Most chiropractors claim they can effectively treat a wide range of conditions. I have looked far and wide but I fail to see sound evidence to show that this assumption is true. On a good day, I might agree that chiropractic works for back pain (but this would need to be a very good day and I would need to close at least one eye) – and that’s basically it! Unsurprisingly, chiropractors vehemently disagree with me. Yet, they have an all too obvious conflict of interest in that question and, therefore, they are unlikely to be objective.
One regular commentator of this blog recently reminded me that the UK ‘ADVERTISING STANDARDS AUTHORITY’ (ASA) state on their website that based on all evidence submitted and reviewed to date, the ASA and CAP accept that chiropractors may claim to treat the following conditions:
- Ankle sprain (short term management)
- Elbow pain and tennis elbow (lateral epicondylitis) arising from associated musculoskeletal conditions of the back and neck, but not isolated occurrences
- Headache arising from the neck (cervicogenic
- Joint pains
- Joint pains including hip and knee pain from osteoarthritis as an adjunct to core OA treatments and exercise
- General, acute & chronic backache, back pain (not arising from injury or accident)
- Generalised aches and pains
- Mechanical neck pain (as opposed to neck pain following injury i.e. whiplash)
- Migraine prevention
- Minor sports injuries
- Muscle spasms
- Plantar fasciitis (short term management)
- Rotator cuff injuries, disease or disorders
- Shoulder complaints (dysfunction, disorders and pain)
- Soft tissue disorders of the shoulder
- Tension and inability to relax
This is an impressive yet very odd list:
- Why is ‘joint pain’ listed twice?
- Can lateral epicondylitis arise from musculoskeletal conditions of the back and neck?
- What exactly are ‘generalised aches and pains’?
- Isn’t lumbago and backache the same?
- Are ‘minor sports injuries’ (including a cut, bruise or haematoma?) a category that is well-defined?
- What is a ‘soft tissue disorders of the shoulder’
But let’s not be pedantic. Let’s assume these are all defined conditions that need to be treated. The problem still remains that there is hardly any good evidence that they can be effectively treated by chiropractic spinal manipulation (in case you disagree, please post the evidence in the comments section).
And here we come to the crux of the matter, I think.
Chiropractors would say that they use so much more than spinal manipulations.
- For a sport injury, they might apply an ice-pack.
- For the inability to relax, they might give a massage.
- For rotator cuff problems, they might administer exercises.
- For tennis elbow, they might recommend immobilizing the joint.
- Etc., etc.
But that’s not chiropractic!
Yes, it is what we do, insist the chiropractors.
I do not doubt it, but survey after survey shows that chiropractors treat almost all their patients with spinal manipulation. And the history of chiropractic is purely based on spinal manipulation. Yes, today they also use treatments borrowed from other disciplines, yet spinal manipulation is the treatment that defines them.
Let me try an example to make my point clear. Imagine a surgeon who specialises in an obsolete type of operation (e.g. ligation of the mammary artery as a treatment of coronary artery disease). Following the chiro-logic, he could claim that:
- my approach is not ineffective because I do so much more than just operate,
- I also prescribe medications,
- I give dietary advice,
- I give nutritional advice,
- I recommend relaxation,
- I suggest regular exercise.
And the results would, of course, show that many of his patients benefit from all this.
Does that mean our surgeon provides effective care for his patients?
Similarly, crystal healing could be seen as being effective, because some crystal healers tell their obese patients to eat less and exercise more?
So, the above-cited list of claims that the ASA now allows UK chiropractors to make is either way too long or much too short – in any case, it is nonsense. If we base it on the proven effectiveness of spinal manipulation, it must be very short indeed. If we base it on everything chiropractors might do in addition, it is far too short; in this case, it should include everything in the medical textbooks from AIDS to ZOSTER (I cannot imagine many conditions for which life-style advice, exercise or cryotherapy [for pain-control] etc. would not be helpful).
My conclusions from all this are as follows:
- Chiropractors have tried to reinvent themselves by borrowing some treatments from other healthcare professions.
- They have done this, I suspect, to avoid being judged by their largely ineffective hallmark intervention, spinal manipulation. The move may be commercially clever, but it is nevertheless transparently nonsensical and wholly unconvincing.
