Wednesday, September 06, 2006

Chiropractors: The Good, The Bad, and The Ugly

Sorry for the delay in posting, I've been busy moving up to University for the term, and then after that I couldn't decide which of a few topics I wanted to address first. Anyways, onto the content.

Anyone who's spent time in the Skeptic community has likely heard about the claims of Chiropractors. Most of what you hear about are the bads ones, as these are the overwhelming majority and also represent the traditional views of Chiropractors. But, there are a couple of other groups that have notable distinctions. I'm going to use this post to explain these three groups.

The Bad

First, the bad ones (I know, it's not the order in the title, but this is the best way to present it). These are the ones you hear about mostly, the ones who claim that correcting vertebral subluxations (misalignments of vertebrae) can cure literally any disease in the body. At that point, you should be immediately suspicious. One of the first rules I use when dealing with medical woo claims is "There is no Panacea." A single pill or procedure that claims to cure everything is almost always bogus; the body just doesn't work like that. Aside from that, how about the fact that there is no evidence to support their claims. As one Chiropractor famously said, "That's why we never use double-blind tests. They never work."

Many of these Chiropractors belong to the International Chiropractors Association (ICA), the American Chiropractors Association (ACA), the National Association for Chiropractic Medicine, or the European Chiropractors Union. They have their own distinctions within themselves, but I'm not going to bother with it. It's just a minor difference in what brands of woo they subcribe to.

The Good

Wait, did I just say "Good" Chiropractors? Yes, I actually did. While there isn't evidence that Chiropractic helps with most of the stuff it claims, there actually is evidence that it helps with lower back pain and tension headaches. A single procedure that helps one or two ailments? I can buy that. So, what was a Chiropractor to do? Unfortunately, most of them chose to keep claiming it treated everything.

A few, however, were smart. "If it can only be shown to treat these, how about we only use it to treat these?" They thought. So, they branched off and started calling themselves "Straight Chiropractors." (The name was since picked up by the bad ones, so these ones are now "Objective Straight" and the bad ones are "Traditional Straight" or a variety of "Mixers.") These ones are generally trustworthy, and actually know what they're talking about. If someone comes in and asks about a medical problem they can't help, they - *gasp* - refer them to a medical doctor!

These ones are usually members of the Federation of Straight Chiropractic Organization (FSCO) (I know, redundant...) or the World Chiropractic Alliance (WCA).

See the FACE's first position paper for an example of an organization that's taking the first steps towards respectability. (Sadly, they suffer from Giant Block of Text syndrome over there....) It's far from perfect, but it's a start.

EDIT: For a better example of a good organization, see http://www.chiromed.org, the homepage of the National Association of Chiropractic Medicine (NACM). These organizations still have their share of problems, but I still feel that we should encourage those who are moving in the right direction, rather than criticize them for not miraculously giving up every piece of woo overnight (of course, we should still encourage them to go all the way).

The Ugly

And then there're the ugly ones. These ones show up mostly in first-world countries that have strict requirements to become a real doctor. A lot of foreigners just can't cut it, often because they can't speak the local language, or the standards weren't as high where they came from. Since being a Chiropractor takes no training, they do that instead, generally masquerading as one of the bad ones.

These ones also generally claim to treat everything, but often this is because they're using real medicine (or real medicine as it was taught to them in their home country) instead of Chiropractic to treat it. If someone has lower back pain or tension headaches, they might take on the role of an Objective Straight Chiropractor and do that.

There are a few problems here, though. The first is that there's no easy way to distinguish these ones from the bad Chiropractors without paying to see them. The second is that the medicine they were taught might not be so good. Some are actually good doctors who just couldn't get certification as they couldn't speak the language well enough, but some are just bad doctors. In the end, if you want medical advice, there's no reason to go to a bad Chiropractor hoping you get one of the good ugly ones; just go to a real doctor. They are nice to have, though, in that they may provide good advice to some people who came because they were genuinely deluded.

Conclusion

I hope that, in time, the bad ones will fade out, and the term "Chiropractor" will only be used for the good ones (though sadly, that's rarely the way things go). All I can do for now is help to make sure people know the situation as it is, and only go to see the good ones, and them only for the right problems. Sometimes, they're aren't all bad.

17 comments:

TheBrummell said...

Pedantic Man Says: You've got "The Bad" listed twice as headings.

Infophile said...

Could have sworn I caught that one myself... thanks, though.

Anonymous said...

