Case reports are perhaps the weakest form of medical evidence. They are essentially well-documented anecdotes. They do serve a useful purpose, however: they can illuminate possible correlations, the natural course of illness and treatment, and serve as cautionary tales regarding possible mistakes, risks and complications. I say “possible” because they are useful mainly for generating hypotheses and not testing or confirming hypotheses.
Dramatic case reports, however, with objective outcomes, like death, can be very useful by themselves in pointing out a potential risk that should be avoided. For example, case reports of objective and severe adverse outcomes are often used as sufficient evidence for pulling approved drugs off the market, or at least adding black box warnings.
The chiropractic community, it seems, does not respond in a similar way to dramatic adverse events that suggest possible risk from chiropractic manipulation. A recent and unfortunate case raises once again the specter of stroke following chiropractic neck manipulation. Jeremy Youngblood was 30 years old, completely healthy, and saw his chiropractic for some neck pain. According to news reports, Jeremy suffered a stroke in his chiropractor’s office while being treated with neck manipulation for the neck pain. According to reports the chiropractor did not call 911, but instead called Jeremy’s father who had to come and pick him up and then bring him to the ER. Jeremy suffered from a major stroke and later died.
Unsafe playtime activity?
During my first clinical rotation in medical school, I found myself at the pediatric nurse station one afternoon waiting for a patient to arrive from the emergency department. An adorable older infant was there sitting in a bouncy chair, smiling and drooling as babies tend to do, and looking rather well for an inpatient. The nurse watching her explained that she had come a long way since first being transported to the facility by ambulance after being admittedly shaken (and almost certainly also beaten) by her mother’s new boyfriend one evening when she wouldn’t stop crying.
Now, cortically blind and facing a lifetime of disability, the child was awaiting placement by social services. I had experienced my first exposure to child abuse, a scourge of pediatric medicine that I hadn’t thought of at that point despite having decided on a career in pediatrics well before being accepted into medical school. I’ve since had many more opportunities to care for abused children, some of which involved considerably more visually disturbing findings and a couple that resulted in a child’s death. But I will never forget her and the feeling of utter revulsion I felt that day.
Child abuse is common and it comes in many forms that can involve physical abuse as well as neglect. Children under the age of 4 years are the most frequently affected, but children under a year tend to suffer the most severe manifestations. Head injuries make up the bulk of physical abuse in this age group, and they are often fatal. Roughly 40% of child abuse-related deaths occur in the first year of life and there is frequently both a history of abuse prior to the fatal event as well as missed opportunities for medical professionals to have intervened.
The head injuries that children suffer at the hands of abusive caregivers, if not fatal, are frequently still devastating. It is not uncommon for these children to suffer permanent neurologic injury which can include persistently altered mental status, cognitive impairment, cerebral palsy, blindness and recurring seizures. In addition to the child’s injuries, the psychosocial impact on the family can also be quite severe. I’ve seen families torn apart because of guilt and anger. (more…)
A correspondent asked me to look into Airrosti because her employer’s insurance company had started covering it, and she was skeptical. She had tried to look up its effectiveness and safety record on the Internet and hadn’t found much. The information on their website didn’t tell me what I wanted to know, so I did a little digging. Like my correspondent, I am skeptical of their claims.
The name Airrosti stands for Applied Integration for the Rapid Recovery of Soft Tissue Injuries. One writer jokingly renamed it Owwwrosti because his first treatment was so excruciatingly painful. They say, “Wherever you hurt, we can help.” They claim to have special knowledge about the underlying cause of soft tissue injuries and pain problems and how to treat them; they claim they can resolve the problems of most of their patients in only 3 visits. The providers are chiropractors who have been trained by the company in their special methods…whatever they are. Their website is vague about what their modality actually consists of. I was able to piece together some of what they are doing from discussion groups and patient reports. There are plenty of testimonials, and the treatments are described as painful but effective. They offer quality 1-on-1 care for an entire hour, with detailed examination, hands-on soft tissue therapy, foam rolling, instruction in exercise and rehabilitation, and Kinesio Taping. Their main competitors are said to be the Graston technique and Gua Sha technique, and their treatment appears to be centered on myofascial release (MFR). In other words, it’s a mixed bag.
The Airrosti website, prominently featuring several bold claims. Click screenshot to see full size.
I am often asked, “What do chiropractors do?” That’s not an easy question to answer. The answer is usually expected to be, “They treat back trouble.” But as alternative medicine practitioners, chiropractors do a lot of things, and they treat a variety of ailments, based largely on a scientifically-invalid vertebral subluxation theory which proposes that nerve interference resulting from a misaligned vertebra or a dysfunctional spinal segment can affect general health.
As a co-host of the Chirobase web site, I frequently answer questions about chiropractic, some of which are published in a section titled “Consumer Strategy/Consumer Protection.” In this post, I’ll focus on these:
- Are Subluxations Causing My Health Problems?
- Is a Misaligned Atlas Causing My Back Pain?
