Chiropractic for the Beginning Skeptic

I hope that everyone is having a happy, safe, and joyous holiday season. This weeks topic is one that has bothered me for quite a few years, and I have personally experienced. I'm talking about chiropractic. As with many of the various alternative medicine practices, it makes a lot of claims about what it is able to do, ranging from helping with lower back back, which is the most likely, to helping with erectile dysfunction and asthma, which are very dubious claims.

History:
The story of chiropractic starts way back in the fog of ancient China and Greece. At least according to the American Chiropractic Association. They say that there are written records that describe spinal manipulation for lower back pain. I have no way to substantiate these claims, so I'll leave them alone. The official origin of chiropractic is a bit more recent. In 1895, Daniel David Palmer, who ran a magnetic healing clinic, tried the first adjustment on a partially deaf janitor in Davenport, Iowa. According to the stories, a few days later, the janitor remarked to Palmer that his hearing seemed to be a bit better. As far as I've been able to find, there were no tests done on the mans ability to hear before or after Palmer's treatment. Palmer began to promote chiropractic shortly afterwards, which was comparable to osteopathy. According to Mirriam-Webster, osteopathy is: a system of medical practice based on a theory that diseases are due chiefly to loss of structural integrity which can be restored by manipulation of the parts supplemented by therapeutic measures (as use of drugs or surgery). Notice that the definition includes the use of drugs or surgery. Chiropractic generally tends to shun the use of more modern medical techniques. Basically, it sounds a lot like physical therapy, except for the whole disease is caused by a loss of structural integrity bit. Both were based in many of the beliefs that drove the spiritualism movement at the end of the 19th century, including magnetism, vitalism, and naturalism, which makes it very difficult to use the scientific method to ascertain the efficacy of treatment. In 1897, Palmer started the Palmer School of Chiropractic, which is still around. Palmer had made the claim that adjustments, or as they are known in the business, subluxations, are the key to curing all disease. Since then, the interest and use of chiropractic had waxed and waned for decades, until the 1990's when there was a steady rise in the interest and use of chiropractic. There have been several schisms in the history of chiropractic. One of the first was over what Palmer described as "innate intelligence". This is directly related to the magnetism and vitalism ideas of the late 1800's. Many practitioners have moved away from this idea because they feel that it prevents them from being taken seriously in the scientific medicine community. Another schism occurred over the idea of chiropractic being the "only" treatment for disease, or as part of a suite of treatments. The straights, as Palmer called them, believed that chiro (yes, I'm shortening the word from here on out.) was not just the best treatment for all illnesses, but it was the only one. The mixers, which Palmer despised, thought that chiro could be used in addition to surgery and drugs. Palmer felt that the mixers were polluting the "specific, pure, and unadulterated" chiropractic tradition. His words, not mine. This schism still exists today, with the straights being in the minority.
 As I mentioned earlier, Palmer started the first chiropractic college in 1897, and today, there are dozens of accredited colleges around the world. Many of them follow a similar education program, though some are regarded as being better than others. Most of the accreditation seems to be through the ACA (American Chiropractic Association) and not the AMA (American Medical Association) In regards to the US, each state requires practicing chiropractors to be licensed. This started in 1907, and Louisiana was the last state to require it in 1974. When it comes to monitoring and discipline of chiropractors, they are pretty much self regulated, reporting to the Federation of Chiropractic Licensing Boards. An interesting read on licensing, with a few notations, can be found at http://www.chirobase.org/05RB/AHCPR/05.html. To date, chiro is still viewed as an alternative or fringe medical procedure by the medical community at large, though holistic and integrated practitioners do include it in their services.

Theory and Practices:
The basic theory behind chiro concerns subluxation, which is that there is a misalignment of the spine, which causes various illnesses and conditions.  There are some interesting articles on the Science Based Medicine Blog and Quack Watch on this, as well as chiro in general, which I'll put in the footnotes. Many chiropractors, though not all, believe that a misalignment of the spine can cause problems in the nervous system, which in turn can lead to disease and problems with various organs. If you can fix the problem by manipulating the spine, then you can cure the disease. The way this is normally achieved is by attempting to move the vertebrae into what the practitioner deems to be a proper position, which often results in the familiar popping sound. Many chiros will use X-rays to see if the spine is out of alignment and try and determine what they will need to do to put it back. Many people do often report that they feel better for a while after one of these treatments, though how much is due to either endorphin release or the placebo effect is nearly impossible to tell. There is a minority of chiros that don't believe in the subluxation theory, and feel that chiro should be viewed more as a form of physical therapy or for relief of lower back pain. These folks are often dismissed by the larger chiropractic crowd. I would go into the details of what is involved, but almost everyone has some idea. Just in case you don't, basically it involves the practitioner contorting the patient's back and applying pressure along the spine in an attempt to realign the back. There are some minute variations, but that is basically the gist of it. Of course, there are some chiros that will incorporate TCM (traditional chinese medicine) such as acupunture and acupressure or they will include chakras, Reiki, crystals, herbalism, natural medicine, or homeopathy into their practice, but these are all separate topics, many of which I have already written about and don't feel like going into here.

