[Editor's Note: Today, we have a guest post from Sam Homola, who, as you recall, practiced as a chiropractor until he ultimately realized that there is no evidence that subluxations exist. Since then, he's discussed in various places, including, we are pleased to say, SBM, his skepticism regarding chiropractic. Enjoy!]
Much has been written (and published on this site) about the implausibility of chiropractic vertebral subluxation theory which proposes that a vertebral subluxation complex or a spinal joint dysfunction “may affect organ system function and general health.” Associated chiropractic gimmickry that might be harmful as well as a waste of time and money should be also be brought to the attention of concerned consumers. As a chiropractor (retired) who has renounced subluxation theory, it might be helpful to share my concerns about some dubious chiropractic methods that are foisted upon an unsuspecting public, unchallenged in the market place.
The Neck Curve Pitch
I often receive mail expressing concern about treatment or services provided by a chiropractor. One of the most common concerns comes from chiropractic patients who have been told that they have a flattened or reversed cervical curve that portends dire consequences if the normal cervical curve is not restored. The patients are informed that failure to undergo a treatment program to realign the cervical vertebrae will allow degenerative changes to occur, progressing to “Stage 4 degeneration” that will trigger the development of life-threatening illness. Frightened by such scare tactics, these patients are usually persuaded to undergo a long course of neck treatment, which may involve use of a special traction harness to force hyper extension of the cervical spine.
It is not unusual for some individuals to have a straight cervical spine or some reversal of the normal cervical curve and have no symptoms at all. Such deviations from normal may be structural in nature, usually cannot be changed, and are not often significant. A cervical curve can be temporarily altered when neck muscles are in spasm, but the curve (or lack of curve) that is normal for the individual returns when the spasm subsides. When there is no pain or loss of mobility in the neck or cervical spine, no treatment is needed. Any attempt to “restore the normal cervical curve” by using manipulation or forced cervical extension is unnecessary and may subject the patient to risk of injury to vertebral arteries.
Stretching the Truth
One of the most popular forms of treatment currently being offered by chiropractors is a form of motorized computer-controlled traction called “decompression therapy.” It is an expensive form of axial or longitudinal traction provided by machines that cost up to $125,000. While any form of traction might be helpful in relieving some types of back pain, promoters of decompression therapy claim that using a computer-driven table to control the level of disc decompression will rehydrate and restore a disc structure by pulling nutrients into ruptured or degenerated disc cartilage. Advertisements promoting decompression therapy often suggest that surgery for a herniated disc can be avoided by using decompression therapy to “restore the disc.” There is no credible evidence to support this contention.
Expensive decompression therapy is unlikely to be any more effective that simple mechanical or manual manipulative traction in the treatment of back pain or disc herniation. According to a current Aetna Bulletin (No. 0180) dealing with vertebral axial decompression therapy, “…there is no adequate scientific evidence that proves that vertebral axial decompression is an effective adjunct to conservative therapy for back pain. In addition, vertebral axial decompression devices have not been adequately studied as alternatives to back surgery.”
Consumers should beware of testimonials extolling the miracle cures of decompression therapy, and they should refuse to pay for a course of traction treatments that may cost several thousand dollars. Patients are often enticed into paying for such treatment in advance in order to reduce the cost of the treatment.
When there is no progressive neurological damage caused by disc herniation, disc surgery is rarely needed or indicated. With time, the disc protrusion will be absorbed and the ruptured disc cartilage will degenerate, with or without treatment, as it would normally do after disc surgery. While a degenerated disc can cause some chronic or recurring back pain, nerve root encroachment rarely occurs unless there is spur formation or bony overgrowth near the intervertebral foramen (where a spinal nerve passes between two vertebrae).
Locating Imaginary Subluxations
Many chiropractors maintain that they can use fingertip palpation to locate vertebral subluxations. Some use computerized instruments that combine thermography with surface electromyography to measure skin temperature differentials and electrical activity in muscles claimed to be associated with vertebral subluxations. A hand-held scanning device is moved up and down the spine, in contact with the skin, measuring electrical activity or skin temperature on each side of the spine. The results appear on a screen that displays graphic bar colors alleged to indicate the location of subluxated vertebrae. Even when there are no physical or neurological symptoms, such testing may be used to persuade a patient to undergo treatment for correction of multiple vertebral subluxations in order to prevent the development of symptoms.
While surface electromyography (not to be confused with needle electromyography) testing might be helpful in evaluating the function of muscles, and thermography might be helpful in detecting the symptoms of such things as reflex sympathetic dystrophy (an autonomic disturbance affecting blood flow to the skin), it is an oxymoron to suggest that either of these tests can locate a chiropractic subluxation that has never been proven to exist. Thermography and surface electromyography are considered to be experimental and investigational with no established validity as diagnostic techniques.