- Chiropractors must be judged not by the treatments they borrowed and might use occasionally, but by the only therapy that is inherent to chiropractic: spinal manipulation.
- And spinal manipulation is certainly not effective for a wide range of conditions.
Probiotics (live microorganisms for oral consumption) are undoubtedly popular, not least they are being cleverly promoted as a quasi panacea. But are they as safe as their manufacturers try to convince us? A synthesis and critical evaluation of the reports and series of cases on the infectious complications related to the ingestion of probiotics was aimed at finding out.
The authors extensive literature searches located 60 case reports and 7 case series including a total of 93 patients. Fungemia was the most common infectious complications with 35 (37.6%) cases. The genus Saccharomyces was the most frequent with 47 (50.6%) cases, followed by Lactobacillus, Bifidobacterium, Bacillus, Pedioccocus and Escherichia with 26 (27.9%), 12 (12.8%), 5 (5.4%), 2 (2.2%) and 1 (1.1%) case, respectively. Adults over 60 years of age, Clostridium difficile colitis, antibiotic use and Saccharomyces infections were associated with overall mortality. HIV infections, immunosuppressive drugs, solid organ transplantation, deep intravenous lines, enteral or parenteral nutrition were not associated with death.
The authors concluded that the use of probiotics cannot be considered risk-free and should be carefully evaluated for some patient groups.
Other authors have previously warned that individuals under neonatal stages and/or those with some clinical conditions including malignancies, leaky gut, diabetes mellitus, and post-organ transplant convalescence likely fail to reap the benefits of probiotics. Further exacerbating the conditions, some probiotic strains might take advantage of the weak immunity in these vulnerable groups and turn into opportunistic pathogens engendering life-threatening pneumonia, endocarditis, and sepsis. Moreover, the unregulated and rampant use of probiotics potentially carry the risk of plasmid-mediated antibiotic resistance transfer to the gut infectious pathogens.
And yet another review had concluded that the adverse effects of probiotics were sepsis, fungemia and GI ischemia. Generally, critically ill patients in intensive care units, critically sick infants, postoperative and hospitalized patients and patients with immune-compromised complexity were the most at-risk populations. While the overwhelming existing evidence suggests that probiotics are safe, complete consideration of risk-benefit ratio before prescribing is recommended.
Proponents of probiotics will say that these risks are rare and confined to small groups of particularly vulnerable patients. This may well be so, but in view of the often uncertain benefits of probiotics, the incessant hype and aggressive marketing, I find it nevertheless important to keep these risks in mind.
As with any therapy, the question must be, does this treatment really generate more good than harm?
The German Association of Medical Homeopaths (Deutscher Zentralverein homöopathischer Ärzte (DZVhÄ)) have recently published an article where, amongst other things, they lecture us about evidence-based medicine (EBM). If you feel that this might be a bit like an elephant teaching Fred Astaire how to step-dance, you could have a point. Here is their relevant paragraph:
… das Konzept der modernen Evidenzbasierte Medizin nach Sackett [stützt sich] auf drei Säulen: auf die klinischen Erfahrung der Ärzte, auf die Werte und Wünsche des Patienten und auf den aktuellen Stand der klinischen Forschung. Homöopathische Ärzte wehren sich gegen einen verengten Evidenzbegriff der Kritiker, der Evidenz allein auf die Säule der klinischen Forschung bzw. ausschließlich auf RCT verengen möchte und die anderen beiden Säulen ausblendet. Experten schätzen, dass bei einer solchen Auffassung von EbM rund 70 Prozent aller Leistungen der GKV nicht evidenzbasiert sei. Nötiger als eine Homöopathie-Debatte hat die deutsche Ärzteschaft aus unserer Sicht eine klare Verständigung darüber, welcher Evidenzbegriff nun gilt.
For those who cannot understand the full splendour of their argument because of the language problem, I translate as literally as I can:
… the concept of the modern EBM according to Sackett is based on three pillars: on the clinical experience of the doctors, on the values and wishes of the patient and on the current state of the clinical research. Homeopaths defend themselves against the narrowed understanding of ‘evidence’ of the critics which aims at narrowing evidence solely to the pillar of the clinical research or exclusively to RCT, while eliminating the other two pillars. Experts estimate that, with such an view of EBM, about 70% of all treatments reimbursed by our health insurances would not be evidence-based. We feel that we more urgently need a clear understanding which evidence definition applies than a debate about homeopathy.
