The American Heart Association and the American Stroke Association recently published in the journal Stroke a thorough analysis of the evidence for an association between cervical manipulative therapy (CMT) and both vertebral artery dissection (VAD) and internal carotid artery dissection (ICAD). The full article is online: “Cervical Arterial Dissections and Association With Cervical Manipulative Therapy: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.” For background, an arterial dissection is essentially a tear in the inner lining of the artery. This tear disrupts the normal flow of blood, and also causes platelets to gather at the site of injury. This can result in a blood clot at the site of the dissection. This blood clot can block flow through the artery, or it can break off and lodge downstream, blocking flow at that point. Dissections, therefore, can result in a stroke (a lack of blood flow to a portion of the brain causing damage). There are four arteries in the neck that bring blood from the heart to the brain, two carotid arteries in the front, and two vertebral arteries in the back. A dissection in one or more of these arteries is associated with 2% of all strokes, but with 8-25% of strokes in patients <45 years old. This is mostly because strokes associated with processes like atherosclerosis are much less common in the younger population. Arterial dissections are classified as either spontaneous or traumatic. Trauma can be either severe, such as whiplash injury from a car accident, or subtle, such as from yoga or simply turning one’s neck to look past the shoulder. (more…)
Archive for Chiropractic
Ladies, how would you like a chiropractor to deliver your baby? How about perform your annual well-woman exams, such as breast exam, bi-manual pelvic exam, speculum exam, recto-vaginal exam and Pap smear?
Sound out of their league? I thought so too. Way out. But, in some parts of the U.S., the law allows chiropractors to do all of these things and a great deal more. Including “adjusting” your basset hound.
A 2011 survey asked chiropractic regulatory officials whether their jurisdictions (all states, plus D.C., Virgin Islands and Puerto Rico, but I’ll refer to them collectively as the “states”) allowed 97 different diagnostic, evaluation, and management procedures. The results were recently reported and interpreted in the Journal of Manipulative and Physiological Therapeutics, in an article authored by Mabel Chang, DC, MPH, who was primarily responsible for the survey. Missouri allows the most procedures (92) and Texas, the fewest (30). A handful of states did not respond or did not respond to all questions, but the overall response rate was 96%. Results from a survey of Canada, Australia and New Zealand will be reported in a separate article. (more…)
Chiropractors often deny that neck manipulation can be a primary cause of stroke by injuring vertebral arteries. But according to Jean-Yves Maigne, M.D., head of the Department of Physical Medicine at the Hôtel-Dieu Hospital in Paris, France:
It is now a well established fact that cervical thrust manipulation can harm the vertebral artery. This accident was formerly regarded as very rare, although severe, and related to atherosclerosis. Clinical tests were proposed to detect patients at risk. The problem is now better known. It is no longer attributed to atherosclerosis…but to a dissection of a vertebral artery, a clinical entity observed in younger patients (20-45 years). It remains very rare, but mild symptoms appear to be not so infrequent. Finally, the predicting tests seem to be deprived of any value.1
In 1997, the French Society of Orthopaedic and Osteopathic Manual Medicine (SOFMMOO), following presentations by anatomists, neurologists, radiologists, and practitioners in the field of French Manual Medicine, adopted the neck-manipulation proposals made by Dr. Maigne.1 “Acknowledging the fact that prevention is out of reach,” said Dr. Maigne, “the aim of these recommendations is to reduce the number of (not to say to suppress) rotational cervical thrust manipulations in a targeted population. This population consists mainly in females of less than 50 years old. Five recommendations were developed, in addition to classic contraindications of spinal manipulative therapy.”
The recommendations of the SOFMMOO, dealing with cervical manipulation in general and allowing the use of neck manipulation in special cases, are worth considering since they were reviewed by medical specialists in different disciplines and approved by licensed practitioners who use manual therapy, long before the stroke-neck-manipulation furor reached its peak in the United States.
When Forbes.com published Steven Salzberg’s article “New Medicare Data Reveal Startling $496 million wasted on Chiropractors” (April 20, 2014), a flood of mail (more than 300 comments) from chiropractors and their patients provided a wealth of evidence that subluxation-based chiropractic is alive and well despite rejection by the scientific community. Pro-chiropractic comments laced with anti-medical rhetoric and ad hominem attacks, expressed with religious fervor, failed to distinguish between generic spinal manipulation (that can be useful in the treatment of mechanical-type back and spinal problems) and chiropractic adjustments used in an attempt to restore and maintain health by correcting vertebral subluxations. No distinction was made between a real, symptomatic orthopedic subluxation and an imaginary, asymptomatic chiropractic “vertebral subluxation complex,” neither of which has been shown to be a cause of bad health. While the chiropractic profession may have some justification for objecting to any suggestion that chiropractic treatment has no value whatsoever, especially in the case of mechanical-type back pain and other musculoskeletal problems, the tone and content of many of the comments by chiropractors provide good examples of why chiropractic is so often criticized by the scientific community.