I am afraid you are too generous with your assessment of "Good" chiros. FACE still adheres to the absurd notion of the "chiropractic subluxation," which does not exist. (There is a medical subluxation; but it is an entirely separate idea.) And there is no "innate intelligence;" which is the nonsensical "life force" (The movie featuring Mathilda May notwithstanding).

There is an association of rational chiropractors who reject the subluxation notion and severely limit their practice. They are The National Association of Chiropractic Medicine.

Your best source for critical information on chiro is:
http://www.chirobase.org/

Consider this: your straight chiros are going to subtly improve you life by adjusting the spine and reducing interference with nerves. Then consider that people with spinal cord damage have no (zero, bupkis) nervous connection to the brain, and most organs function fine. You say that's not enough? You want more" Okay, transplanted organs work well with no connection to the nervous system!

How can anyone believe that a minor interference with the nervous system (which is, also, imaginary) is important when a complete disconnection is not? Sorry, your "good" chiropractors are still, ignorant witch doctors.

Joe

Infophile said...

Thanks for your comment, Joe. I've added in a note to the post, which also serves as a reply to some of your points:

For another good example of an objective straight organization, see http://www.chiromed.org, the homepage of the National Association of Chiropractic Medicine (NACM). These organizations still have their share of problems, but I still feel that we should encourage those who are moving in the right direction, rather than criticize them for not miraculously giving up every piece of woo overnight.

A couple of other replies:

FACE still adheres to the absurd notion of the "chiropractic subluxation," which does not exist.

Yeah, FACE isn't the best example; they're more on the edge. Also, "subluxations" were originally defined as misalignments of the vertebrae, though there's no real evidence that this happens. At this point, this leave Chiropractic at a point similar to Acupuncture: There's evidence that it helps with some things, but we have no real idea why (there's limited evidence that acupuncture helps relieve pain in general to a small extent). Still, the lack of a mechanism doesn't mean that it doesn't actually help.

Consider this: your straight chiros are going to subtly improve you life by adjusting the spine and reducing interference with nerves.

Not all straights believe that. I've met a few who were quite serious, and only dealt with back/nervous system problems.

Anonymous said...

Bryan,

I am afraid you are still mistaken. The FACE paper you cite says “Objective straight chiropractors correct subluxations not because they cause disease or are associated with any medical condition but simply because the body works better without them.” This is BAD, pure quackery- they take your money for a sham treatment of a non-existent condition. It is also double-talk. The sublux doesn’t cause any problems; but correcting it helps?!

According to The Association of Chiropractic Colleges “A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.” And/or, anything we can bill you for fixing.

The problem is- chiropractic is a cult, and they cannot deny their subluxs. The members of NACM have renounced it, and they are shunned by other chiros; that is cult behavior. Also, when you talk to any quack, they don’t make positive claims to the skeptical, and they deny the obvious nonsense in their field (“we don’t treat asthma by manipulation any more” is quackery 101). I have heard it all. “Some doctors are quacks.” That doesn’t excuse chiros. Doctors make a lot of mistakes. Doctors see people who are seriously ill, chiros mostly treat the “worried well” and slightly injured.

You need to look at objective reviews, which you can find at/through Chirobase. Chiro apologists will tell you that is a biased anti-chiro site; but they cannot point to anything, there, that is incorrect.

Joe

Anonymous said...

I meant to address another point. But, first, "Doctors make a lot of mistakes." should have been in quotes as a chiro claim.

You wrote "These organizations still have their share of problems, but I still feel that we should encourage those who are moving in the right direction, rather than criticize them for not miraculously giving up every piece of woo overnight."

Yes, we should encourage them to scrap their curriculum and A) adopt evidence-based medicine (as osteopaths did many decades ago). Or, B) simply offer a two-year associates degree in massage.

At chirobase you can find a recent analysis of chiro education, by chiros, and they do not include "subluxation" among the problems they identified. Their ignorance is institutional and they are not going to do anything about it in the near future.

Infophile said...

Yes, as I said before, FACE isn't the best example I could have chosen. But the problem is, we don't know for sure whether they're saying that stuff about "innate intelligence" because they believe it, or to simply cover up for the fact that they don't know why the measures should help at all and to not be shunned by traditional chiros. I really doubt it's the latter, though, to be honest.

Reading through your posts, aside from your complaint that I used a bad example, it seems like it's just a general rant against mainstream chiropractic. One more response, though:

Which is better, a chiro who claims that they adjust your back to fix all problems in your body, or one who says, "Well, I don't know specifically what it does, but it helps"? I'd go with the latter, because if nothing else, they've rejected many of the false claims of the former. They still have work to do in getting to the point where they can say specifically what good is being done (and knowing when it needs to be done), but they're on the right track. We should simultaneously applaud them for making the first step and encourage them to make the rest.