END OF MY TRANSLATION
So, where is the hilarity in this?
I don’t know about you, but I find the following things worth a giggle:
- ‘narrowed understanding of evidence’ – this is a classical strawman; non-homeopaths tend to apply Sackett’s definition which states that ‘evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical experience with the best available external clinical evidence from systematic research‘;
- as we see, Sackett’s definition is quite different from the one cited by the homeopaths;
- the three pillars cited by the homeopaths are those subsequently developed for Evidence Based Practice (EBP) and include: A) patient values, B) clinical expertise and C) external best evidence;
- as we see, these three pillars are also not quite the same as those suggested by the homeopaths;
- non-homeopaths do certainly not aim at eliminating the ‘other two pillars’;
- current best evidence clearly includes much more than just RCTs – to mention RCTs in this context therefore suggests that the ones guilty of narrowing anything might, in fact, be the homeopaths;
- even if it were true that 70% of reimbursable treatments are not evidence-based, this would hardly be a good reason to employ homeopathic remedies of which 100% are not even remotely evidence-based;
- unbeknown to the German homeopaths, the discussion about a valid definition of EBM has been intense, is as old as EBM itself, and would by now probably fill a mid-size library;
- this discussion does, however, in no way abolish the need to bring the debate about homeopathy to the only evidence-based conclusion possible, namely the discontinuation of reimbursement of this and all other bogus therapies.
In conclusion, I do thank the German homeopaths for being such regular contributors to fun and hilarity. I shall miss them, once they have fully understood EBM and are thus compelled to stop prescribing placebos.
The 2018 World Federation of Chiropractic ACC Education Conference was held on 24-27 October in London. It resulted in several consensus statements developed by the attendees. I happen to know this from a short report that has just been published; it can be found here.
Of the 10 points made in this consensus, I find only the following noteworthy:
“Chiropractic education programs have an ethical obligation to support an evidence-based teaching and learning environment.”
Perhaps it is me – English is not my first language – but I find the phraseology used in this sentence strangely complicated and confusing. I have been a teacher of medical students for most of my life, but I am not sure what an ‘evidence-based teaching and learning environment’ is. I know what ‘evidence-based’ means, of course. However, what exactly is:
- a teaching environment?
- a learning environment?
- and how does ‘evidence-based’ apply to either of the two?
Is there evidence that some environments are better suited than others for teaching?
Is there evidence that some environments are better suited than others for learning?
I suppose the answer must be YES!
The environment, i. e. the space and conditions in which teaching and learning happen should, for instance, be/include:
- not cramped,
- not too cold,
- not too hot,
- equipped with ergometric chairs and desks,
- there should be visual aids,
- access to computers,
- a library,
- good mentoring and support,
So, the consensus of the education conference wanted to optimise the environmental conditions of teaching and learning for chiropractic lecturers and students? Most laudable, I must say!
But still, it seems like a missed opportunity for an ‘Education Conference’ not to have stated something about the content of teaching and learning. Personally, I find it a pity that they did not state: Chiropractic education programs have an ethical obligation to be evidence-based.
Or is that what they really wanted to say?
Naaahh … come to think of it … they cannot possibly make such a demand.
Because, in this case, they would have to teach students not to become chiropractors.
I came across an embarrassingly poor and uncritical article that essentially seemed to promote a London-based clinic specialised in giving vitamins intravenously. Its website shows the full range of options on offer and it even lists the eye-watering prices they command. Reading this information, my amazement became considerable and I decided to share some of it with you.
Possibly the most remarkable of all the treatments on offer is this one (the following are quotes from the clinic’s website):
Stemcellation injections or placenta lucchini (sheep placenta) treatments are delivered intravenously (via IV), although intramuscular (IM) administration is also possible. Stem cells are reported to possess regenerative biological properties.
We offer two types of Stemcellation injections: a non-vegetarian option and a vegetarian-friendly option. Please enquire for further details.
Alongside placenta lucchini, Stemcellation injections at Vitamin Injections London contain a range of other potent active ingredients, including: physiologically active carbohydrate, nucleic acid, epithelial growth factor, amino acids, hydrolysed collagen, concentrated bioprotein and stem cells.
