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Chiropractic Vertebral Subluxations: Science vs. Pseudoscience

A 1997 publication by the Foundation for Chiropractic Education and Research, supporting the vertebral subluxation theory, noted that “…we [chiropractors] have successfully distanced the concept of a chiropractic subluxation from that of an orthopedic subluxation.”1 When discussing “subluxations” or misaligned vertebrae, however, chiropractors often fail to point out the difference between an orthopedic subluxation and a chiropractic subluxation. Reference to subluxations in medical literature is often presented as support for the practice of chiropractic as a method of adjusting vertebral subluxations to “restore and maintain health.”

In the eyes of the public, the chiropractic vertebral subluxation theory has confused the definition of the word “subluxation,” a common medical term. Unlike the mysterious, undetectable and asymptomatic chiropractic “vertebral subluxation complex” alleged to be a cause of disease, a real vertebral subluxation, that is, an orthopedic subluxation, can be a cause of mechanical and neuromusculoskeletal symptoms but has never been associated with organic disease.

Subluxations: Real and Imaginary

An orthopedic subluxation, recognized and named as such since the days of Hippocrates, is a painful partial dislocation. Simple misalignment of a vertebra, also referred to as a “subluxation,” is commonly caused by disc degeneration, curvatures, spondylolysis, and structural abnormalities. Such a subluxation may or may not be mechanically symptomatic and can be seen on a plain x-ray image. In the absence of pathology such as disc herniation or osteophyte formation, these common vertebral subluxations or misalignments rarely affect spinal nerves and have never been associated with organic disease. Spinal nerves supply musculoskeletal structures. The body’s organs are supplied primarily by autonomic nerve ganglia and plexuses located outside the spinal column and by cranial and sacral nerves that pass through solid bony openings, providing overlapping nerve supply independent of any one spinal nerve that passes between two vertebrae.

An orthopedic subluxation, a true vertebral misalignment, or a mechanical joint dysfunction that affects mobility in the spine is not the same as a “chiropractic subluxation” that is alleged to cause disease by interfering with nerve supply to organs. Such a subluxation has never been proven to exist. There is no plausible theory and no credible evidence to support the contention that “nerve interference” originating in a single spinal segment can cause an organic disease.
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Kaiser Rejects Neck Manipulation

Despite quackademia, anti-vaccine propaganda, and other discouraging trends, the news is not all bad. A major HMO has taken a decisive action in support of science-based medicine. 

Kaiser Permanente Mid Atlantic States and Mid-Atlantic Permanente Group recently announced the elimination of neck manipulation from their chiropractic coverage. The revised policy states,

Given the paucity of data related to beneficial effects of chiropractic manipulation of the cervical spine and the real potential for catastrophic adverse events, it was decided to exclude chiropractic manipulation of the cervical spine from coverage. 

Their decision was applauded by some  but was predictably attacked by chiropractors. (more…)

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Germ theory denialism: A major strain in “alt-med” thought

The longer I’m in this whole science-based medicine thing, not to mention the whole skepticism thing, the more I realize that no form of science is immune to woo. To move away from medicine just for a moment, even though I lament just how many people do not accept evolution, for example, I can somewhat understand it. Although the basics of the science and evidence support the theory of evolution as the central organizing principle of all biology, much of the evidence is not readily apparent to those who don’t make it a calling to study biology, evolution, and speciation. It’s not like, for example, gravity, which everyone experiences and of which everyone has a “gut level” understanding. So, not unexpectedly, when the theory of evolution conflicts with a person’s religious beliefs, for most people it’s very easy to discount the massive quantities of evidence that undergird the theory of evolution. It’s not so easy to discount the evidence for gravity.

