Defending chiropractic?

The Great Chiropractic Debate rumbles on in the pages of the New Scientist.  This week Richard Brown, a Chiropractor and vice-president of the BCA, has a comment piece entitled, “Defending chiropractic”. 

It is worth looking at it as an exemplar of fallacious argument and claims about Chiropractic practise that do not stand scrutiny.  For instance, he uses a typical quack defence: critics claim that chiropractic lacks evidence, but they overlook, “the fact that many accepted medical interventions have little or no research evidence to support them.” 

This is just indulging in plain old tu quoque. It also obscures the fact that whilst many^* medical interventions may, “have little or no evidence to support them” the same can be said of nearly all^** chiropractic treatments.  The problem with this fallacy is that it allows the user to avoid engaging with criticism.  Brown is effectively saying until all conventional therapies are supported by research evidence, then don’t criticise my massively less well supported therapy. 

There is much that could be said about some of the other planks of his defence, but I’ll leave them to others.  I’d like to examine two of his main contentions^***. 

A few rogues?

Apparently, only, “a tiny minority retain [the] view” that “spinal misalignments are responsible for the majority of diseases”; whilst, “most are aware that such claims have long since been debunked.” 

This surprised me.  In a survey of GCC registered UK Chiropractors^**** Pollentier and Langworthy (2007) found that “Traditional chiropractic beliefs (chiropractic philosophy) were deemed important by 76% of the respondents and 63% considered subluxation to be central to chiropractic intervention.” (P<0.001) 

So actually, there is strong evidence that most UK Chiropractors don’t believe that traditional chiropractic beliefs have been debunked.  On the contrary, they think they are an, “important and integral part of chiropractic.”  Brown’s argument, most likely, seeks to invert reality. 

This helps explain my personal experience: I’ve looked in detail at the issue of chiropractic treatment of bedwetting (nocturnal enuresis) and looked at many Chiropractors’ websites.  It’s not hard to find members of Brown’s association (BCA) who haven’t heard that this view has been “debunked”. 

Here are a few specific examples.  Proud BCA members Walsall Chiropractic Health Clinic (cached URL) in their, “Chiropractic in 100 words or less” explains ill health in this way: 

Aches and pains are signs that your body isn’t working correctly. Your brain, spinal cord and all your nerves control how your body works.  Physical, chemical or emotional stresses produce a defensive posture.  Muscles contract, locking spinal joints that pinch or irritate nearby nerves.  Lack of nervous system integrity sets the stage for disease and ill health.   A thorough examination helps Chiropractors find these vertebral subluxations.  Applying a precise force to stuck spinal joints helps the body correct itself.  Health usually returns as repeated visits restore nervous system integrity.  That’s why chiropractic care has helped millions get well and stay well.

It’s not hard to find more examples of Chiropractors who follow the “debunked” view of disease causation.  BCA members SALVEO spinal healthcare clinics: (Cached URL) claim that, “A healthy spine is the key to total body fitness” (Cached URL) and then go on to talk about the need to correct subluxations: 

“Correcting subluxations opens up a whole new world of wellness and health care because the body is able to function as it was designed. Without any nerve blockages due to subluxations, the body can boost its immune system and much more effectively fight disease and illness. Relief from back pain, neck pain and headaches, which are the most common symptoms that bring people into a Chiropractor’s office, might come about from the adjustments, but there are no guarantees. However, living with subluxations is like trying to ride a bike with one hand, you are only half as effective as you would be if you had the full use of both hands. Allowing subluxations to exist in your body, even if they are not causing you pain, means you have a reduced nervous system function and a lower level of wellness and health.” 

These people clearly think that spinal misalignment is a general impediment to health.  well4ever Putney (Cached URL) have very similar views: 

“The philosophy of Chiropractic is that the body has an inborn ability to heal itself. Correcting subluxations by a Chiropractic adjustment allows the nervous system to work properly and heal the body naturally. Correction of the problem and maintaining good health is the goal of the Chiropractor. By restoring normal function to the neuro-musculoskeletal system Chiropractors can play a major part in relieving disorders, and any accompanying pain or discomfort, arising from accidents, stress, lack of exercise, poor posture, illness and the everyday wear and tear that happens to all of us.”

There are many more examples.  Clearly there are members of the BCA who sell their wares on the basis of “debunked” notions.  This agrees with the available research data.  It’s Brown who appears to be out of step with reality, invoking something like a ‘no true Chiropractor’ fallacy. 

Manipulating the argument?

He also chides critics who “make the mistake of equating chiropractic with spinal manipulation, especially with regard to treating non-spinal conditions such as asthma. This demonstrates a lack of understanding of the fact that Chiropractors utilise a range of treatments, including postural advice, reassurance and exercise.” 

Well, I am (in a small way) one of those critics.  But when I started looking at chiropractic claims around nocturnal enuresis (bedwetting) I didn’t equate chiropractic with spinal manipulation: the Chiropractors did! 

Let’s be clear: manipulation is the most commonly used chiropractic intervention.  A survey by the General Chiropractic Council (2004) found that 90% of UK Chiropractors use or advise manipulation with between 81-100% of their patients (the big red bar on the chart).  Yes, they do other^† things as well, but spinal manipulation evidently dominates both advice and practise.

 

When it comes to bedwetting, for example, some of the chiropractic websites I critiqued contained claims that bedwetting can be caused by misalignment.  Here’s a typical example from Essence of Life, Wellness Care (Cached URL): 

Bladder Physiology

Two key muscles control the emptying of the bladder. Their technical names are the detrusor and trigone muscles. Nerves that exit the spinal column in the lower back and sacrum control these muscles. 