Please visit our Vitamin 101 section to learn more about the ingredients in Stemcellation sheep placenta injections.
Renowned for their powerful regenerating properties, Stemcellation injections can stimulate collagen production as well as:
- Remedy cosmetic problems such as wrinkles, discolouration, pigmentation, eye bags and uneven skin tone;
- Can be undertaken by those who are interested in maintaining their physical activity levels;
- Can be undertaken alongside other IV/IM injections.
Vitamin Injections London is headed by skilled IV/IM Medical Aesthetician and Skin Specialist Bianca Estelle. Our skilled IV/IM practitioners will conduct a full review of your medical history and advise you regarding your suitability for Stemcellation injections.
END OF QUOTES
The only Medline-listed paper I was able to locate on the subject of placenta lucchini injections was from 1962 and did not substantiate any of the above claims. In my view, all of this begs many questions; here are just seven that spring into my mind:
- Is there any evidence at all that any of the intravenous injections/infusions offered at this clinic are effective for any condition other than acute vitamin deficiencies (which are, of course, extremely rare these days)?
- Would the staff be adequately trained to diagnose such cases?
- How do they justify the price tags for their treatments?
- What is a ‘medical aesthetician’ and a ‘skin specialist’?
- Is it at all legal for ‘medical aestheticians’ and ‘skin specialists’ (apparently without medical qualifications) to give intravenous injections and infusions?
- How many customers have suffered severe allergic reactions after placenta lucchini (or other) treatments?
- Is the clinic equipped and its staff adequately trained to deal with medical emergencies?
These are not rhetorical questions; I genuinely do not know the answers. Therefore, I would be obliged, if you could answer them for me, in case you know them.
A few weeks ago, I was interviewed by a journalist who wanted to publish the result in a magazine. He now informed me that his editor decided against it, and the interview thus remained unpublished. I have the journalist’s permission to publish it here. The journalist who, in my view, was well-prepared (much better than most), prefers to remain unnamed.
Q: How would you describe yourself?
A: I am a researcher of alternative medicine.
Q: Not a critic of alternative medicine?
A: Primarily, I am a researcher; after all, I have published more Medline-listed research papers on the subject than anyone else on the planet.
Q: You are retired since a few years; why do you carry on working?
A: Mainly because I see a need for a critical voice amongst all the false and often dangerous claims made by proponents of alternative medicine. But also because I enjoy what I am doing. Since I retired, I can focus on the activities I like. There is nobody to tell me what to do and what not to do; the latter happened far too often when I was still head of my research unit.
Q: Fine, but I still do not quite understand what drives you. Who is motivating you to criticise alternative medicine?
A: Nobody. Some people claim I am paid for my current activities. This is not true. My blog actually costs me money. My books never return enough royalties to break even, considering the time they take to write. And for most of my lectures I don’t charge a penny.
Q: There are people who find this hard to believe.
A: I know. This just shows how money-orientated they are. Do they want me to publish my tax returns?
Q: Sorry, but I still don’t understand your motivation.
A: I guess what motivates me is a sense of responsibility, a somewhat naïve determination to do something good as a physician. I am one of the only – perhaps even THE only – scientist who has researched alternative medicine extensively and who is not a promoter of bogus therapies but voices criticism about them. There are several other prominent and excellent critics of alternative medicine, of course, but they all come ‘from the outside’. I come from the inside of the alternative medicine business. This probably gives me a special understanding of this field. In any case, I feel the responsibility to counter-balance all the nonsense that is being published on a daily basis.
Q: What’s your ultimate aim?
A: I want to create progress through educating people to think more critically.
Q: Which alternative medicine do you hate most?
A: I do not hate any of them. In fact, I still have more sympathy for them than might be apparent. For my blog, for instance, I constantly search for new research papers that are rigorous and show a positive result. The trouble is, there are so very few of those articles. But when I find one, I am delighted to report about it. No, I do not hate or despise any alternative medicine; I am in favour of good science, and I get irritated by poor research. And yes, I do dislike false claims that potentially harm consumers. And yes, I do dislike it when chiropractors or other charlatans defraud consumers by taking their money for endless series of useless interventions.
Q: I noticed you go on about the risks of alternative medicine. But surely, they are small compared to the risks of conventional healthcare, aren’t they?
