On one of the internal mailing lists at my workplace (a service department in a major education institution) there was a request for a recommendation for a local chiropractor. The internal discussion mailing list is often used for requesting any recommendations on local builders or other people one might employ. Initially I decided to answer the respondent privately, who after my detailed explanation of what chiropractor’s believe, may be reconsidering his decision to approach them for a shoulder problem.
However, after several positive recommendations of this or that provider, and mentions that some posters felt chiropractors were of course better than NHS physiotherapists, I felt someone should point out the skeptical point of view on this profession.
So I wrote:
Against my better judgment since there have been a number of posts about this I thought I should chip in with some devil’s advocate thoughts on why you might think twice before using a chiropractor. While I’m glad that those in [WORKPLACE] using chiropractors have had such good results and fully support informed patient choice, there are some things about chiropractors and chiropractic in general that you may wish to bear in mind before using their services.
- Chiropractic was founded in 1895 by Daniel David Palmer who was a grocer and “magnetic healer” and did not believe in the germ theory of disease, but instead that diseases are the result of misplaced spinal bones. Chiropractors tend to believe that energy “subluxations” of the spine cause disease by interfering with the flow of “nerve energy” or “innate intelligence” from the brain to the body’s tissue cells. Chiropractic “subluxation” is not the same as real or medical subluxation, which represents a partial dislocation of joint structure and would in fact be a contraindication to “adjusting” or “manipulating” these joint structures.
- Chiropractors are not medical doctors but ‘alternative medicine practitioners’. Although they have to be approved by their regulatory body in the UK, the GCC, they do not necessarily have as much medical training as you’d expect. They are only allowed to claim they are ‘Doctors of Chiropractic’ but are expressly forbidden from claiming they are Doctors as this might mis-represent them as having medical training. It is illegal for them to perform invasive procedures, surgery, prescribe any real medicine, or convince people that they are doctors.
- Chiropractic neck manipulation has been found to be directly related to a significantly increased incidence of stroke, and patients have had strokes due to tears to the vertebral artery suffered in chiropractic manipulations (5-6 times more likely in one study, 20% of a particular type of stroke in another study). A large percentage of chiropractic malpractice suits are related to stroke (but possibly because the patient having a stroke on the Chiropractor’s table is a clear correlation compared to other damage and side effects). I’ve found lots of advice which says you should avoid chiropractic manipulations of the neck as these are the techniques that are associated with the highest risk of death, stroke, or permanent damage.
- Analyses of good clinical trials on chiropractic and spinal manipulation fail to find a significant evidence for beneficial effects and there is a large risk of minor adverse effects, a small risk of extremely serious effects. While there is some limited potential benefit for conditions relating directly to the spine, a large percentage of those receiving chiropractic treatment also end up with minor adverse effects. Meta-analyses find that when a study’s methodology is more rigorous the benefits of chiropractic tend to be less pronounced. Meta-analyses also find that “there is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.”
(http://www.annals.org/content/138/11/871.abstract) There are certainly cases of people dying because of Chiropractic treatment and others having very serious adverse affects. While all medical treatment has risks associated with it, patients should be informed of those risks, and the benefits (unproven in chiropractic treatments) should outweigh these risks.
- ‘Straight’ or ‘Traditional’ chiropractors tend to believe that the germ theory of medicine is false while ‘mixers’ believe this might exist but is of significantly less importance than “nerve energy”. Many websites seem to espouse the believe that randomly controlled clinical trials are somehow inherently biased against chiropractic techniques, or that all sorts of diseases (which have nothing to do with one’s “nerve energy” or spine) can be cured by manipulation of the spine. They are generally against the idea of science-based medicine since it consistently shows there to be little benefit and significantly more risk to their treatments than corresponding non-alternative treatments. Similarly a majority of chiropractors were found to also recommend patients away from childhood vaccinations.
- Many chiropractors unnecessarily expose patients to xrays when these have been consistently shown to be of no diagnostic benefit in attempting to find the energy “subluxations” that chiropractors believe in. Many chiropractors were found to not interpret major spinal problems correctly from xrays. Increases in frequency of xrays (especially full back ones) has been shown to be significantly detrimental to patient health.