But aside from that, as we agree, there are organizations and individual practitioners who have gone even further, and are actually approaching respectability. I just picked a bad example to highlight as I couldn't find a better one in the limited time I had free to right this post (as you'll note, I said "It's far from perfect, but it's a start." at the beginning). I'll go in and change around the wording to present them as a moderate, with the NACM as much better.

Anonymous said...

Bryan,

You asked "Which is better, a chiro who claims that they adjust your back to fix all problems in your body, or one who says, "Well, I don't know specifically what it does, but it helps"?"

This is called "begging the question." You are assuming that chiro adjustments are effective. Read the medical literature, there is no evidence for this beyond certain back pain and, possibly, tension headache. (Note, chiro lit is not medical lit.)

Bottom line- you need to study anatomy and physiology and then you can read and understand the criticism of chiropracty.

Then, rather than saying I was "ranting," you would either see the truth of what I say, or offer a detailed rebuttal. In science, data settles arguments; not the best sound-bite.

I have offered you a treasure trove of reliable information, and I can offer much more. You have yet to offer any reliable sources of information in rebuttal. Sorry; but, your site sophomoric.

Infophile said...

This is called "begging the question." You are assuming that chiro adjustments are effective. Read the medical literature, there is no evidence for this beyond certain back pain and, possibly, tension headache. (Note, chiro lit is not medical lit.)

Go back and read my post. What two symptoms did I say chiro actually might help? Lower back pain and tension headaches. Besides that, "begging the question" means using circular logic. The worst I could be doing there was having an unsupported assumption underlying that question.

Then, rather than saying I was "ranting," you would either see the truth of what I say, or offer a detailed rebuttal. In science, data settles arguments; not the best sound-bite.

Did it ever cross your mind that I might agree with a lot of what you said, and thus not want to argue with it?

You have yet to offer any reliable sources of information in rebuttal.

Ditto. Hell, you even went and made some of my points for me.

Sorry; but, your site sophomoric.

That put-down would be much more effective if you didn't include two major (and one minor) grammatical errors within it. The use of an intellectual put-down within it makes it even more humorous.

Anonymous said...

Your identification of "good" chiros is grounded in ignorance. No typos on my part change that. That is a weak, ad hom attack. And, yes, you are guilty of cyclic reasoning. And, yes, experiment says chiros are wrong in the vast majority of their claims:

http://www.intelihealth.com/IH/ihtPrint/WSIHW000/8513/34968/368023.html?d=dmtContent&hide=t&k=basePrint

Study the subject, then we can discuss it.

Joe

Infophile said...

Your failure to acknowledge that there are moderately "good" chiros is grounded in ignorance. No ad homs on my part change that. That is a weak non sequitur. And, no, I am not guilty of cyclic reasoning. And, yes, experiment says chiros are right in their claims regarding lower back pain and tension headaches:

http://www.intelihealth.com/IH/ihtPrint/WSIHW000/8513/34968/368023.html?d=dmtContent&hide=t&k=basePrint

Study the subject, then we can discuss it.

Okay, seriously. See how content-free your arguments actually were? All I had to do was change a few words and it's just as applicable to you (even the link you provided backed up my point). Onto serious rebuttals:

Your identification of "good" chiros is grounded in ignorance.

It's grounded in experience, which led to my own research. But apparently, since I didn't use the exact same sites as you and didn't come to the same conclusion, it's all irrelevant.

No typos on my part change that. That is a weak, ad hom attack.

Yet another misidentification of a logical fallacy. What I said would be an ad hom if I claimed you were wrong because you used bad grammar (or heavily implied it). All I actually did was come down to your level. A logical argument gets you a logical reply, a put-down gets you a put-down.

And, yes, you are guilty of cyclic reasoning.

I say that I don't see any way I'm using circular logic, and your only reply is that I am? How about you show how I am (but be careful--no straw man of my argument).

And, yes, experiment says chiros are wrong in the vast majority of their claims:

http://www.intelihealth.com/IH/ihtPrint/WSIHW000/8513/34968/368023.html?d=dmtContent&hide=t&k=basePrint


Allow me to quote from that page: "Preliminary evidence suggests benefits in patients with tension headache or low back pain."

