a science it's a pre-scientific belief system it is not based on neurology anatomy and physiology it's based on a myth the myth of the so-called Chiropractic subluxation chiropractors are not doctors of the nervous system neurologists are doctors of the nervous system chiropractors are more like physical therapists and there's no evidence that chiropractic care improves health or quality of life I'm going to tell you how Chiropractic originated what Chiropractic Theory says and why science Rejects it I'm going to tell you about some of the complications Chiropractic can cause I'm going to show you that chiropractic is a magnet for quackery for unproven and implausible tests and treatments I'm going to tell you about some of the harmful and unethical things that some chiropractors do and finally I'm going to tell you what chiropractors do that really works and I'm going to give you some guidelines on how to choose one Chiropractic is not a science it's the brainchild of a single individual who invented Chiropractic all by himself in a single day the day was September 18th 1895 it says so right there on his Monument the inventor had no training in science or medicine he was a grocer and a magnetic healer named DD Palmer he based his whole theory on one patient he thought a bone was out of place in a deaf janitor's back he pressed on the janitor's back and thought he had replaced the bone and immediately the janitor said he could hear again according to Palmer according to the janitor's daughter her daddy remained deaf until the day he died we'll never know what really happened but we can be sure that nothing Palmer did to the J to the janitor's back could have restored his hearing Palmer was ignorant of anatomy he didn't know that the nerves to the ear are all in the skull with no connection to the spine and today few if any Chiro rors would even try to treat deafness but Palmer was convinced and from this one case he extrapolated to say that he had found the one cause of all disease really he thought that all disease was due to subluxation bones out of place 95% subluxation in the spine and 5% subluxations of other bones he didn't test his idea to see if he was right he knew he was right so he proceeded to develop a thriving practice cracking backs now think about the state of medicine in 1895 conventional Medical Treatments of the day were just as likely to harm as to heal pasture who discovered germs died in 1895 and The Germ theory of disease wasn't yet widely accepted the first antibiotic didn't come along for another 50 years in 1895 was the same year Ren discovered x-rays so when dd Palmer thought he felt a bon out of place he had no way of verifying it DD Palmer lived in a pre-scientific world and he didn't know any better but modern chiropractors don't have that excuse don't confuse Chiropractic with osteopathy do is Doctor of Osteopathic Medicine DC is Doctor of Chiropractic chiropractors and osteopaths originated about the same time and they did the same back manipulations but the Osteopath thought they were restoring blood flow and the chiropractors thought they were restoring restoring nerve flow Do's accepted scientific medicine and today an American do gets the same training as an MD plus training in spinal manipulation techniques in the United States dos have to pass the same licensing exams as MDS and they take the same internships and residency training they practice mainstream medicine and they seldom do manipulations once they're out in practice for chiropractors manipulations are their main reason for existing there are three parts to Chiropractic Theory sublation nerve impairment and innate sublation is the idea that displacement of Bones is the root of all disease Palmer imagined that he could feel bones out of place in the spine and he thought he could put them back nerve impairment is the idea that all body functions are governed by nerves from the spine and that displaced bones interfere with nerve function by stretching or compressing nerves where they exit the spine inate Palmer thought a mystical vital force called innate was transmitted through the nerves and that realigning the spine would restore proper flow of inate which would cure disease all three of these ideas are false first subluxation subluxation is a medical term for a partial dislocation you can see real subluxations on x-rays the picture on the left shows a torn finger ligament that has allowed a subluxation or a partial dislocation or slippage the X-ray on the right shows a complete dislocation of the same joint actual bone displacements are obvious on x-rays the Chiropractic sublation is not chiropractors think they can see subluxations on x-rays but different chiropractors see them at different locations on the same X-ray and Radiologists don't see them at all when chiropractors were tested on before and after x-rays they couldn't tell a difference when Chiropractic schools were challenged to produce sample teaching x-rays demonstrating subluxations they weren't able to do so when a chiropractor produces an audible crack in your back he may tell you it's the sound of the bone B popping