A quote in the Forbes article, from my Science-Based Medicine article “Chiropractic: A Summary of Concerns,” brought this comment from a prominent chiropractor:
…Harriet Hall, Edzard Ernst, Jann Bellamy, and other current renowned medical bigots who attack all CAM providers but turn a blind eye to the dangers of the medical profession….Steven, your chiro critics are invalid—none of them are researchers or educators, but they are just disgruntled practitioners from yesteryear. Don’t get me started on the Science-Based guys who are just haters like you—Harriet Hall, Edzard Ernst, Jann Bellamy are renown medical bigots.
All of us at SBM have repeatedly expressed frustration at the continuing influx of pseudoscience into the health care system. Judging from comments posted on this site and private communications we receive, our readers share this frustration but are at a loss to figure out how to get through to legislators and other policy makers. Unlike naturopaths and chiropractors, we don’t have the money to hire professional lobbyists. Fortunately, an opportunity to sound off against SCAMs has presented itself, completely free of charge.
Now that the Affordable Care Act enrollment debacle is dying down, the Department of Health and Human Services (HHS) is turning its attention to divining just what the heck Section 2706 of the ACA, the non-discrimination provision, means. (Actually there are other federal agencies involved; to simplify things, here we’ll refer to them collectively as “HHS.”) HHS has opened the issue to public comment, but only until June 10. Let’s take a look at why this is important and what you can do about it.
(There are providers other than chiropractors, naturopaths and acupuncturists involved in this fight. For example, you’ll see public comments from nurse anesthetists and nurse practitioners. But I’m not worried about providers who stick to science.) (more…)
Legislative Alchemy is the process by which credulous state legislators turn practitioners of pseudoscience into state-licensed health care professionals. In addition to unleashing quackery such as homeopathy, colonic irrigation, moxibustion, reiki, cranial sacral therapy and the detection and correction of subluxations on the public, these practice acts typically give chiropractors, naturopaths and acupuncturists the freedom of being governed by their own regulatory boards, to which the practitioners themselves are appointed. The boards, in turn, write the administrative rules governing practitioners and handle public complaints about their services. In the worst cases, legislatures simply hand out the privilege of practicing medicine to pretty much anyone.
State practice acts also establish the education and training standards for practitioners by requiring graduation from their accredited schools. Here the federal government lends a hand, by turning accreditation over to private agencies run by the practitioners themselves. The federal government also supports the schools by giving them taxpayer-funded student loans and research money. (more…)
Think you need to see a doctor? How about seeing him (or her) on your computer (or tablet or smart phone) screen instead of in the doctor’s office?
The technology of telemedicine, or telehealth, is here. So far, there is no single definition of what it does, and does not, encompass. For example, in some definitions, one of which we discuss today, it includes only video communication. Other definitions are broader, including fax, telephone, and e-mail. Here, we focus mainly on the direct patient-physician telemedicine encounter, unmediated by the presence of a physician who has actually seen the patient face-to-face. This is unlike, for example, the more common specialist consultation, in which the patient and physician have met face-to-face and the specialist is brought in via technology. A typical example of this is the radiologist who reads x-rays from a remote location. (Sometimes so remote that the radiologist isn’t even in the same country.) There is some evidence, but not much yet, that certain kinds of physician-mediated telemedicine can benefit the patient.
One can think of many ways a patient’s accessing a doctor via computer might improve access to healthcare. This could be a godsend for patients in rural areas who must drive an hour or more to find a doctor’s office. For example, here’s a program from the University of Mississippi Medical Center:
The Diabetes Telehealth Network will [put telemedicine] technology in the hands of the patients themselves in the form of Internet-capable tablets equipped with the Care Innovations™ Guide platform.
The Care Innovations™ Guide platform enables health-care providers to offer a clinically driven, fully integrated remote care management solution for populations with chronic conditions. The project will recruit up to 200 patients in Sunflower County, MS, who will use Care Innovations technology to share health data, such as weight, blood pressure, and glucose levels, daily with clinicians.
