Nov 23 2012
Chiropractic “Research” on Tourette Syndrome: The Trouble with Case Reports…..
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22 Responses to “Chiropractic “Research” on Tourette Syndrome: The Trouble with Case Reports…..”
Welcome, Clay. Excellent article, hope to see many more from you.
Indeed! Well written and already in the ranks of Dr. Crislip in literally making me laugh out loud a number of times.
Thank you for the well written article and your activism in promoting critical scientific thought in our field.
Welcome Dr. Jones! And thank you for the informative summary of TS. In college a professor of mine was married to a woman with the most severe copropraxia you can imagine. She was a charming woman and everyone in the department (small state college) knew her and made sure we all were informed about the condition. This woman took a liking to me for some reason and always sat next to me at any meetings or events so I got to observe TS in all its glory up close and personal for the couple of years that I spent most of my time in my major department.
I sometimes dreaded her sitting right next to me all the time as it could be quite disruptive, although luckily she had no arm tic! In retrospect, though, I’m glad that I had this relatively early exposure to a somewhat unusual medical condition. The next time I encountered a TS patient, I was able to put him greatly at ease by having some personal experience.
I also saw a documentary years ago (probably PBS) about a Canadian surgeon with a severe TS tic who manages to do complex surgery in spite of it. Once he hyper-focuses on the surgery, the tic sort of goes into remission for the duration–kind of like ADHD, with which I am more familiar and is a condition that is horribly open to woo intervention.
Thanks for exposing yet another angle that chiropractic has tried to use to further its useless adjustments.
Thanks for the positive feedback Dr. Hall et al.
I’m very lucky in that I don’t think I would ever be considered disruptive. I go long periods of time without thinking about it but am occasionally approached and asked about it or, maybe a little more commonly, it is pointed out by a young patient. Kids. The phenomenon of being able to suppress tics is fascinating and I’m not suprised someone even with fairly severe tics can achieve that measure of success. I personally found that it was a great annoyance during my surgical rotations in medical school. The stress of being scrubbed in, knowing that I would not touch anything, was unbearable. At the time I had a compulsion to touch certain objects. Of course I was also stressed because I already knew that I had no interest whatsoever in going into surgery which added to my stress and probably worsened my tics.
Janet:
I remember that, I think it was a presentation with Dr. Oliver Sacks. He wrote about the surgeon in his book An Anthropologist on Mars.
Thank you Dr. Jones. Great article – in the tradition of SBM blog: honest, personalized, and information, furthering the cause of increasing the scientific basis of medicine.
Thank you Dr. Jones for this excellent article from which I learned a lot about Tourette’s and had many bad notions vanquished. I look forward to reading more of your writings.
However, you wrote: “I usually stick to reputable sources but every now and then I like to go “slumming” in the world of chiropractic research.”
I must rise in the strongest possible protest to this unnecessary maligning of slums which, when compared to the abandoned backlot & stage-prop facades of “chiropractic research,” are garden-terraced palaces of perpetual sunshine, spotless streets and charming, timeless architecture.
Welcome!
There’s a lot of dental woo around TS, here in the UK. Certain shady practitioners are charging up to £10k forr private dental “treatment” (under 18s get free NHS dental care) that will allegedly cure TS.
There was a recent BBC Three documentary series where a radio DJ brought together a group of young people with Tourette’s (all severely affected, albeit with varying motor and verbal tics) who found that singing or performing with a musical instrument suppressed their tics.
The aim of the programme was to put on a musical event with solo and group performances, as a way of dispelling some TS myths, and also showcasing the group’s talent.
It was really interesting, intensely emotional, and hopefully gave some insight to previously uninformed viewers.
I don’t have TS, but do have ADHD and OCD,and abhor the way that non-neurotypical people are reduced to very basic stereotypes apparently out of sheer laziness. Ignorance only boldens the woomeisters, they feed on it.
Whoops! Link: http://www.bbc.co.uk/programmes/p00y21n9
Thanks for the link. I’m curious how the dentists claim to be able to cure TS. Are they biological dentists that are removing mercury fillings? We have that in here in the states. Is it some kind of craniosacral therapy?
Thanks Dr. Jones. Informative piece with an illuminating description of the the value and limitations of case reports! I’m particularly glad that you used the label “irregular medicine.” I’d like to see use of this term catch on.
I have a couple of quibbles. I hope I’m not being pedantic in making these points:
We should not refer to regression toward the mean as if it is a phenomenon that is recognizable for an individual patient or as if it refers to some kind of causal tendency toward moderation. (I’ve observed that more than a few people who have doubts about irregular remedies have described regression toward the mean in misleading ways.) Regression toward the mean is a phenomenon arising out of imperfect correlation between measures taken at different times. It is demonstrable for sample data, not for individual cases.
We should avoid references to journal impact factor as if a low impact factor implies poor quality. Some “CAM”-advocacy journals promoting nonsense have higher impact factors than some journals offering good science.
Patients with TS have tics that go through periods of worsening and calming but they have an average severity. If they seek care during a spike it can easily seem as if that therapy helped when it may have had no effect. It could also lead to the mistaken assumption that something makes tics worse. Regression to the mean may by definition be a term that is applied to populations rather than individuals but it is so commonly used in the way in which I used it that I would argue the definition has changed or is well on its way. The common usage of begging the question is a similar phenomenon. I’m curious to know others thoughts on this.
Fair point about impact factors. I honestly didn’t think of that. My point was that they are terrible journals with very low quality. My judgement was clouded by my desire to put a little humor into the piece.
@ William London,
Isn’t the term “regression to the mean” applicable to repeated measurements in an individual patient? If an individual has varying BP readings, his mean BP can be calculated. If he has a reading substantially above that mean, the next reading is likely to be lower, closer to the mean. I’ve been calling that regression to the mean. Am I wrong to do so? If so, what words should I use?