In many ways, medicine is similar to evolution, but the situation is possibly even worse. The reason is that much of the evidence in medicine is conflicting and not readily apparent to the average person. There’s more than that, though, in that there are a number of confounding factors that make it very easy to come to the wrong conclusion in medicine, particularly when looking at single cases. Placebo effects and regression to the mean, for example, can make it appear to individual patients that, for example, water (i.e., what the quackery that is homeopathy is) or placebo interventions (i.e., acupuncture) cures or improves various medical conditions. Add to that confirmation bias, the normal human cognitive quirk whereby all of us — and I do mean all of us — tend to remember information that reinforces our preexisting beliefs and to forget information that would tend to refute those beliefs — and, at the level of a single person or even practitioner, it’s very, very easy to be misled in medicine into thinking that quackery works. On the other hand, at the single patient/practitioner level, one can also see evidence of the efficacy of modern medicine; for example, when a person catches pneumonia, is treated with antibiotics, and recovers quickly. Regardless of whether they’re being used to demonstrate quackery or scientific medicine, because personal experience and the evidence that people observe at the level of the people they know can be very deceptive in medicine, science-based medicine, with its basic science underpinnings and clinical trial evidence, is necessary to try to tease out what actually works and what doesn’t.

Medicine does, however, have its version of a theory of evolution, at least in terms of how well-supported and integrated into the very fabric of medicine it is. That theory is the germ theory of disease, which, just as evolution is the organizing principle of biology, functions as the organizing principle of infectious disease in medicine. When I first became interested in skepticism and medical pseudoscience and quackery, I couldn’t envision how anyone could deny the germ theory of disease. It just didn’t compute to me, given how copious the evidence in favor of this particular theory is. It turns out that I was wrong about that, too.

On Friday there was a video released that provides a very clear, succinct explanation of germ theory denialism:

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Posted in: Chiropractic, Naturopathy, Nutrition, Vaccines

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Not to worry! Chiropractic Board says stroke not a risk of cervical manipulation.

Back in January, the Connecticut Board of Chiropractic Examiners held a four-day hearing to decide whether chiropractors must, as a part of the informed consent process, (1)warn patients about the risk of cervical artery dissection and stroke following neck manipulation and (2) give patients a discharge summary listing the symptoms of stroke.1 On June 10th, the Board of issued a written opinion that stroke or cervical artery dissection is not a risk of cervical spine manipulation, so no warning is necessary. Presumably, although it is not specifically mentioned in the decision, no discharge summary is required because, if there is no risk of a stroke after neck manipulation, what would be the point?

Background

Janet Levy and Britt Harwe are two Connecticut women who suffered strokes resulting from neck manipulation by chiropractors. That’s not just their lay opinion, it’s the opinion of their respective treating physicians, right there in the medical records.

Each decided that some good should come of their unfortunate situations, so each formed a non-profit and began warning patients of the risk of stroke following manipulation. Victims of Chiropractic Abuse, Levy’s organization, put giant ads on the sides of busses in Bridgeport, CT., much to the chagrin of the folks at the University of Bridgeport. Within the hallowed halls of the University (Go Purple Knights!) is a College of Chiropractic, a College of Naturopathic Medicine, and the Acupuncture Institute. The chiropractors demanded that the ads be taken down, which got exactly nowhere.

Some chiropractors also began harassing Levy and Harwe, calling them Nazis and KKK members, for example, and threatening their personal safety and that of their families.(What is it with the pseudoscience crowd and calling people Nazis? Perhaps, having used up their entire supply of imagination creating their nostrums, they are reduced to these tired tropes.) The FBI recommended Levy and Harwe have one of the harassers arrested, which they did, and that calmed things down for a while. (more…)

Posted in: Chiropractic, Politics and Regulation

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Professional Integrity for Sale? “Sure,” Says Medscape!

Some chiropractors also practice homeopathy. According to Frank King, D.C., many more should be doing just that:

Homeopathy is an energetic form of natural medicine that corrects nerve interferences, absent nerve reflexes, and pathological nerve response patterns that the chiropractic adjustment alone does not correct. The appropriate homeopathic remedies will eliminate aberrant nerve reflexes and pathological nerve responses which cause recurrent subluxation complexes.