The Claims:
Here is where we get into the fun stuff folks, what the believers in chiropractic claim it can do. Much like every other alternative medicine under the sun, there are a wide variety of claims. However, unlike many other types of alt-med, there are practitioners that will tell you it is good for 1 thing, and anything else, you need to see either a general practitioner or a specialist. Due to the various medical and advertising laws, many chiros are pretty careful about what they say they can do. They tend to avoid words like "cure" and "heal" and instead use more generic terms like "treat" or "relieve" or "help with". But they still make a number of claims on what they can do. According to the ACA, they can treat back and neck pain, headaches, injuries of the musculoskeletal system, and general health issues, because the structure affects overall health. You will also find chiros advertising that they can help with some of the following;

• Athletic injuries
• Allergies
• Arthritis
• Asthma
• ADD/HD
• Back and neck pain
• Carpal Tunnel Syndrome
• Chronic sinus issues
• Constipation                                                  
• Colic
• Ear Infections                                               
• Gastrointestinal dysfunction
• Headaches/Migraines                                
• Herniated/Degenerative Disc                       
• Hip/Sacro-Iliac Pain
• Learning Disorders
• Menstrual dysfunction
• Menopausal symptoms
• Neurodevelopmental conditions
• “Pinched” nerve
• Poor immune system function
• Reflux
• Sciatica
• Scoliosis
• Stress
• Whiplash
  (I pulled all these from a single chiropractic clinics website)

Plus many, many more. Notice that the body systems that are claimed to be effected are much more than just the spine. The immune system, the respiratory system, the gastrointestinal system, and there's a couple of neurological conditions listed as well. Other practitioners will claim that they can treat a wide variety of viral and bacterial infections as well. It's making me think of that old song "Dem Bones". You know the one. "The head bone is connected to the neck bone"...etc. I think that the chiropractic community knows a few more verses than most other people. The site I got the list from says that they don't treat, just diagnose and remove subluxations, which in turns allows better communication between the brain and body, which is a common belief among many practitioners. The exact mechanism that purports to do all this is a complete unknown, and even chiros will admit it. I will grant that all the bodily systems are connected in the loosest sense by all being in the same bag of skin and it's all controlled by the nervous system, but that's about it. Popping your back will not help with asthma. There is absolutely no reason that it would. Asthma is often an inflammation in the lungs, so trying to realign the spine wouldn't have any effect on that.

Evidence:
Now to pull the curtain aside and have a look at the evidence:

That's pretty much what I found. There is some evidence that chiropractic adjustments can have some effect on lower back pain, but that's really about it. Just using your Google machine, you'll find lots of reports on how well it can treat a wide variety of conditions, but most of these are pretty biased. Trying to find an unbiased view is actually fairly difficult. I don't want to rely too heavily on people like Steve Novella or Mark Crislip, who are well known in the skeptic communities as promoters of science based medicine. So I try and stick to relatively unbiased sites and just see what the studies and evidence happen to say. If you look at the CDC you'll see a few studies on the efficacy of chiro, and for the most part, they seem to show some effect for back pain, but not much else. The studies that claim to show efficacy for other conditions are poorly done, with few if no controls, rely heavily on anecdotal evidence, or are completely unrepeatable. If you look at the NIH, you'll see a lot of the same. If you look close, you'll see a lot of papers with a particular name on them. Edzard Ernst. He has spent most of his life studying forms of alternative medicine, including going through a chiropractic college. He has probably done more study into these issues than anyone else alive, and to be honest, I tend to believe what he has found. Here is a link to an article that he wrote on chiro, and just for the hell of it, here is his site. (Because I don't put enough links in my posts. :p) A major critique of chiro, as well as most other alt med practices, is a complete lack of well done studies that actually show a statistical significance for their efficacy, though this doesn't stop the believers from using them as evidence that they were right, and Big Pharma is trying to keep them silent on the issue. Yep, there is a minor conspiracy thread that is woven throughout most alt med mythology.