Needless to say, computerized instruments used to locate subluxations that “cannot be detected any other way” can be an effective gimmick for selling chiropractic adjustments to asymptomatic patients who have imaginary vertebral subluxations.
Space-Age Subluxation Correction
Once “subluxations” have been located, an attempt is usually made to correct them by manually adjusting the spine. In many cases, however, instruments may be used to “tap the vertebrae into alignment.” The most common instrument used is a hand-held spring-loaded rubber-tipped stylus that delivers a tap to the offending vertebra. Other variations, some electrically powered, deliver a rapid succession of taps, or a tap with a torque. A special table-top machine designed exclusively to deliver a stylus tap to the atlas, the uppermost cervical vertebra, is sometimes used by chiropractic “upper cervical specialists” who maintain that a misaligned atlas is the primary subluxation causing most ailments.
One “NASA-inspired” instrument uses a piezoelectric sensor to locate and correct vertebral subluxations. A hand-held device shaped like a tuning fork is placed on the spine (straddling the spinous processes). The instrument delivers a vibratory force that measures movement in a spinal segment, which is graphically displayed on a computer screen to indicate the degree of movement or fixation of a vertebra. It is claimed that correction of the subluxation or fixation can be made by using the same hand-held instrument to deliver an oscillating force to restore normal movement, as determined by the piezoelectric sensor. This instrument is used as both a diagnostic instrument and a therapeutic instrument.
If there were any scientific evidence to support the contention that use of adjusting instruments to realign the vertebrae would improve health, such “space-age” instruments would be used in hospitals around the world; at the present time, they are used almost exclusively by chiropractors. FDA approval of the use of instruments for chiropractic adjustment of the spine does not mean that the instruments have been proven to be effective.
Patients who are fearful of back-cracking spinal manipulation (especially the elderly who may have fragile bones) are often subjected to instrument adjusting to correct imaginary subluxations that are alleged to be the cause of back pain and a multitude of other ailments. Some subluxation-based chiropractors treat all of their patients with adjusting instruments.
Paying in Advance for Unnecessary Treatment
One of the most disturbing complaints I hear comes from chiropractic patients who have paid thousands of dollars in advance for a course of treatment lasting several months─after succumbing to a high-pressure sales pitch involving scare tactics. These patients have usually opted to discontinue treatment because symptoms have either worsened or disappeared. Most have signed a contract, however, that does not allow a refund, even if the treatment regimen was not completed. Some have used a chiropractic “health care credit card” to borrow the advance payment from a loan company, leaving the patient legally bound to repay the loan.
It’s never a good idea to pay for chiropractic services in advance. Treatment should be discontinued if symptoms have worsened after one week of treatment or have not improved after two to four weeks of treatment. In many cases of neck or back pain, symptoms will often resolve after a few weeks, eliminating the need for further treatment. Patients who have signed a contract for discounted long-term treatment that involves correction of vertebral subluxations, however, may be told that subluxation-detection instruments indicate that they still have subluxations that need to be corrected to prevent a recurrence of symptoms. Treatment may then be continued as a preventive-maintenance measure, even in the absence of symptoms─all in keeping with subluxation theory which proposes that correction of vertebral subluxations will “restore and maintain health.” Such unnecessary treatment is a needless expense, and it poses a risk that outweighs benefit, especially in the case of neck manipulation which is potentially dangerous.
It is generally considered to be unethical to ask for contracted payment in advance for long-term treatment of a health problem, since such an agreement is tantamount to a guarantee that the treatment will be effective. There is no way to determine if chiropractic treatment might be effective or how many treatments might be needed. I generally advise chiropractic patients to pay for treatment per visit on an as-needed basis and only for treatment of mechanical-type back pain and related problems. A “free exam” or a request for payment in advance should raise a red flag. Few consumers are aware that a diagnosis of “subluxations” in a chiropractor’s office is in itself a red flag.
To smite all humbug, however big; to give nobler tone to science; to set an example to abstinence from petty personal controversies; and of toleration of everything but lying; to be indifferent as to whether the work is recognized as mine or not, so long as it is done.
(A personal note: Science-Based Medicine has evolved to become one of this nation’s most respected blog sites. Journalists, lay persons, and health professionals who are seeking reliable information about health-related subjects are visiting this site on a daily basis. A new post, published daily by health-care professionals who are authorities in their fields, covers a different subject each day, ranging from quackery to controversial issues in science-based medical care. These blogs are written in a reader-friendly fashion that allows readers at every level to understand and benefit from what they have read. An occasional argumentative response to critical analysis of a pseudoscientific healing method often provides a good example of how someone can be adversely influenced by indoctrination into a belief system, further illustrating the need for an informative site like Science-Based Medicine where there is no reluctance to “smite all humbug, however big.”)