Not only does homeopathy correct nerve interferences, it empowers the doctor of chiropractic to reach the entire nervous system. What this means is that we can now better affect the whole person, and all of the maladies that affect us. Homeopathy’s energetic approach reaches deep within the nervous system, correcting nerve interferences where the hands of chiropractic alone cannot reach. Homeopathy is the missing link that enables the chiropractor to truly affect the whole nervous system!

But that’s not all:

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Posted in: Chiropractic, Health Fraud, Homeopathy, Medical Academia, Medical Ethics, Naturopathy, Politics and Regulation, Science and Medicine

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Cancer Treatment Centers of America and “naturopathic oncology”

EDITOR’S NOTICE: NOTE THE DISCLAIMER.

On “wholistic” medicine

If there’s one aspect of so-called “alternative medicine” and “complementary and alternative medicine” (CAM) is that its practitioners tout as being a huge advantage over what they often refer to sneeringly as “conventional” or “scientific” medicine is that — or so its practitioners claim — alt-med treats the “whole patient,” that it’s “wholistic” in a way that the evil reductionist “Western” science-based medicine can’t be. Supposedly, we reductionistic, unimaginative physicians only focus on disease and ignore the “whole patient.” Of course, to me this claim is belied by the hectoring to which my own primary care physician has subjected me about my horrible diet and lack of exercise on pretty much every visit I’ve had with her, but then maybe she’s an anomaly, along with Dr. Lipson on this very blog and pretty much every other primary care doctor I’ve ever dealt with. Anecdotal experience, I know, but since alt-med mavens appear to value anecdotal evidence above pretty much all else I thought it appropriate to mention here. Also belying the claim of alt-med practitioners that they “individualize” treatments to their patients in a way that science-based medicine does not is the maddening tendency of various alt-med modalities to settle on just One True Cause of All Disease, be it liver flukes as the One True Cause of Cancer, heavy metal toxicity as the One True Cause of cancer, autism, and various other diseases, or “allergies,” acid, or obstruction of the flow of qi as the One True Cause of All Disease.

Given the claim of “wholism” that is such an advertising gimmick among many of the varieties of woo, I’m always interested when I see evidence that alt-med is imitating its envied and disliked reductionistic competition. True, this is nothing new, given how alt-med has tried to seek legitimacy by taking on the mantle of science-based medicine wherever it can. Examples include the National Center for Complementary and Alternative Medicine (NCCAM), various organizations that try to confer legitimacy to pseudoscience by providing “certification” in various flavors of woo, and moves to push state medical boards to go further than that and confer legally protected status to practitioners by actually licensing them. This latter tactic has been very successful in that many states now license acupuncturists, while some states even license naturopaths and “homeopathic physicians,” the latter of which I find quite amusing because the term perfectly encapsulates what must remain of such a physician’s medical training after being diluted to 30C with woo. The only difference is that, unlike what is claimed with homeopathy, diluting MD medical knowledge with woo does not make it stronger. In terms of naturopathy, though, one of the most alarming aspects of the infiltration of naturopaths into the health care system is that some states in the U.S. and provinces in Canada are seriously considering allowing them to prescribe real pharmaceutical medications, even though they lack the training and knowledge to use such drugs safely.

Imagine my combination of bemusement and alarm, then, when I learned of a new specialty of pseudoscience, namely the field of naturopathic oncology.

Be afraid. Be very afraid. (I know I was when I first encountered this specialty.)
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Posted in: Cancer, Chiropractic, Homeopathy, Science and Medicine

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Brief Note: The Chiropractic Subluxation is Dead

The General Chiropractic Council, a UK-wide statutory body with regulatory powers, has just published a new position statement on the chiropractic subluxation complex:

The chiropractic vertebral subluxation complex is an historical concept but it remains a theoretical model. It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.

They remind chiropractors that they must make sure their own beliefs and values do not prejudice the patient’s care, and that they must provide evidence-based care. Unfortunately, they define evidence-based care as

clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners, including the individual chiropractor her/himself. [emphasis added]

This effectively allows “in my experience” and “the patient likes it” to be considered along with evidence, effectively negating the whole point of evidence-based medicine.