A: That’s a big topic. To make it simple: alternative medicine is usually portrayed as risk-free. The truth, however, is that there are numerous risks of direct and indirect harm; the latter is usually much more important than the former. Crucially, the risk-free image is incongruent with reality. I want to redress this incongruence. And as to conventional medicine: sure, it can be much more harmful. But one always has to see this in relation to the proven benefit. Chemotherapy, for instance, can kill a cancer patient, but more likely it saves her life. Homeopathic remedies cannot kill you, but employed as an alternative to an effective cancer treatment, homeopathy will certainly kill you.
Q: Homeopathy seems to be your particular hobby horse.
A: Perhaps. This is because it exemplifies alternative medicine in several ways, and because I started my alternative ‘career’ in a homeopathic hospital, all those years ago.
Q: In what way is homeopathy exemplary?
A: Its axioms are implausible, like those of many other alternative modalities. The clinical evidence fails to support the claims, like with so many alternative therapies. And it is seemingly safe, yet can do a lot of harm, like so many other treatments.
Q: You have no qualification in homeopathy, is that right?
A: No, I have no such qualifications. And I never said so. When I want to tease homeopaths a little, I state that I am a trained homeopath; and that is entirely correct.
Q: In several countries, homeopathy has taken spectacular hits recently. Is that your doing?
A: No, I don’t think so. But I do hope that my work has inspired the many dedicated activists who are currently protesting against the reimbursement of homeopathy by the public purse in the UK, Germany, France, Spain, etc.
Q: You often refer to medical ethics; why is that?
A: Because, in the final analysis, many of the questions we already discussed are really ethical issues. And in alternative medicine, few people have so far given the ethical dimensions any consideration. I think ethics are central to alternative medicine, so much so that I co-authored an entire book on this topic this year.
Q: Any plans for the future?
Q: Can you tell me more?
A: I will publish another book in 2019 with Springer. It will be a critical evaluation of precisely 150 different alternative modalities. I am thinking of writing yet another book, but have not yet found a literary agent who wants to take me on. I have been offered a new professorship at a private University in Vienna, and am hesitant whether to accept or not. I have been invited to give a few lectures in 2019 and hope to receive more invitations. Last not least, I work almost every day on my blog.
Q: More than enough for a retiree, it seems. Thank you for your time.
A: My pleasure.
The Spanish Ministries of Health and Sciences have announced their ‘Health Protection Plan against Pseudotherapies’. Very wisely, they have included chiropractic under this umbrella. To a large degree, this is the result of Spanish sceptics pointing out that alternative therapies are a danger to public health, helped perhaps a tiny bit also by the publication of two of my books (see here and here) in Spanish. Unsurprisingly, such delelopments alarm Spanish chiropractors who fear for their livelihoods. A quickly-written statement of the AEQ (Spanish Chiropractic Association) is aimed at averting the blow. It makes the following 11 points (my comments are below):
1. The World Health Organization (WHO) defines chiropractic as a healthcare profession. It is independent of any other health profession and it is neither a therapy nor a pseudotherapy.
2. Chiropractic is statutorily recognised as a healthcare profession in many European countries including Portugal, France, Italy, Switzerland, Belgium, Denmark, Sweden, Norway and the United Kingdom10, as well as in the USA, Canada and Australia, to name a few.
3. Chiropractic members of the AEQ undergo university-level training of at least 5 years full-time (300 ECTS points). Chiropractic training is offered within prestigious institutions such as the Medical Colleges of the University of Zurich and the University of Southern Denmark.
4. Chiropractors are spinal health care experts. Chiropractors practice evidence-based, patient-centred conservative interventions, which include spinal manipulation, exercise prescription, patient education and lifestyle advice.
5. The use of these interventions for the treatment of spine-related disorders is consistent with guidelines and is supported by high quality scientific evidence, including multiple systematic reviews undertaken by the prestigious Cochrane collaboration15, 16, 17.
6. The Global Burden of Disease study shows that spinal disorders are the leading cause of years lived with disability worldwide, exceeding depression, breast cancer and diabetes.
7. Interventions used by chiropractors are recommended in the 2018 Low Back Pain series of articles published in The Lancet and clinical practice guidelines from Denmark, Canada, the European Spine Journal, American College of Physicians and the Global Spine Care Initiative.