- The ASA has consistently upheld many complaints about chiropractors mis-representing themselves or the efficacy of their treatments for the unsubstantiated claims that they can help at all whiplash, chronic pain, and especially things such as treatment of infants for colic, ear infections, asthma, etc.
- The British Chiropractic Association is currently suing for libel Dr Simon Singh over his attempts to expose that there is no evidence base for the use of chiropractic on infants for things such as colic, sleeping and feeding problems, frequent ear infections, asthma, and prolonged crying. This court case, along with many other examples of the silencing of the press, have helped to spark a very successful campaign for libel reform (see http://www.libelreform.org). The abuse of UK courts for ‘Libel Tourism’ and silencing of fair comment by academics and investigative science journalists certainly needs reform of some sort in my opinion.
Chiropractors are quite good at advertising themselves online, so I thought it might be reasonable to put some of the possible concerns with this alternative therapy forward as well. Again, if chiropractic works for you and you are happy with the risks, then I’m happy for you, please take this in the spirit in which it is intended. I’m simply trying to promote informed choice.
Some links you may be interested in if you’ve read this far:
Apologies for wittering on so long. For the record, I have no vested interest in wanting you to carefully consider such medical decisions other than my general desire for my colleagues not to be injured.
Most people in my workplace of 150-200, I am quite sure, took one look at the length of my reply and (perhaps knowing my skeptical leanings) simply deleted it. A couple people continued on in giving recommendations, with one recounting how his chiropractor had given him some quite sensible advice (orthodics, back strengthening exercises, etc.) for his condition and with regular exercise he has since managed to keep it under control. (No, I did not respond, publicly at least with indications that anecdote is not data!) What surprised me was the number of private responses that I got which were positive. This was interesting because I wasn’t expecting any sort of swell of support, nor was I expecting anyone who wanted to say ‘oh yeah, that was a good post’ or something to feel they had to do it privately.
Responses included (slightly anonymised):
Good on you [againstallwoowoo] for taking the time to write such a well-researched e-mail. Your reticence is understandable but where prevention of harm to one’s colleagues is the main motivating factor I don’t think anyone could criticise you unduly.
Thanks [againstallwoowoo]. This was very useful!
Great post! I dare anyone to mention homeopathy right now!
Wow, good email!
What’s the difference between an osteopath and a chiropractor?
No, not the first line of a lame joke – a genuine question!
(as well as a few other private comments in person).
Firstly, Bah! If they think that email is well-researched… well it makes me doubt their opinions on what makes good research. I’m the first to admit that it over-generalises, doesn’t provide adequate citations (though most of the information is taken from the links at the bottom), is quite one-sided, is superficial, might be misleading whilst also contains only a few of the reasons you might not want to visit a chiropractor. Of course, I suppose that commenter could have been being sarcastic! That my ‘reticence is understandable’ is what bothered me most though. Not that I don’t understand why I was reluctant to post it…but that we both recognised instantly that this reluctance was understandable. Why should I feel uneasy in posting a summary of skepticism about chiropractic? Is it that I don’t want to offend those people in my department who strongly believe in it, or that I fear (even unintentional or subconscious) reprisals from those people when I next have to deal with them? I would like to think my colleagues wouldn’t be so (even unintentionally) petty-minded…but who knows! I think partly it comes from wanting one’s work colleagues to like you.
That others found it useful enough to email me to say so, I guess means my mission was accomplished successfully in that some people have been made aware to at least consider that there may be some risks with chiropractic and that they should perhaps go and do some research first. The joke about homeopathy arises from one person’s knowledge that I’ve been involved in the local participation in the 1023 campaign against homeopathy. I really hope no one does post about it “What homeopathic remedy is best for complaint X” or something, because I feel if I post too many long non-work related posts to this internal mailing lists, I’ll just get further stereotyped in my department.
One of the people asked about the difference between an osteopath and a chiropractor, and I provided what I thought was a brief summary based on my very skimpy knowledge, and some references to more sources of information online. (Why would someone ask this without going and looking at say the wikipedia articles on chiropractic and osteopathy?? Surely that is simple enough?) But good, I guess, that my post made her think enough about the topic to post an answer.