During the early years of life, the sacrum has five separate segments. Later, they fuse together to form the triangular-shaped bone that adults have at the base of the spine. If these segments misalign (falling, learning to walk, ride a bike, etc.) they can compromise nerves that are responsible for bladder function. 

We look for these sometimes subtle misalignments during our examination. When these misalignments are reduced with safe and natural chiropractic adjustments, nervous system control and regulation of the bladder can be restored.

 According to this the Chiropractors look for “subtle misalignments” of the sacrum and reduce them by adjustment: classic chiropractic.  This example is from Canada, but the same claims are made by some UK Chiropractors. 

Like Isis, before they took their webpage down (Cached URL).  There’s also the The Ideal Spine Centre of Canterbury (Cached URL), whose list of case studies only mentions treatment by spinal adjustment.  Proud BCA members Walsall Chiropractic Health Clinic (Cached URL) offer the same explanation of their treatment of bedwetting. 

Even a representative of the Stanmore Chiropractic Clinic (Cached URL) who insisted that their claims were not based on Chiropractic manipulation, but Chiropractors who using other interventions, said he had cured an episode of bedwetting by giving a child, “an adjustment to her lumbar spine.” 

Three research articles are often cited as evidence that Chiropractic can treat bedwetting in children. (Reed et al, 1994; Leboeuf et al 1991; Blomerth, 1994) 

Blomerth (1994) is a case study where an eight year-old boy had his, “lumbar spine […] manipulated”.  Reed et al (1991) treated bedwetting with, “High velocity, short lever adjustments of the spine consistent with the Palmer Package Techniques.”  Leboeuf et al (1991) reported a trial where, “One hundred and seventy-one enuretic children, aged 4 to 15, were treated with chiropractic adjustments.” 

Given the strong focus by some Chiropractors, in both clinical practise and research, on spinal adjustments it’s not surprising to find critics looking at both the safety and efficacy of this kind of intervention. 

If at least some Chiropractors didn’t make these claims, critics wouldn’t criticise them!  Perhaps the BCA should crack down on these rogue Chiropractors rather than attacking those who helpfully point out their “debunked” practises.   It seems to me that the BCA’s time would be better spent educating and regulating their members than dragging critics through the courts or making fallacious defences in the media. 

Disclaimer

This article does not offer medical advice.  If you need that please consult a medical doctor.

Notes

* Estimates for the number of medical interventions unsupported by evidence from trials ranges from 3% to 58%. See http://www.shef.ac.uk/scharr/ir/percent.html .  A distinction also needs to be drawn between the number of available medical technologies that are unsupported by evidence and the number of medical interventions on patients that use them: these are not the same thing.  It is perfectly plausible to suggest that the best attested treatments may be used more frequently.  Also, an episode of care may involve the use of multiple medical technologies. Anyway, Steven Novella has summarised the evidence on this point better than I could ever hope to.

**There is some evidence that chiropractic has an effect on back pain.  However, Ernst and Harkness (2001), after reviewing sham-controlled trials of chiropractic, came to the view that, “The most rigorous of these studies suggest that spinal manipulation is not associated with clinically-relevant specific therapeutic effects.” 

***Given the litigious nature of the BCA I think that it’s important for me to make clear that I am neither stating nor implying any dishonesty here.  I am sure that this gentleman is sincerely deluded. 

****263 replied from a randomly selected sample of 490.

†Aside from those interventions named in the chart Chiropractors responding the survey named “other” techniques they used or advised: Vitamins, Cryotherapy, Massage, Rehabilitation, Orthotic therapy, Stretches, Thermotherapy, Activator, DROP, Mobilisation, Acupuncture, Herbal/homeopathy, Soft tissue work, TPT, Thumper, Cranio-sacral therapy, Dry needling, Glucosamine sulphate, Analgesia, Ice, EMS Galvanic current modality, Meditation/relaxation where physical/mental tension is underlying factor, Strapping, Life coaching and NLP, SOT, Blocking, Fibromyalgia mapping, Pathomechanics. 

References

Consulting the Profession: A Survey of UK Chiropractors, 2004.  General Chiropractic Council.  44 Wicklow Street London WC1X 9HL.  page 39.  Available from: http://www.gcc-uk.org/files/link_file/ConsultTheProfession.pdf.

Blomerth PR. Functional nocturnal enuresis. Journal Of Manipulative And Physiological Therapeutics. 1994 June;17(5):335–338. Available from: http://view.ncbi.nlm.nih.gov/pubmed/7930968. 

Ernst E, Harkness E. Spinal Manipulation A Systematic Review of Sham-Controlled, Double-Blind, Randomized Clinical Trials. Journal of Pain and Symptom Management. 2001 October;22(4):879–889. Available from: http://dx.doi.org/10.1016/S0885-3924(01)00337-2. 

Leboeuf C, Brown P, Herman A, Leembruggen K, Walton D, Crisp TC. Chiropractic care of children with nocturnal enuresis: a prospective outcome study. Journal Of Manipulative And Physiological Therapeutics. 1991 February;14(2):110–115. Available from: http://view.ncbi.nlm.nih.gov/pubmed/2019820. 

Pollentier A, Langworthy J. The scope of chiropractic practice: A survey of Chiropractors in the UK. Clinical Chiropractic. 2007 September;10(3):147–155. Available from: http://dx.doi.org/10.1016/j.clch.2007.02.001. 

Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. Journal Of Manipulative And Physiological Therapeutics. 1994;17(9):596–600. Available from: http://view.ncbi.nlm.nih.gov/pubmed/7884329.

Edits

14^th June 2009. Added link to Steven Novella’s excellent post “How Much Modern Medicine is Evidence-Based“.

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