Allow me to quote myself: "Go back and read my post. What two symptoms did I say chiro actually might help? Lower back pain and tension headaches." My post also made it clear that this is what those I identified as "good" claim to treat.

Study the subject, then we can discuss it.

I have, but since I haven't come to your conclusions, obviously my studying is unsatisfactory.

Anonymous said...

Bryan,

There are some acceptable chiros, just not many. See their own survey: WP McDonald et al in "Seminars in Integrative Medicine" 2:3 (2004) pp.92-8. Since you haven't provided evidence, besides the quacks at FACE, I will give you a few years to study the subject.

I believe you have my e-mail, if you want to learn something. I have sources other than Chirobase; although, that should keep you occupied for a while.

Ciao, Joe

Infophile said...

Joe,

Thank you for the sources and the lively debate. The reason I didn't provide any other evidence of good chiros is simply because you did so for me, so I didn't see the need.

But anyways, my studies are tied up with physics for now and the foreseeable future, so I won't be doing as extensive studying as you might prefer. However, I will be sure to at the least consult chirobase and such if I decide to do another post relating to chiropractic.

Anonymous said...

Yes there are good and bad in all professions...however 'we' chiropractors do not adhere to the fact that 'we' cure all diseases by adjusting subluxations....no one can cure anything...the body does its own healing provided it is in balance with all of its systems and most importantly the nervous system. If indeed spinal vertebrae are misaligned due to stresses on the body this causes 'impingement' that can affect nerve integrity thus hindering ones optimal health potential. Call us good, call us bad...but please just call us! Chiropractic has a fabulous track record for those who practice fundamental traditional chiropractic. Subluxation does exist. Those who do not understand this and criticize chiropractic and our focus to correct subluxation need to be educated. Your narrow conventional thinking is a detriment to our society. This is unfortunate since those individuals who read the garbage and mistruths that people like you publish could very well be swayed to not seek chiropractic and thus miss out on a great health opportunity...shame shame....I guess us chiropractors and our subluxation corrections just scare you. "The Good the Bad and the Ugly"....wasn't that a movie?

Anonymous said...

I totally agree with the anonymous comments above...you are just ignorant and I believe chiropractors scare you because you do not understand...OR are you being paid by the AMA or other organization that wants to discredit chiropractic...god luck...the drug companies and the medical profession are the ones you have to worry about with all the people getting sick and dying every year from that mess....check those stats. Ever wonder why an MD pays thousands of dollars for malpractice insurance and a chiropractor pay only a fraction?...Tell me whose the ...Bad and the Ugly? I'll stick to me Good Chiropractor. He under stands health care....not sick care
Doug

Infophile said...

You know what scares me? That there are people dumb enough to think I'd fall for that type of double-posting. My Sitemeter tells me pretty clearly that no one came to this post after the first anon commented today.

Here's a hint: When trying to convice people, being caught acting underhandedly is not a good idea.

mattchiro said...