back into place but it isn't it's just the same kind of sound you get when you crack your knuckles and it's produced by gas rushing in to fill a vacuum when two bones are pulled apart at a joint to create a potential space it creates a little bubble with a big sound remember when your mom told you to stop cracking your knuckles because it was bad for you well it probably wasn't but some Orthopedic Specialist worry that repeatedly forcing a spinal joint beyond the normal range of motion May stretch the ligaments it might loosen the joints and make the patient more prone to developing back pain we don't know if that's true but some patients do seem to become addicted to adjustments the more they get the more they seem to need chiropractors originally believed in Boop bones out of place when that theory couldn't be demonstrated on x-ray they said silly things like well there is a displacement that's enough to cause disease but it's too tiny to show up on an X-ray eventually had they had to give up on Boop they redefined subluxation and said it was a complex of functional Andor stru structural and or pathological articular changes that compromise neural integrity and may influence organ system and General Health does that even mean anything I think it's just gobbly g a disease like diabetes is defined so that every Doctor Who evaluates the patient will make the same diagnosis but this vague definition of subluxation can be interpreted pretty much any way you choose it really just amounts to a pretext an excuse to treat anyone the chiropractor wants to treat some chiropractors are now rejecting the subluxation concept entirely a recent study by chiropractors found no supportive evidence for the Chiropractic subluxation being associated with any disease process or creating suboptimal health conditions they concluded the subluxation construct has no valid clinical applicability but the law still defines Chiropractic in terms of the sub sublation and the word subluxation is still very much in common use the second part of Chiropractic theory is nerve impairment Palmer thought all body functions were governed by nerves from the spine they aren't he didn't know about cranial nerves and he didn't know about hormones and apparently he didn't realize that some spinal nerves exit through the sacrum and the sacrum can't be manipulated today with organ transplants we know that you can sever all the nerves to an organ and Transplant it into another person's body and it still works just fine and true subluxations don't necessarily affect nerves you can have a sublation without nerve impairment and you can have nerve impairment without subluxation in a condition called spond thesis true subluxations have occurred and you can see them on x-ray but they may not cause any pain or impairment unless the displacement is very Advanced and the pain is usually muscle pain rather than nerve pain one condition where nerves are affected is a ruptured disc when a disc ruptures the disc material breaks through the fibrous anulus and puts pressure on the nerve but there is no displacement of the bones with a ruptured disc Chiropractic claims that pressure on a nerve impedes the flow of messages through the nerve like stepping on a garden hose as in this picture from an early Chiropractic advertisement today we know that's false nerve impulse don't flow like water they are electrical impulses and today we can actually measure nerve conduction speeds in carpal tunnel syndrome the nerve is compressed in a small area at the wrist we make the diagnosis by showing that the nerve conduction is normal above and below the wrist and slowed only across the area of compression and just how easy is it to pinch a nerve well here's a picture showing how the relatively small spinal nerves come out of a big hole between the vertebrae the spine is built to allow movement the cross-section on the right shows the available space in White and the diameter of the nerve in Black it shows that there's plenty of room so that even a large displacement of Bones would not cause a problem one pathologist took a spine from an autopsy and he showed that you could bend the spine into a u-shape before there was any impingement on spinal nerves if nerves were that easy to pinch this woman would be in real trouble the third part of Chiropractic theory is innate innate is a mystical power that maintains Health it is a semi-religious concept and DD Palmer actually thought of making Chiropractic a religion at one point this is a diagram the chiropractors have used to show how the patient's innate is flu influenced by the chiropractors innate kind of like ESP I don't know what that little trapo in the patient's head is supposed to be the cab I dissected in my gross anatomy class didn't have one of those does this sound a bit like new age you create your own reality nonsense this is not science this is a philosophical position called vitalism the idea that some unmeasurable undefined undetectable Life Energy invest material bodies there is absolutely no objective evidence that any such Force exists vitalism has been soundly rejected by science like many