8. The AEQ supports and promotes scientific research, providing funding and resources for the development of high quality research in collaboration with institutions of high repute, such as Fundación Jiménez Díaz and the University of Alcalá de Henares.
9. The AEQ strenuously promotes among its members the practice of evidence-based, patient-centred care, consistent with a biopsychosocial model of health.
10. The AEQ demands the highest standards of practice and professional ethics, by implementing among its members the Quality Standard UNE-EN 16224 “Healthcare provision by chiropractors”, issued by the European Committee of Normalisation and ratified by AENOR.
11. The AEQ urges the Spanish Government to regulate chiropractic as a healthcare profession. Without such legislation, citizens of Spain cannot be assured that they are protected from unqualified practitioners and will continue to face legal uncertainties and barriers to access an essential, high-quality, evidence-based healthcare service.
END OF QUOTE
I think that some comments might be in order (they follow the numbering of the AEQ):
- The WHO is the last organisation I would consult for information on alternative medicine; during recent years, they have published mainly nonsense on this subject. How about asking the inventor of chiropractic? D.D. Palmer defined it as “a science of healing without drugs.” Chiropractors nowadays prefer to be defined as a profession which has the advantage that one cannot easily pin them down for doing mainly spinal manipulation; if one does, they indignantly respond “but we also use many other interventions, like life-style advice, for instance, and nobody can claim this to be nonsense” (see also point 4 below).
- Perfect use of a classical fallacy: appeal to authority.
- Appeal to authority, plus ignorance of the fact that teaching nonsense even at the highest level must result in nonsense.
- This is an ingenious mix of misleading arguments and lies: most chiros pride themselves of treating also non-spinal conditions. Very few interventions used by chiros are evidence-based. Exercise prescription, patient education and lifestyle advice are hardy typical for chiros and can all be obtained more authoratively from other healthcare professionals.
- Plenty of porkies here too. For instance, the AEQ cite three Cochrane reviews. The first concluded that high-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. The second stated that combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute/subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. And the third concluded that, although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices. Hardly the positive endorsement implied by the AEQ!
- Yes, but that is not an argument for chiropractic; in fact, it’s another fallacy.
- Did they forget the many guidelines, institutions and articles that do NOT recommend chiropractic?
- I believe the cigarette industry also sponsors research; should we therefore all start smoking?
- I truly doubt that the AEQ strenuously promotes among its members the practice of evidence-based healthcare; if they did, they would have to discourage spinal manipulation!
- The ‘highest standards of practice and professional ethics’ are clearly not compatible with chiropractors’ use of spinal manipulation. In our recent book, we explained in full detail why this is so.
- An essential, high-quality, evidence-based healthcare service? Chiropractic is certainly not essential, rarely high-quality, and clearly not evidence-based.
Nice try AEQ.
But not good enough, I am afraid.
Many chiropractors tell new mothers that their child needs chiropractic adjustments because the birth is in their view a trauma for the new-born that causes subluxations of the baby’s spine. Without expert chiropractic intervention, they claim, the poor child risks serious developmental disorders.
This article (one of hundreds) explains it well: Birth trauma is often overlooked by doctors as the cause of chronic problems, and over time, as the child grows, it becomes a thought less considered. But the truth is that birth trauma is real, and the impact it can have on a mother or child needs to be addressed. Psychological therapy, physical therapy, chiropractic care, acupuncture, and other healing techniques should all be considered following an extremely difficult birth.
And another article makes it quite clear what intervention is required: Caesarian section or a delivery that required forceps or vacuum extraction procedures, in-utero constraint, an unusual presentation of the baby, and many more can cause an individual segment of the spine or a region to shift from its normal healthy alignment. This ‘shift’ in the spine is called a Subluxation, and it can happen immediately before, during, or after birth.
Thousands of advertisements try to persuade mothers to take their new-born babies to a chiropractor to get the problem sorted which chiropractors often call KISS (kinetic imbalance due to suboccipital strain-syndrome), caused by intrauterine-constraint or the traumas of birth.
This abundance of advertisements and promotional articles is in sharp contrast with the paucity of scientific evidence.