I’d like to see this sorted out, too. There is also the fact that with naturally fluctuating conditions patients will seek medical help (and hence be recruited into clinical trials) when symptoms are particularly troublesome. Many would be expected to be improved at later end-points whatever is done.
I thought this was an excellent overview of the illusions that can afflict some areas of medical practice. I would have mentioned the potential/possibility of stroke from neck manipulation, even in young people. It is likely that would be the mainstay of chiropractic care.
There are reported cases of TS patients with neck tics having verterbral artery dissections. I imagine that the chiropractic response would be that the patient had the stroke prior to coming in for treatment. I didn’t get into risk associated with chiropractic manipulations, direct or indirect, because it has been covered so well before on SBM.
Apparently, Francis Galton coined the term “regression to the mean”.
He looked at the height of children in relation to their parents’ height and found that, for example, if both parents were taller than the population average, their children, on average would be somewhere between the population average and their parents’ height.
So the term did originally apply to populations rather than individuals.
Still, I have seen it most often applied to individuals, the common example being the patient who tends to seek treatment for a fluctuating chronic medical condition when symptoms are at their worst. In this situation, the smptoms are likely to improve and the improvement is likely to be atributed to whatever treatment was given or tsken at that time.
They’re claiming that TS is caused by misaligned temperomandibular joint.
In another TS documentary on Three (the name escapes me) there was a boy in his late teens who developed motor. tics, echolalia and coprolalia after an apparent seizure during a party.
His mother was woo-struck, they were a wealthy family, and she was sending the lad to aromatherapy sessions, chiropractors, acupuncturists, etc. I was actually shouting at the tv, especially when they said how much she’d spent on sCAM “remedies”. I did wonder, given the etymology of “coprolalia”, what a homeopathic nostrtm might contain!
Anyway, TMJ realignment as TS “fix” here in the UK:
http://jnnp.bmj.com/content/83/10/e1.17.abstract
(Based on informal survey of Tourette’s Action UK members)
http://www.thisisms.com/forum/chronic-cerebrospinal-venous-insufficiency-ccsvi-f40/topic18524-15.html#p182421
(a dentist who claims, worryingly, that he can cure MS, Parkinsons,migraine, TS, and every functional somatic disorder you can think of. He apparently believes that none of these conditions exist, and are merely expressions of misaligned jaw and atlas joint TS not mentioned there, but he’s popped up on private TS/OCD/ADHD fora
http://www.tmjstack.com/
(US dentist claiming jaw realignment cures TS and Parkinsons)
The woo was strong on that MS group. CCSVI, NUCCA, so much false hope, including people who believe that dentistry could help them walk again. Sigh. As someone with demyelinated nerves, I’d bet my lungs that my teeth aren’t the cause!
Slightly off topic, but how would you handle it if your spouse, who is more inclined to woo than you, asks if she can purchase a Groupon for 4 chiro visits for $24? Its for her hips, so I asked her if she’s considered a physical therapist because insurance would cover it and they have more medical training, but her response is that copay might be $15/visit for a total of $60 for 4 visits compared to the chiro groupon.
of course it won’t just cost 24 bucks. It will very likely be a bait and switch. They will push xrays, supplements, maintenance adjustments for months to come. They will likely try to scare her into doing these things by pushing the dangers of subluxations. But you wouldn’t necessarily go to the cheapest mechanic in town to fix your car, right? Sometimes you get what you pay for.
Clay Jones, you’re my new favorite contributor on here! Thanks for a great article!
I didn’t get into risk associated with chiropractic manipulations, direct or indirect, because it has been covered so well before on SBM.
True. Yet it is as important for readers to know this, if not more so, than to hear our opinion that chiropractic manipulations probably have no intrinsic medical activity with this condition. It is this risk, along with other possible complications including the potential for substandard medical care in other respects from some chiropractors, that makes chiropractic unsatisfactory, even as a vaguely tolerable placebo treatment that the patient may opt to try out at their own expense and risk.
The so-called “shruggies” are also likely to be responsive to patient risk, even if they have a laid-back “good luck to them if they think it is helping” approach to patients’ use of CAM in general.
Remember, you yourself allow that patients may be helped by chiropractors. You say: Perhaps simply receiving hands on treatment from a perceived authority figure adamantly claiming a high rate of success resulted in less stress and fewer tics. Much of our own science is permissive of that likelihood but still being worked through. We nevertheless must weigh cost and risk against uncertain benefits.
It also takes a booklet to fully explain why we think that good reports of chiropractic for this condition are still consistent with it being a placebo, but only one or two sentences to advise people to weigh up the risks and to take certain precautions if they still wish to try it.
Welcome to SBM, Dr. Jones. I very much appreciated this article.
For readers who don’t follow the chiropractic literature, the Journal of Pediatric, Maternal & Family Health is part of Matthew McCoy’s chiropractic empire. McCoy evidently no longer treats patients; he makes his money by
*Teaching at Life University
*Expert witness testimony
*Selling malpractice insurance to chiropractors
*Selling practice-management and growth strategies to other chiropractors
*running McCoy Press, which also publishes the following journals:
Journal of Upper Cervical Chiropractic Research
Dialogues – The Journal of Chiropractic Philosophy, Principles & Practice
Annals of Vertebral Subluxation Research
As is not surprising, McCoy is also vehemently anti-vaccine:
McCoy distributed a PowerPoint presentation criticizing the flu vaccine, reading in part:
Writing in The Skeptical Inquirer, Sam Homula DC asked, Should Chiropractors Treat Children?. In that article Homula wrote
Chiropractors claiming to treat pediatric conditions such as ADHD, autism, Tourette’s, and even dyslexia are one of my bêtes noires.