myths this one has a grain of truth behind behind it doctors don't heal patients the body heals itself medical treatment only makes it easier for the body to do that but the healing isn't accomplished by any woow woo Force healing occurs through physiologic processes that can be detected and studied Chiropractic manipulations can cause harm neck manipulations can cause Strokes by damaging the vertebral arteries here's how it happens this is the normal position of the vertebral artery going straight up up the side of the neck into the base of the skull when you turn your head it Kinks now arteries are pretty elastic and turning your own head is usually no problem but imagine being jerked into this position forcefully during manipulation or having the joint forced Beyond its normal range of motion that can cause a small tear in the delicate lining of the artery sometimes this causes immediate damage from bleeding but sometimes the tear is temporarily sealed with a clo clot and later on the clot Breaks Loose travels to the brain and clogs an artery causing a delayed stroke as much as several days later with a delayed reaction the connection to manipulation may be missed how often does that happen well by one estimate 20% of one kind of stroke basil Strokes are due to spinal manipulations that works out to, 1300 Strokes a year in the United States patients with basil Strokes who were under the age of 45 were five times more likely than controls to have visited a chiropractor within a week of the event Chiropractic Strokes are under reported neurologists who see stroke patients don't routinely ask about chiropractic care and if the stroke is delayed the connection may not be apparent this is Sandra netti she was a healthy 40-year-old woman who was feeling fine but she went to her chiropractor for a maintenance adjustment that she thought would help keep her health healthy when the chiropractor used a rapid thrust maneuver on her neck she suddenly felt dizzy and unwell when she complained the chiropractor didn't recognize that it was an emergency his only response was to offer to sell her massage services he let her try to drive herself home she only made it part way doctors found tears in both of her vertebral arteries one of them 3 in long as the stroke progressed she developed locked in syndrome an intact mind locked in a paralyzed body she was in pain was unable to eat or breathe on her own and was able to move one arm just enough to type on a special keyboard she sued the chiropractor later admitted to the court that after he learned he was going to be sued he had forged Sandra's signature on an informed consent form chiropractors have tried to defend themselves by saying the patients who had Strokes had come to them with neck pain because they were already in the early stages of a stroke but Sandra had no neck pain neither did laori g miasin she originally went to a chiropractor for pain in her tailbone by one account she had a whopping 186 manipulations over a 6-month period I haven't been able to confirm that but other sources said she had over 20 neck man manipulations with the last one she went into convulsions on the chiropract 's table the chiropractor's only response was to try to revive her by slapping her face she died in a coma 3 days later even when patients do have neck pain if chiropractors can't identify patients in the early stages of stroke they have no business manipulating their necks we don't know the actual risk of stroke from neck manipulation because the appropriate studies haven't been done Strokes are undoubtedly rare but if a drug had the the same small risk of stroke and so little demonstrable benefit then it would almost certainly have been taken off the market here are some of the other undesirable effects from manipulation half of patients experience local discomfort headache tiredness and radiating discomfort more serious complications include broken bones herniated discs disability paralysis and even death I read about one family that kept going back to the same chiropractor until three family members had suffered Strokes some chiropractors deny that manipulation can cause strokes but their insurance companies are aware that there's a problem in 2002 9% of the claims paid by the major Chiropractic insurance company were for strokes that isn't proof that they were caused by manipulation but it is proof that the insurance companies can't deny that there's a problem when it comes to quackery Chiropractic is a veritable duck Pond chiropractors are quack magnets they adopt every new idea that might increase their patient count no matter how crazy and they keep using quack methods even after they've been disproven I'll give just a few examples Mo Contour analysis Maps the surface of the body and supposedly picks up asymmetries that help locate disease areas it doesn't work chiropractors have been using these gadgets for almost a century run it down your back with a prong on either side of the spine it's supposed to pick up temperature differences to pinpoint subluxations unfortunately the needle also moves when you press harder so it's real easy to fool