A review of 1993 concluded that birth trauma remains an underpublicized and, therefore, an undertreated problem. There is a need for further documentation and especially more studies directed toward prevention. In the meantime, manual treatment of birth trauma injuries to the neuromusculoskeletal system could be beneficial to many patients not now receiving such treatment, and it is well within the means of current practice in chiropractic and manual medicine.
A more critical assessment of … concluded that, given the absence of evidence of beneficial effects of spinal manipulation in infants and in view of its potential risks, manual therapy, chiropractic and osteopathy should not be used in infants with the kinetic imbalance due to suboccipital strain-syndrome, except within the context of randomised double-blind controlled trials.
So, what follows from all this?
How about this?
Chiropractors’ assumption of an obligatory birth trauma that causes subluxation and requires spinal adjustments is nothing more than a ploy by charlatans for filling their pockets with the cash of gullible parents.
The over-use of X-ray diagnostics by chiropractors has long been a concern (see for instance here,and here). As there is a paucity of reliable research on this issue, this new review is more than welcome.
It aimed to summarise the current evidence for the use of spinal X-ray in chiropractic practice, with consideration of the related risks and benefits. The authors, chiropractors from Australia and Canada who did a remarkable job in avoiding the term SUBLUXATION throughout the paper, showed that the proportion of patients receiving X-ray as a result of chiropractic consultation ranges from 8 to 84%. I find this range quite staggering and in need of an explanation.
The authors also stated that current evidence supports the use of spinal X-rays only in the diagnosis of trauma and spondyloarthropathy, and in the assessment of progressive spinal structural deformities such as adolescent idiopathic scoliosis. MRI is indicated to diagnose serious pathology such as cancer or infection, and to assess the need for surgical management in radiculopathy and spinal stenosis. Strong evidence demonstrates risks of imaging such as excessive radiation exposure, over-diagnosis, subsequent low-value investigation and treatment procedures, and increased costs. In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The authors state that the use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.
The problem, however, is that many chiropractors do not abide by those guidelines. The most recent data I am aware of suggests that only about half of them are even aware of radiographic guidelines for low back pain. The reasons given for obtaining spinal X-rays by chiropractors are varied and many are not supported by evidence of benefit. These include diagnosis of pathology or trauma; determination of treatment options; detection of contraindications to care; spinal biomechanical analysis; patient reassurance; and medicolegal reasons.
One may well ask why chiropractors over-use X-rays. The authors of the new paper provide the following explanations:
- lack of education,
- ownership of X-ray facilities,
- and preferred chiropractic technique modalities (i. e. treatment techniques which advocate the use of routine spinal X-rays to perform biomechanical analysis, direct appropriate treatment, and perform patient reassessment).
Crucially, the authors state that, based on the evidence, the use of X-ray imaging to diagnose benign spinal findings will not improve patient outcomes or safety. For care of non-specific back or neck pain, studies show no difference in treatment outcome when routine spinal X-rays have been used, compared to management without X-rays.
A common reason suggested by chiropractors for spinal X-ray imaging is to screen for anomalies or serious pathology that may contraindicate treatment that were otherwise unsuspected by the clinical presentation. While some cases of serious pathology, such as cancer and infection, may not initially present with definitive symptoms, X-ray assessment at this early stage of the disease process is also likely to be negative, and is not recommended as a screening tool.
The authors concluded that the use of spinal X-rays in chiropractic has been controversial, with benefits for the use of routine spinal X-rays being proposed by some elements of the profession. However, evidence of these postulated benefits is limited or non-existent. There is strong evidence to demonstrate potential harms associated with spinal X-rays including increased ionising radiation exposure, over-diagnosis, subsequent low-value investigation and treatment procedures, and increased unnecessary costs. Therefore, in the vast majority of cases who present to chiropractors, the potential benefit from spinal X-rays does not outweigh the potential harms. Spinal X-rays should not be performed as a routine part of chiropractic practice, and the decision to perform diagnostic imaging should be informed by evidence based clinical practice guidelines and clinician judgement.
So, if you consult a chiropractor – and I don’t quite see why you should – my advice would be not to agree to an X-ray.
Alternative medicine is an odd term (but it is probably as good or bad as any other term for it). It describes a wide range of treatments (and diagnostic techniques which I exclude from this discussion) that have hardly anything in common.