Hi guys, I read with interest you postings regarding Chiropractic. It is unfortunate that this is a common view of Chiropractic. This is how I see Chiropractic. When mechanical stresses are put on the the joints in either trauma, repetitive stress or prolonged stress, the joint, skin or ligament receptors are stimulated and the nervous system is irritated. This in turn increases neural activity to the local muscles via the alpha motor neurone. This was demonstrated by a professor of biomechanics at the University of Calgary- a professor Hertzog. The increased activity to the local muscle causes the muscle to shorten which subtly changes the motion of the joint by limiting some movements. This can be called a fixation, restriction or by some subluxation. This isn't the joint popping out of joint but more a change in muscle tone limiting the movement of the joint complex. Once the muscle is hypertonic it starts increasing metabolic activity and increased inflammatory chemicals are produced including substance-P, calcitonin gene related peptide, histamine, neurokinin 1 and 2, prostaglandins, amonst others. These chemicals then bind to the chemo receptors and cause a reciprical irritation via the spinal cord and the gamma fusiform motor neurones. This means the muscle and nervous system is in a neuro-chemical vicious cycle. This is constantly causing increased neural tone and tight muscles which in-turn affects the function of the joint. Pain is generated by mechanical and chemical irritation and the joint is restricted in its motion. Jull, Hide and Hodges (2002) were physiotherapists in Australia who demonstrated that within 2 weeks of this neuro muscular hypertonicity the multifidus (local spinal muscles) started to atrophy (get smaller) and that this must neurological due to the hypeertonic state because the muscles above , below and on the opposite side were not affected thus it was not due to disuse. Professor Hertzog also demonstrated that a chiropractor could break this vicious cycle with a thrust to the joint 50% of the time (in his study, but I think that this is partly to do with the skill of the Chiropractor - some may achieve greater results and some less). It was demonstrated that the thrust acted in a similar way to a reflex respnse like when you use a reflex hammer. The thrust quickly stretches the Golgi tendon organs (stretch receptors in the tendon) which then fires up the type A alpha fibres and synapses in the anterior horn of the spinal cord. This splits in to a reflex which comes down to the muscle causing a contraction whilst the second synapse travels up the spinal cord to the brain and ellicits an inhibitory response. The adjustment essentially takes hypertonic muscles around the spine and relaxes them. This in turn allows the joint to move normally and the pain should reduce. Now it gets a little more complicated. Because the muscle has been tight and it is inflamed the chemicals are still there. These chemicals can obviously start the spasm back off so inflammatroy management such as ice and anti-inflammatories is very important to keep the vicious cycle broken. Also substance-p and CGRP isa neural hypersensitizer so for period of time these chemicals make the local nerve endings more sensitive to stress thus making it much easier for the patient to irritate the area again so advice on activity levels and ergonomics is also very important. Ie if you drive for a living sitting for 6 hours the next day in your car is likely to re-aggravate the area. So it is important to manage these issues and re-treat as appropriate initially. The muscles will also be atrophying rapidly according to Jull and Hodges and is the problem is managed within 2 months the patient will still be atrophied locally to the injury for up to 6 months. If it takes 6 months to fully recover the local stability after 6-8 weeks how long will it take after 2 years or 10 years? we don't know but probably longer. So it is important once the vicious cycles are broken, and a relative level of stabilty has been gained to rehabilitate these muscles. So Chiropractic adjustments do have a role in the management of patients but it should be in conjunction with anti-inflammatory management ergonomic advice, activity advice and eventually rehabilitation. This is an evidence based approach based on current management approaches. In the UK Chiropractic is a statuary regulated profession and part of the NICE guidelines published by the government. Recent papers you may want to look at include the BEAM trial which was published in the British Medical Journal (BMJ) and sponsored by the government Medical Research Council (MRC). Also Meade et al was another large scale study publiushed in the BMJ I believe and a large study showed that with over 50,000 subsequent neck adjustments there wasn't a single adverse reaction, which at least 10 times safer than taking ibuprofen for 1 month. I can get the details of this study if anyone wants it. Overall, I feel that there is a place in mainstream healthcare for chiropractic as a primary healthcare profession. Whether or not these neural changes affect the general function of the nervous system or not remains to be seen but can I just say this. It is easy to be skeptical of such things and it is right to be. However, science is all about observing changes caused by one thing with another. Isaac Newton Identified gravity by dropping something and calculating its exact velocity and was able to calculate the exact force that gravity exerted. Now managing patients is not as simple as they all have a variety of factors contributing to their own problems including but not exclusively the length of time the problem has been present, the ergonomics of their jobs, their own mechanics such as foot pronation or sitting position, their level of fitness, their level of stress, their consumption of stimulants. If people increase their general neural activity with stress or stimulants it has been shown to reduce pain tolerance (common sense really). Lots of studies have looks at pain and what affects it, even the color of someones hair can dictate pain tolerance, apparently people with red hair have lower pain tolerance than other groups?! Anyway the comment about research not working is silly but research has to be conducted in ways that truly look at what such treatments do and if done too randomly or too specifically like taking a general pain group and adjusting them it doesn't really take account of all the other factors involved and Chiropractic isn't just about adjusting, its about managing pain patients with correct education, advice on diet and lifestyle and explaining how patients can help themselves. Chiropractic should be integrated more with other professions that can work together to improve function such podiatry, occupational health, medical doctors, physiotherapist, stress councillors, nutrionists amongst others. Mechanical pain is a multimodal problem and requires a multidisciplinary approach which Chiropractors are well trained and skilled to fit into and we can provide a specific skill that few other professions are as well trained to provide. Thank you for your time. PS i am also a good and caring person and put my patients at the centre of my care often to the detriment of my own well being as I often get very stressed when patients fail to make adequate improvement. I also often treat patients at reduced fee's and for longer than most others would. Most of my colleagues are the same and it is very hurtful to read these kinds of comments. We spend many years training and could have become physiotherapists or medical doctors in the same or less time. Please bear this in mind. I know some Chiropractors are a little evangelical but I don't think I have ever met an ill meaning Chiropractor and there is a lot of very good science supporting what we do as well as many very happy and pain free patients.