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Pediatric Chiropractic Care: Scientifically Indefensible?

In a paper published in 2008, two academic chiropractors offered this observation: “The health claims made by chiropractors with respect to the application of manipulation as a health care intervention for pediatric health conditions continue to be supported by only low levels of scientific evidence. Chiropractors continue to treat a wide variety of pediatric health conditions.”1

Despite lack of support by the medical and scientific community, chiropractic treatment of children is growing in popularity, and more chiropractors are specializing in “chiropractic pediatrics.”

The International Chiropractic Association offers a post-graduate “Diplomate in Clinical Chiropractic Pediatrics” (DICCP) and publishes a “peer reviewed” Journal of Clinical Chiropractic Pediatrics. The diplomate syllabus is a 30-module, 360+ hours classroom course during weekends over a three-year period. There is no hospital training and no contact with diseased or injured children — only a “mandatory observational/training weekend at a chiropractic center for special needs children under multi-disciplinary care.”2 A post-graduate certification in chiropractic pediatrics (CICCP) can be earned after 180 hours of classroom instruction.

In a June 2008 joint press release, the American Chiropractic Association’s (ACA) Council on Chiropractic Pediatrics and the Council on Chiropractic Pediatrics of the International Chiropractors Association (ICA) announced that the ICA’s Diplomate in Clinical Chiropractic Pediatrics (DICCP) is now recognized by the ACA and its council as the official credential for specialization in chiropractic pediatrics.3

Noting increasing public support for chiropractic treatment of children, a January 2009 press release from the American Chiropractic Association made this announcement: “Survey data indicates that the percentage of chiropractic patients under 17 years of age has increased at least 8.5 percent since 1991.…Studies are beginning to show that chiropractic can help children not only with typical back and neck pain complaints, but also with issues as varied as asthma, chronic ear infections, nursing difficulties, colic and bedwetting.”4

A trend toward greater utilization of chiropractic by children has not gone unnoticed by the medical profession. An article in the January 2007 issue of Pediatrics (the official journal of the American Academy of Pediatrics) described chiropractic as the most common complementary and alternative medicine practice used by children, who made an estimated 30 million visits to US chiropractors in 1997.5 In 1998, children and adolescents constituted 11% of patient visits to chiropractors.6
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Posted in: Chiropractic, Science and Medicine

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Brief Note: Followup on Spinal Decompression Machines

In September 2008 I wrote a post on Misleading Ads for Back Pain Treatment. with particular attention to the bogus claims for the DRX 9000.

The Canadian Broadcasting Company (CBC) show “Marketplace” has just done a scathing exposé of so-called nonsurgical spinal decompression treatment with machines like the DRX 9000 and of some of the unscrupulous practitioners who offer it.  Between the hidden camera footage and the weasel words of the chiropractor they interview, it’s quite entertaining.

Posted in: Chiropractic, Health Fraud

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The 2nd Yale Research Symposium on Complementary and Integrative Medicine. Part I

March 4, 2010

Today I went to the one-day, 2nd Yale Research Symposium on Complementary and Integrative Medicine. Many of you will recall that the first version of this conference occurred in April, 2008. According to Yale’s Continuing Medical Education website, the first conference “featured presentations from experts in CAM/IM from Yale and other leading medical institutions and drew national and international attention.” That is true: some of the national attention can be reviewed here, here, here, and here; the international attention is here. (Sorry about the flippancy; it was irresistible)

I’ve not been to a conference promising similar content since about 2001, and in general I’ve no particular wish to do so. This one was different: Steve Novella, in his day job a Yale neurologist, had been invited to be part of a Moderated Discussion on Evidence and Plausibility in the Context of CAM Research and Clinical Practice. This was not to be missed.

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Posted in: Chiropractic, Clinical Trials, Health Fraud, Herbs & Supplements, Homeopathy, Medical Academia, Medical Ethics, Nutrition, Politics and Regulation, Science and Medicine

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