Full-page ads promoting free dinner seminars addressing the topic of “Non-surgical, drug-free approach to relief from Peripheral [sic] Neuropathy [sic]” appeared last year on at least nine Sundays in the main news section of the print edition of The Los Angeles Times. The seminars were scheduled at various restaurants in Orange County, Los Angeles County, and Inland Empire.
The Los Angeles Times claims a Sunday circulation of 962,192 and a readership of two million for the Sunday main news section. The cost of full-page ads in the main section of Sundays varies, but I was given a quote of $32,500 by an advertising consultant for the paper.
The ads included on their upper left, in small print, the words “HEALTH TODAY” and on the same line—though perhaps less noticeably—at the far right of the page the word “ADVERTISEMENT.” In a much larger font was the headline:
Do You Suffer from One Of These Seven Symptoms Of This Often Misdiagnosed Problem?
It was followed by this subtitle:
Tens of Millions Suffer And Often Don’t Know Where to Turn
The ads indicated that discussion at the seminars would include:
- What REALLY causes Peripheral [sic] Neuropathy [sic]
- Three crippling effects of Neuropathy [sic]
- Dangers associated with medications
- The Straw Protocol, which utilizes proprietary treatment methods and provides outstanding results for people who suffer from Neuropathy
Today’s post is a reluctant challenge. I’m nominating my own alma mater, the University of Toronto, as the new pseudoscience leader among large universities – not just in Canada, but all of North America. If you can identify a large university promoting or embracing more scientifically questionable activities, I’ll happily buy you a coffee. Yes, it’s personal to me, as I have two degrees from U of T. But I’m more concerned about the precedent. If Canada’s largest university is making decisions that appear to lack a careful consideration of the scientific evidence, then what does that suggest about the scientific standards for universities in Canada? (more…)
The saga of chiropractic began in 1895 when D.D. Palmer, a magnetic healer, announced that “95 percent of all diseases are caused by displaced vertebrae, the remainder by luxations of other joints.” Palmer opened the first chiropractic school in Davenport, Iowa, offering a three-week course of study at the Palmer School and Cure, subsequently renamed the Palmer School of Chiropractic. The school was taken over by B.J. Palmer, the son of D.D. Palmer, in 1906. In 1910, the course of instruction was six months. Kansas and North Dakota were the first states to pass laws legalizing the practice of chiropractic (in 1913 and 1915). By 1921, the Palmer School of Chiropractic, requiring 18 months of study, had 2,000 students, reaching a peak enrollment of 3,600 in 1922. By 1923, 27 states had chiropractic licensing boards. Hundreds of chiropractic schools sprang up, some offering correspondence courses. There were no entrance requirements, anyone could become a chiropractor. H.L. Mencken wrote in the December 11th, 1924, issue of the Baltimore Evening Sun:
Today the backwoods swarm with chiropractors, and in most States they have been able to exert enough pressure on the rural politicians to get themselves licensed. Any lout with strong hands and arms is perfectly equipped to become a chiropractor. No education beyond the elements is necessary.1
Although Palmer’s subluxation theory was contrary to all known laws of anatomy and physiology, the theory was appealing to the general public. Medical science was in its infancy, struggling to find effective and safe remedies for disease and infection. There was no known cure for many common ailments, and many of the medicines used by physicians were ineffective or harmful. In the public marketplace, the door was wide open for snake oil salesmen, entrepreneurs, and opportunists who could mix a concoction or fabricate a new treatment guaranteed to work. With growing numbers of chiropractors treating disease and infection by adjusting the spine to relieve alleged pressure on spinal nerves, offering treatment claimed to be superior to medical care, members of the medical community felt an obligation to oppose what they viewed to be blatant, unbridled quackery.
An old Palmer illustration showing how a displaced vertebra could cause disease by pinching a spinal nerve.
Sometimes, it’s hard not to get the feeling that my fellow bloggers at Science-Based Medicine and I are trying to hold back the tide in terms the infiltration of pseudoscience and quackery into conventional medicine, a term I like to refer to as quackademic medicine. In most cases, this infiltration occurs under the rubric of “complementary and alternative medicine” (CAM), which these days is increasingly referred to as “integrative medicine,” the better to banish any impression of inferior status implied by the name “CAM” and replace it with the implication of a happy, harmonious “integration” of the “best of both worlds.” (As I like to point out, analogies to another “best of both worlds” are hard to resist.) Of course, as my good buddy Mark Crislip has put it, the passionate protestations of CAM advocates otherwise notwithstanding, integrating cow pie with apple pie doesn’t make the cow pie better. Rather, it makes the apple pie worse.
In any case, over the last three months, Steve Novella and I published a solid commentary in Trends in Molecular Medicine decrying the testing in randomized clinical trials of, in essence, magic, while I managed to score a commentary in Nature Reviews Cancer criticizing “integrative oncology.” Pretty good, right? What do I see this month in the Journal of the National Cancer Institute (or JNCI, as we like to call it)? An entire monograph devoted to a the topic, “The Role of Integrative Oncology for Cancer Survivorship”, touting integrative oncology, of course. And where did I find out about this monograph? I found out about it from Josephine Briggs, the director of the National Center for Complementary and Alternative Medicine (NCCAM) herself, on the NCCAM blog in a post entitled “The Evidence Base for Integrative Approaches to Cancer Care“, in which she touts her perspective piece in the JNCI issue entitled “Building the Evidence Base for Integrative Approaches to Care of Cancer Survivors.” In an introductory article, Jun J. Mao and Lorenzo Cohen of the Department of Family Medicine and Community Health, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania and the University of Texas M.D. Anderson Cancer Center, respectively, line up this monograph thusly:
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…)
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.
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.
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.
Too Much Texting?
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…)