- What is that “Thumper” My Chiropractor Uses on My Back?
- How Does a Chiropractor Locate Subluxations?
- Should I Let a Chiropractor Adjust My Baby?
- Why Is Every Chiropractor’s Treatment Different?
- Can Neck Manipulation Cause a Stroke?
- Should I Go to a Chiropractic College?
- Are There Any Good Chiropractors?
- Is It Possible to Reform the Chiropractic Profession?
By far, most of the questions I receive express concern about questionable methods and advice offered in the offices of chiropractors. Many questions are generated by the suspicions of patients who initially visited a chiropractor for treatment of back pain and who were then offered spinal adjustments as a treatment for health problems unrelated to the spine. Patients are often concerned about the expense involved in such care, usually extended over a long period of time, followed by “maintenance care” to correct or prevent “vertebral subluxations” after symptoms have resolved. I generally advise patients to refuse chiropractic care for anything other than a musculoskeletal problem, to seek treatment only when symptoms are present, never pay for treatment in advance, and to discontinue treatment and see an orthopedic specialist if symptoms worsen after a few days or have not subsided after a week or so.
Medical school clinical training
A new law in Missouri will allow medical school graduates who have not completed a residency to practice in underserved areas. They will be able to call themselves “doctor” but will be licensed as “assistant physicians” with significant limitations on their practice. (The first link is to Senate Bill 716, the bill that was passed and signed by the governor. It covers several subjects, so you will need to skip to page 8 to find the portion we’re discussing.)
The Missouri State Medical Association supports the new law and helped draft the original bill. It is designed to address the state’s critical need for primary care physicians – 40% of Missouri’s population lives in underserved areas but only 25% of the state’s physicians practice there, according to a 2009 survey. Underserved areas have high poverty rates, high infant mortality, large senior populations and fewer primary care physicians per capita. (more…)
Chiropractor “adjusting” an infant.
Who would you invite to speak at your conference if you wanted to show the world you are firmly in the anti-vaccination camp? Barbara Loe Fisher, head of the National Vaccine (Mis) Information Center (NVIC)? How about Andrew Wakefield, the thoroughly disgraced British physician who, having been stripped of his medical license, continues his despicable anti-vaccination campaign? How about both?
The International Chiropractic Pediatric Association sprang for both. Fisher and Wakefield will be keynote speakers at the ICPA’s upcoming conference, “Celebrating the Shift to Conscious Choice.” The conference offers the mutually exclusive opportunities of participating “in the discussion of the latest evidence-based holistic research” while at the same time exploring “the vitalistic perspectives of conception, pregnancy and birth through family wellness.” I hate to be the bearer of bad news, but you can embrace evidence-based research or you can embrace vitalism, but not both at the same time. There will also be an opportunity for the requisite bashing of “conventional” medicine.
It’s hard to decide who’s slumming whom here. On the one hand, the ICPA is a small group (3,000 members). They are straight, subluxation-based chiropractors and they don’t need convincing that vaccination is “bad.” Fisher and Wakefield will be preaching to the choir. Wakefield, with his medical education and training, is most certainly aware that their subluxation-based “theory” is nonsense and they are incompetent to diagnose and treat pediatric patients. And this is a far cry from Fisher’s former gigs as an advisor to the government.
Old bad studies: Fantastical autopsy results
I found the following quote at “Chiropractic care can treat more than just bad backs” (FYI. Chiropractic can’t):
Luse references a study published in The Medical Times authored by Dr. Henry Windsor [sic], M.D. that showcases the correlation of spinal health to overall wellness. Windsor dissected 75 human cadavers to investigate their causes of death. The study showed that 138 of the 139 diseases of the internal organs that were present were in connection to the misalignments of the vertebrae.
But I was intrigued. So I went to the video tape. Well, the PDF.
It is an interesting read by a physician who was looking for an association between curvature of the spine and visceral pathology.
He had 50 corpses, age unknown, that he dissected, looked at the spine for curvature and then looked for pathology in organs in the same distribution of sympathetic nervous system as the level of the spine curvature.
The Federal Funding Accountability and Transparency Act (FFATA) was signed on September 26, 2006. The intent is to empower every American with the ability to hold the government accountable for each spending decision. The end result is to reduce wasteful spending in the government. The FFATA legislation requires information on federal awards (federal financial assistance and expenditures) be made available to the public via a single, searchable website, which is www.USASpending.gov.
And what subject is more deserving of being held accountable by the American people than complementary/alternative/integrative medicine? After all, in what other area of government spending does scientific implausibility – indeed, even scientific impossibility – offer no impediment to spending millions of taxpayer dollars in research funds? We’ve complained about the NCCAM’s wasteful spending on pseudomedicine here on SBM several times: here, here, here and here, among others. As you shall see, the problem doesn’t stop at that particular $2.5 billion. (more…)
Extreme rotation of the atlas on the axis (at the atlantoaxial joint) stretches the vertebral artery.
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…)
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…)