yourself for patients who don't like the idea of having their back forcibly cracked the activator is a spring-loaded device that can be adjusted to various impacts that can be as light as a finger tap this machine that looks sort of like a drill press is a special active Ator that Taps a specific spot on the atlas the top cervical vertebrae at a carefully calculated angle adjusting the atlas is supposed to fix the entire spine applied Kinesiology is a bogus muscle testing technique that a whopping 43% of American chiropractors use to diagnose allergies and other conditions they believe it even works by proxy this chiropractor is diagnosing the little girl by testing the strength in her mother's arm this is a toughness device the operator rubs his fingers on the detection plate and claims to feel a stickiness when the device is positioned over a subluxation it's totally bogus it was banned by the FDA in 1980 but it's still being used in 1991 3.3% of chiropractors were still using it in 2007 the FDA confiscated 96 of them and as recently as 2013 the California Board of Chiropractic examiners disciplined chiropractor David Manago for using one some chiropractors use a variety of other bogus tests and treatments this is just a partial list it includes things like Homeopathy and divination with a pendulum I won't read the list now but you can find it in the course guide chiropractors used to routinely take full spine x-rays that expose the pelvis and reproductive organs to unnecessary radiation and we mostly out of Focus because of the different thickness of the body at different levels they still do a lot of unnecessary x-rays x-rays are not indicated for most common cases of low back pain they may recommend repeating X-rays at frequent intervals to assess progress which is silly because subluxations don't show on x-ray the only legitimate reason for x-rays is to make sure there are no fractures or tumors or anything else that would be a contraindication to manipulation CME or continuing medical education for chiropractors often amounts to courses in practice management to boost their patient count they often engage in unethical advertising DD Palmer's son BJ was a publicity genius and something of a con man he had a favorite saying that the spine supports the ribs supports the skull and supports the chiropractor he was interested only in making money they put blind ads in the newspaper that don't reveal that they're chiropractors even though that practice is prohibited by the ethical guidelines of their own organizations they offer to mail you free medical reports about new discoveries to treat back pain or Whiplash or to cure ruptured discs by Space Age Technology with no need for surgery there are no new discoveries just minor variations on Old techniques and they have to sneak this information to you by mailing you a report at your request because the FTC would not allow them to make false claims in direct advertising they do anything and everything to drum up business like the free exam and the double scale at the county fair that diagnoses everyone as lopsided I mean just try standing on two scales and getting them getting them both to register the same weight these free exams are guaranteed to find subluxations in every customer and chiropractors will tell you that everyone needs regular Chiropractic adjustments to maintain normal Health some chiropractors give very bad advice less than 50% of chiropractors support immunizations and some are adamantly against them many are against water fluoridation many of them give diet advice based on unsubstantiated theories and they sell diet supplements and vitamins out of their office at inflated prices many of them try to persuade their patients to avoid conventional Medical Care claiming that it's almost always harmful some want to be your family doctor but they're not trained to to fill that role some of them have missed obvious diagnoses that required referral in one study a patient went to several chiropractors complaining of the symptoms of a heart attack instead of rushing him to the ER they all offered him Chiropractic adjustments for his pain in another study chiropractors fail to recognize that a high fever in a very young infant was an emergency most of them just offered to adjust the infant's spine many chiropractors create a chiropractic Neurosis by doing lifelong maintenance adjustments and convincing patients that every symptom they get every sniffle or itch is a reason to run back to the chiropractor because it means their last adjustment has slipped a chiropractor in my town in peip Washington had a website where he claimed that childbirth stretches the baby's neck up to two and a half times its normal length I tried to tell him that if childbirth could do that you wouldn't have a baby anymore just a corpse it's impossible to stretch a baby's neck that far the bones don't stretch and they can't separate because they're tightly Bound by muscles and ligaments just try stretching your Thanksgiving turkeyy neck to 2 and 1 half times its normal length it can't be done his website also claimed that every newborn should be adjusted