There were no questions asked publicly (just a couple more recommendations, and the one anecdotal defense) nor no public ‘thank you, that was useful’ type posts. People evidently feel that this isn’t proper for a department-wide mailing list. Probably with good reason, I suppose. Though a number of people did say things such as:
In my experience, NHS physios are in general likely to be much better equipped with more up-to-date training and support services than private physios. I’d go to my GP and get a referral to a physio at the hospital (There used to be a good clinic across the road but I guess you’d have to go to the [NHS hospital] now.) Like [againstallwoowoo], I’d keep away from the witch doctors.
which made me happy enough. Though later in the already-to-long thread I did post to
Just to be clear, I’ve never had any physiotherapy, osteology, chiropractic or similar so can’t really comment on their relative merits or make any recommendations. My post was based solely on what I’ve learned whilst following the BCA vs Singh libel court case and the libelreform.org campaign and the wonderful http://www.libelreform.org/the-big-libel-gig that I went to recently, and the intention of the post was simply to raise the other more skeptical side for consideration. The closest I have come was a recent torn medial collateral ligament, which was treated successfully with non-steroidal anti-inflammatories and targeted exercise which means I should be able to get back to jogging and cycling soon. I expressly do not want to denigrate any colleague’s personal choice of alternative therapy, as long as they don’t object to me disagreeing with them. I have campaigned outside of a work context against one particular alternative therapy as part of a local skeptics group for the nationwide http://www.1023.org.uk/ campaign and am happy to discuss that or any of these similar issues outside of work. For any medical condition or desired medical intervention I would always approach my GP first and encourage my colleagues to do so. Much suffering is caused by people not going to their GPs or ignoring their GPs advice (especially with regard to finishing their doses of medicine). That is what one’s GP is for after all and, regardless of the complaints people might have about it, this country has an excellent nationalised health service whatever its failings.
I agree with [OtherPerson] that this thread is already too long.
to me the interesting part, looking back on it, is the pains I’m going to in order to try and separate my work life with those skeptical activities I might be involved in outside of work. Can one really draw a line between areas of one’s life where you employ rational thought? (Well, I suppose there is the famous cognitive dissonance of scientists who seem to believe they can also be creationists.)
But not just that bothers me a bit about what I said: “I expressly do not want to denigrate any colleague’s personal choice of alternative therapy, as long as they don’t object to me disagreeing with them.” On reflection this maybe isn’t what I meant to say. I certainly don’t want to offend any colleague because of their personal choice of alternative therapy, but strongly believe that (if the topic comes up) I should not feel the reticence I obviously seem to feel about promoting a stronger research-based approach to making these decisions. So I’m happy to denigrate, ridicule and satirise though beliefs that I not only don’t believe in but think are wholly untenable. I’m not saying that chiropractic necessarily fits this bill.. on the scale of woowoo in my head, based on the available evidence I’m aware of, chiropractic is down near the nearly normal end of things. Mostly because they actually do something to you and there are observable results, regardless of their permanence, benefit, or their beliefs about what happens and why it happens.
But that it seems I’m saying it is ok to believe these things if you don’t mind me disagreeing also seems to imply that unless something is already well-established in the scientific community, I will automatically disagree with it supposes a model of popular skepticism that I think is harmful and dangerous to a gradual more towards a more rational society. All too often I find skeptics who are negative pessimists who instantly jump on the bandwagon of dislike against this or that weird or wacko thing. There is no challenge in disagreeing with something that all of your peer group also automatically disagrees with, even if they are right. And since peer group communities now are equally virtual and span all ages, this is an even easier trap to fall into because. Instead of any sort of pessimism, I believe that skeptics should be eternal unflinching optimists in the face of new weirdness and woo-woo. Certainly some wacko beliefs, like homeopathy, have been so disproven and are so against the fundamentals of human knowledge that they don’t deserve more thought to be wasted on them. Indeed, we should do what we can so that, perhaps by the year 1023, we can have purged a lot of their mainstream acceptance. However, when new ideas are introduced or become popular, we shouldn’t necessarily dismiss them just because they seem to fall into the same categories of ideas (like Reiki or Homeopathy) that are clearly wacky woo-woo. Instead they should be examined and seen how they might fit into a science and evidence-based understanding of the world. The real test of being a skeptic, I suppose, is either to be skeptical about something that all your skeptic chums are automatically in favour of, or conversely, to have determinedly not made up your mind about something which this peer group has already automatically dismissed. Skeptics should be equally skeptical about assumptions by skeptics. But I think this is straying onto another topic!