Over the weekend, I was perusing my Google Alerts, along with various blogs and news websites, looking for my weekly topic, when I noticed a disturbance in the pseudoscience Force. It’s a phenomenon I’ve noticed many times before, but, as far as I can tell, I haven’t actually blogged about it here, at least not specifically, although I have mentioned it, particularly in posts about Stanislaw Burzynski. I have, however, blogged about it over at my not-so-super-secret other blog, which means that some of the thoughts (if you can call them that) that I plan to lay down in this post will likely seem familiar to some of you, but I think this is an important enough topic that I should cover it here, too. As arrogant as I might sometimes seem, even I’m not so deluded as to think that the fraction of SBM readers who are regulars at my not-so-super-secret other blog is anything greater than a clear minority, and even for those of you for whom there’s overlap I’ll try to make things different enough to be interesting.
On Friday, Sharon Hill published a post over at Doubtful News entitled Chiropractors get their spine out of place over critique. It’s about how chiropractors have reacted to a post by Steve Salzberg over at Forbes entitled New Medicare Data Reveal Startling $496 Million Wasted On Chiropractors. Salzberg’s blog post was basically about just that, namely the amount of money billed Medicare by chiropractors, information that’s possible to obtain since the government released Medicare billing data for individual practitioners. Salzberg pointed out that half a billion dollars is a lot of money, more than twice as much as what is wasted every year on the National Center for Complementary and Alternative Medicine (NCCAM) and the National Cancer Institute’s Office of Cancer Complementary and Alternative Medicine (OCCAM). The result was rapid. Chiropractors swarmed, complaining to Forbes.com, and making the usual threats to sue, much as they actually did sue Simon Singh and, fortunately, saw their lawsuit blow up in their faces.
This, of course, can be looked upon as a purely mercenary protection of turf and livelihood not unlike how Daniel Kopans attacks any study that finds mammography to be less effective than thought (or even ineffective) in decreasing deaths from breast cancer. There is, however, a form of backlash against criticism of pseudoscience that is different and, when I first encountered it, more disturbing to deal with. It’s a level of pure, visceral hatred that is difficult to understand; that is, until you try to put yourself into your “enemy’s” shoes. Consider this post an exercise in doing just that, an exercise that will no doubt shock at least one of our readers.
The United Chiropractic Association has warned that using mobile phones for texting could cause poor posture that could shorten your life. They claim that poor posture is as big a health risk as obesity and that it increases the risk of an early death, especially in elderly people. Chiropractors have said a lot of silly things, but this ranks right up there among the silliest. They are just making stuff up and using scaremongering as a practice-building technique.
They say these claims are based on research studies. They aren’t. They are fanciful imaginings built around a tiny grain of truth that is just large enough to confuse a medically naive public. When people text, they usually bend their head forward; and if you hunch over for long periods, your back is likely to hurt. I have to keep reminding myself not to sit at the computer too long in one position. (more…)
Although obscured by controversy, there is evidence to indicate that spinal manipulation can be as effective as conventional treatment methods in relieving low-back pain.1,2,3,4 This grain of truth mixed with chiropractic vertebral subluxation theory that encompasses a broad scope of ailments makes it difficult for the average person to distinguish between appropriate and inappropriate use of manipulation by chiropractors. A person who is satisfied with chiropractic manipulative treatment for back pain might be led to believe that the same treatment can be used to treat a variety of organic ailments by correcting “vertebral subluxations.” Such treatment is usually described as a “chiropractic adjustment.”
A manual chiropractic adjustment
Although chiropractic care based on subluxation theory has been rejected by the scientific community, spinal manipulation used in the treatment of mechanical-type back pain has a plausible basis that makes it acceptable in mainstream healthcare. A good back-cracking back rub provided by a chiropractor or some other manual therapist can be a pleasurable, pain-relieving experience, and this can be a preferred method of treatment for some types of back pain. But you should be well-informed enough to know where to draw the line in separating subluxation-based chiropractic adjustments from appropriate use of generic spinal manipulation if you should consider treatment by a chiropractor. Otherwise, you might become the victim of the bait-and-switch tactics of chiropractors who offer you treatment for back pain and then attempt to indoctrinate you in subluxation theory.
Much of what follows in this article has been said before in other articles of mine posted on this site. An up-to-date summary of basic concerns about chiropractic care, however, might be useful for new readers and others, including professionals, who want a brief overview for quick reference in seeking answers to questions about the problematic aspects of chiropractic use of spinal manipulation.