as soon as possible after birth preferably right in the delivery room and that delaying chiropractic treatment until puberty could cause irreversible damage this is nothing but the most errant bull spit baby's bones haven't even finished forming they mostly consist of separate osificante without treatment occasionally they miss an infection that does require antibiotics and complications like mastoiditis and brain infections can occur they make other claims for Pediatric conditions like colic but there's no evidence that chiropractic benefits any pediatric condition many authorities feel that no child under the age of 12 should have chiropractic treatment period a skeptical chiropractor named Samuel hola says that manipulating children is scientifically indefensible and it puts children at risk for things like brain bleeds and paraplegia and fatal brain and spine injuries it also delays diagnosis of treatable treatable illnesses like cancer and menitis I found a chiropractic website that had a cynical list of PLO to deliberately undermine the parents trust in their pediatrician and get them to bring their kids to a chiropractor for their Primary Care an example examine a child's spine and say h like you found something worrisome and then ask Mom if the child breastfed more from the right breast or the left breast whichever she answers say I thought so and then ask did your pediatrician ever ask you that chiropractors come in different flavors these are their professional organizations the international chiropractors Association is for Straits the American Chiropractic Association is for mixers The Straits limit their practice to Chiropractic adjustments only the mixers may add anything from massage to Voodoo there is also a small group of upper cervical or nuca practitioners who only work on the top ver vertebra in the neck even most other chiropractors think that they're wrong they follow the whole in-one Theory the idea that if you adjust the atlas the top vertebrae the rest of the spine will somehow magically fall into alignment the picture supposedly shows how health and healing messages travel from the brain down to the atlas vertebrae but can't get past it if the head and neck are misaligned which is nonsense they take unnecessary x-rays they draw lines on x-rays before and after treatment and they pretend to show Improvement by drawing the lines slightly differently they claim to treat everything from allergies and ear infections to Multiple Sclerosis and epilepsy there's a nucar practitioner in Seattle that I call the not touch chiropractor she puts one hand over the other and goes and makes a cracking sound in her own wrists while remaining about an inch away from the patient's skin sometimes instead of using their hands to adjust the atlas they use a machine like this it provides an Impulse to a tiny spot at a at a precisely calculated angle they call this Atlas orthogonal And there's another small slowly growing category of reformed chir prors who reject the subluxation concept and try to provide evidence-based care they limit their practice to short-term treatment of muscular skeletal problems there aren't very many of them and they're hard to find they essentially operate as if they were physical therapists with special expertise in the back it's hard to see how they can call what they're doing Chiropractic chiropractors have lots of satisfied patients and they do help people here's what chiropractors do well they provide effective physical therapy for back pain and they offer sympathy explanations and support the doctor says I don't know why your back hurts here try these pills the chiropractor says I know exactly why your back hurts and I can fix it and I can keep it from recurring it's satisfying to have an explanation even if that explanation is wrong and he provides lots of personal attention Hands-On care and wants to see you again soon and your whole family too for benign self-limiting conditions the chiropractor may keep the patient entertained long enough for the condition to resolve naturally and that may keep them from trying surgery or other treatments that might have dangerous side effects and they're good psychologists they know how to please patients who are dissatisfied with their regular doctors there is one treatment they use that is really effective spinal manipulation therapy has been proven Mo to work for low back pain but it isn't any more effective than other forms of treatment in one study it didn't work any better than just giving the patient a pamphlet about back care but it may offer more rapid relief and it's a reasonable option for patients who want to avoid pills but there's nothing uniquely Chiropractic about it Do's physical therapists and some MDS use it too if a chiropractor offers to provide spinal manipulation therapy for back pain that's acceptable but if he claims to be adjusting your spine to correct subluxations that's not acceptable neck manipulation has been proven effective for neck pain but it's no more effective than gentle mobilization and neither manipulation nor mobilization will work unless they're combined with an