Risks:
The cost of going to a chiropractor may seem to be fairly small, with the average session costing around $65 or so (in the US), but consider that they will often want you to come back anywhere from twice a month to twice a week. That can end up being anywhere from $1,560-$6,760 a year, using the average cost per visit. Of course, some charge less, some charge more, and there are insurance policies that cover this. There are going to be risks any time someone is messing with your back and neck. This can be something as relatively minor as a pinched nerve or stiffness. However, there are much more serious risks, including paralysis, stroke, and even death. These risks are greater for infants and toddlers. Most chiros won't touch a small child, though as with anything else, if you look hard enough, you'll find one that does. According to the Mayo Clinic, some problems that can stem from having an adjustment done are a herniated disk or a vertebral artery dissection (a particular type of stroke). From the website chirobase.org,  "There are well-documented medical cases of serious disorder to the cervical spine, cervical disc, cerebellum, spinal cord or to the cerebral arteries which ascend through the foramina in the cervical vertebrae, all of which are therefore subject to be bruised and injured with forceful manipulation. There are also well-documented cases of occlusion of cerebral vessels and injury to the brain stem which involves a key area for regulation of the head and neck and an area through which all important outgoing stimuli from the nervous System or incoming sensory data are fed. Such thrombotic lesions are productive of grave and permanent neurological defects, either by infection of the brain stem or stricture by injury to the arteries which supply these vital regions." Of course, Edzard Ernst has written an article titled "20 Things Most Chiropractors Won't Tell You". (I'll admit it. Yes, I am using a somewhat biased source here. That is mostly due to the fact that the chiro industry is pretty insular when it comes to reporting injuries and complications from any of their practitioners. They are, for the most part self regulating, so everything is done in-house, unless someone brings a lawsuit, or it gets into mass media.) And there is of course the reported cases of people being crippled or dying due to their treatments. In 2014, here in Oklahoma, a 30 year old man died after receiving a treatment and suffering a stroke on the chiros table. There was a systematic study done on deaths caused by adjustments, and the conclusion is that the risks do not out weigh the possible benefits. Tim Farley, of Whatstheharm.net has an article on there as well. There are also many stories of children being accidentally killed by chiros. These stories are pretty gruesome and depressing, so I'm not going to go into detail or post links to them. If you're in a really morbid mood, just Google the terms Chiropractic child death. I'm just going to say in plain and simple english "Never take a child to a chiropractor! It's a damn bad idea all the way 'round!" A child's skeleton isn't developed enough to withstand a chiropractic adjustment. They are still growing and developing, and these treatments can easily cause permanent problems that the child will have to live with for the rest of their life. 

Conclusion:
As I have said before, I'm not an sort of scientist or researcher. I simply attempt to look into the various issues I cover, and I do try and give everything a fair shake. (I guess that makes me a researcher of sorts?) That being said, most things I write about just don't have the evidence to support their claims, and chiropractic isn't any different. There is some evidence to support the claims of helping with certain types of lower back pain, and there is a small contingent of chiropractic practitioners that will send patients to general practitioners or specialists if it is something other than that. But the majority of proponents for chiro will claim it effective for a great many other problems, saying that they all stem from subluxations. This is another form of magical thinking. Yes, there are hundreds of studies claiming to show the efficacy of chiropractic and the believers will point out that there aren't nearly as many studies showing either little or no effect. It's simply a matter of quantity or quality. And before anyone says it, I'm going to go ahead and say no, chiro won't help with your childs ear infection, and if they have chronic ear infections, take them to a pediatrician damn it! Once again , any cure-all cures nothing. For once, I'm going to include a variety of other skeptical resources for you to look through. These guys are medical professionals and know what they are talking about. I'm just a simple jackass that tries to keep an open mind and look at all the evidence. So, until next time, Be Good, Be Skeptical, and Be sure to wash your hands.



Other resources:
http://edzardernst.com/
https://www.sciencebasedmedicine.org/subluxation-theory-a-belief-system-that-continues-to-define-the-practice-of-chiropractic/
https://www.sciencebasedmedicine.org/chiropractic-a-brief-overview-part-i/
http://www.quackwatch.com/01QuackeryRelatedTopics/chiroeval.html
https://www.sciencebasedmedicine.org/the-end-of-chiropractic/
https://www.sciencebasedmedicine.org/top-10-chiropractic-studies-of-2013/
https://www.sciencebasedmedicine.org/chiropractor-breaks-babys-neck-a-risk-vs-benefit-analysis/
https://www.sciencebasedmedicine.org/stroke-death-from-chiropractic-neck-manipulation/