And that means there are a few common denominators. Here are 7 of them:
- The treatments have a long history and have thus stood the ‘test of time’.
- The treatments enjoy a lot of support.
- The treatments are natural and therefore safe.
- The treatments are holistic.
- The treatments tackle the root causes of the problem.
- The treatments are being suppressed by the establishment.
- The treatments are inexpensive and therefore value for money.
One only has to scratch the surface to discover that these common denominators of alternative medicine turn out to be unmitigated nonsense.
Let me explain:
The treatments have a long history and have thus stood the ‘test of time’.
It is true that most alternative therapies have a long history; but what does that really mean? In my view, it signals but one thing: when these therapies were invented, people had no idea how our body functions; they mostly had speculations, superstitions and myths. It follows, I think, that the treatments in question are built on speculations, superstitions and myths.
This might be a bit too harsh, I admit. But one thing is absolutely sure: a long history of usage is no proof of efficacy.
The treatments enjoy a lot of support.
Again, this is true. Alternative treatments are supported by many patients who swear by them, by thousands of clinicians who employ them as well as by royalty and other celebrities who make the headlines with them.
Such support is usually based on experience or belief. Neither are evidence; quite the opposite, remember: the three most dangerous words in medicine are ‘IN MY EXPERIENCE’. To be clear, experience and belief can fool us profoundly, and science is a tool to prevent us being misled by them.
The treatments are natural and therefore safe.
Here we have two fallacies moulded into one. Firstly, not all alternative therapies are natural; secondly, none is entirely safe.
There is nothing natural about diluting the Berlin Wall and selling it as a homeopathic remedy. There is nothing natural about forcing a spinal joint beyond its physiological range of motion and calling it spinal manipulation. There is nothing natural about sticking needles into the skin and claiming this re-balances our vital energies.
Acupuncture, chiropractic, herbal medicine, etc. are burdened with their fair share of adverse effects. But the real danger of alternative medicine is the harm done by neglecting effective therapies. Anyone who decides to forfeit conventional treatments for a serious condition, and uses alternative therapies instead, runs the risk of shortening their lives.
The treatments are holistic.
Alternative therapists try very hard to sell their treatments as holistic. This sounds good and must be an excellent marketing gimmick. Alas, it is not true.
There is nothing less holistic than seeing subluxations, yin/yang imbalances, auto-intoxications, energy blockages, etc. as the cause of all illness. Holism is at the heart of all good healthcare; the attempt by alternative practitioners to hijack it is merely a transparent attempt to boost their business.
The treatments tackle the root causes of the problem.
Alternative therapists claim that they can identify the root causes of all conditions and thus treat them more effectively than conventional clinicians who merely treat their symptoms. Nothing could be further from the truth. Conventional medicine has been so spectacularly successful not least because we always aim at identifying the cause that underlie a symptom and, whenever possible, treat that cause (often in addition to treating symptoms). Alternative practitioners may well delude themselves that energy imbalances, subluxations, chi-blockages etc. are root causes, but there simply is no evidence to support their deluded claims.
The treatments are being suppressed by the establishment.
The feeling of paranoia seems endemic in alternative medicine. Many practitioners are so affected by it that they believe everyone who doubts their implausible notions and misconceptions is out to get them. Big Pharma’ or whoever else they feel prosecuted by are more likely to smile at such wild conspiracy theories than to fear for their profit margins. And whenever ‘Big Pharma’ does smell a fast buck, they do not hesitate to jump on the alternative band-waggon joining them in ripping off the public by flogging dubious supplements, homeopathics, essential oils, vitamins, flower remedies, detox-remedies, etc.
The treatments are inexpensive and therefore value for money.
It is probably true that the average cost of a homeopathic remedy, an acupuncture treatment or an aromatherapy session costs less than the average conventional treatment. However, to conclude from it that alternative therapies are value for money is wrong. To be of real value, a treatment needs to generate more good than harm; but very few alternative treatments fulfil this criterion. To use a blunt analogy, if someone offers you a used car, it may well be inexpensive – if, however, it does not run and is beyond repair, it cannot be value for money.
As I already stated: alternative medicine is so diverse that its various branches are almost entirely unrelated, and the few common denominators of alternative medicine that do exist are unmitigated nonsense.