exercise program Chiropractic has many of the Hallmarks of pseudoscience it has its own journals and publishes studies but they're of very low quality they publish a lot of case reports and uncontrolled studies designed to impress readers that chiropractic works not to find out if it works science makes progress Chiropractic doesn't science rejects things that have been shown not to work Chiropractic doesn't they just keep adding more adjustment techniques well over a hundred now they haven't tested them against each other to see if some are more effective than others they just want to have the freedom to choose any any treatment they want this book is a travesty somatovisceral aspects of Chiropractic it's a textbook intended for use in schools of Chiropractic it's about treating disease in other parts of the body instead of just the spine it claims that chiropractic can treat asthma colic ear infections endocrine disorders menstrual pain and a host of other internal disorders the subtitle claims it is an evidence-based approach but I read this entire book and I didn't find anything in it that could be classified as evidence based medicine or science-based medicine their concept of evidence is anecdotal reports uncontrolled studies and poorly designed studies that have never been replicated if you still want to consult a chiropractor after hearing all this here's how to choose a safe one look for one who rejects subluxation therapy who doesn't take unnecessary x-rays who doesn't use quack procedures or tests who doesn't do preventive or maintenance adjustments who doesn't promote un proven dietary supplements who doesn't pretend to be a family doctor who doesn't treat young children who doesn't recom doesn't demonstrate antagonism to Scientific medicine who doesn't discourage immunizations who limits his practice to short-term treatment of muscular skeletal problems and who knows when to refer the skeptical chiropractor Samuel homola used to tell his patients I can't predict whether manipulation will help you but let's try it for three treatments if it's not helping at that point we'll stop remember Lori Jee matias's multiple treatments over 6 months don't you think she should have realized before that point that it wasn't working pick a chiropractor who's wearing the Hat on the left trust me I'm a scientist rather than the one on the right bat crazy I think I've made it clear that chiropractic is not science-based but let me add a few horror stories in a recent online Forum chiropractors were argu arguing about whether you could ever die if your spine were kept in perfect alignment some of them thought you couldn't die since everyone dies I guess they thought that no one's spine is ever kept in perfect alignment a chiropractor told me categorically that germs can't possibly cause disease because if they did we'd all be dead he has never had an immunization and he claims that he can't catch anything because his spine is in alignment incidentally he happens to be morbidly obese maybe all that fat is help helping hold his spine in place I met a chiropractor who diagnos his allergies by having the patient hold a sealed glass vial of allergen in one hand while he tests their muscle strength in the other arm if their muscles seem weaker when they hold the vial that proves to him that they're allergic to the vial contents he suspected one patient was allergic to something at work and he didn't have a vial of bowing so he just had the patience think about VOE and that worked just as well I heard that a child in my neighborhood had died of menitis because he was treated with Chiropractic adjustments instead of antibiotics I asked if the family had sued the chiropractor and I was told that they couldn't very well do that because the treating chiropractor was the child's own father his false beliefs killed his own child a friend of mine had a narrow Escape he had a back aach that just wouldn't go away and on a Friday afternoon he called a chiropractor and made an appointment for Monday on Saturday his back pain stopped and it never came back Chiropractic must really be powerful if it works by just making an appointment remember the post Haw ero propor Hawk fallacy from lecture one if he had seen the chiropractor on Friday and the pain went away the very next day who do you think would have gotten the credit he probably would have thought the chiropractor was a miracle worker and he would have kept seeing him forever so to summarize Chiropractic is a pre-scientific belief system it's based on a myth the subluxation it has tried to establish scientific credibility for over a century and has failed sometimes chiropractors help people feel better but they can also cause harm when Chiropractic does help it's not really anything uniquely Chiropractic that helps if a chiropractor offers spinal manipulation therapy for short shortterm treatment of certain kinds of muscular skeletal pain he might be able to help you if he offers to adjust your subluxations or to treat problems elsewhere in the body he's not to be trusted in the next lecture I'll talk about another Cam that is highly overrated acupuncture