4 questions | Applied Sciences homework help

1. Bausell RB. Snake Oil Science: The Truth about Complementary and Alternative Medicine. New York, 2007, Oxford University Press.

A Close look At ChiroprACtiC Chiropractic is the greatest tribute to the efficacy of technically applied public rela- tions the world has ever known. These people have been delivering a package since 1895, the sale of which depends entirely on the wrapping. The contents are not there. Joseph A. sAbAtier, Jr., M.D.1 Chapter Nine Chiropractors seldom react constructively to criticism. When specific wrongdoings are exposed, they typically claim that the criticized practices are not representative or that the critic is biased. . . . or they attack the medical profession. stephen bArrett, M.D.3 Every action the chiropractor does should have the one purpose to slowly but surely direct the patient’s attention to the fact that chiropractic is capable of correcting the ‘condition’ that is ‘causing’ the patient’s ill health. siD e. WilliAMs, D.C.2 “As you can see, for nearly all chiropractors there are equal and opposite chiropractors.” Part Two Health-Care Approaches164

• Chiropractic’s “subluxation” concept lacks anatomic and clinical validity. The “nerve interference” that chiropractors postulate has not been scientifically demonstrated. Reliance on these concepts places patients at significant risk.
• Chiropractic has not defined its scope.
• Most methods that chiropractors use are unproven and lack a scientifically plausible rationale.
• Chiropractic “maintenance” care has not been substantiated or even tested.
• Research studies on spinal manipulation may not reflect how patients are managed in chiropractic offices.
• Chiropractic’s recognition as a profession is the result of political efforts rather than scientific achievement.

keep these points in Mind As You studY this ChApter Key Concepts Chiropractic is a wide array of practices with em- phasis on spinal “adjustments.” Chiropractic the- ory claims that (a) spinal misalignments, which chiropractors refer to as subluxations, impair health by interfering with the integrity of the nervous system and (b) spinal adjustments restore the integrity of the nervous system, enable the body’s inherent recuperative power to restore health, and thereby prevent or remedy a wide range of health problems. Chiropractors may help people with certain musculoskeletal ailments, but the problems described in this chapter are widespread and, in some cases, integral to chiropractic philosophy and practice. Thus, even though some of the source materials and opinions cited in this chapter originated long ago, they remain relevant to the current marketplace. historiCAl perspeCtive Various forms of spinal manipulation have been noted throughout recorded history.4 The “discovery” of chiro- practic was announced in 1895 by Daniel David (“D.D.”) Palmer, a grocer, spiritualist, and “magnetic healer” who practiced in Davenport, Iowa. Palmer believed that he had restored the hearing of a deaf janitor by “adjusting” a hump on his spine. Even though the nerve that con- trols hearing is inside the skull and does not traverse the spine, Palmer concluded that the basic cause of disease was nerve interference caused by displaced vertebrae.5 He originally declared that such misalignments cause abnormal tension (“tone”) in the nearby nerves and that disturbed nerve tone causes 95% of all diseases. Later he elaborated a vitalistic doctrine which held that (a) “In- nate Intelligence,” or “nerve energy,” flows throughout the nervous system and controls every bodily activity not under voluntary control; (b) even slight spinal mis- alignments hinder this flow, causing people to become ill; and (c) manual manipulation (“adjustment”) of the spine is the remedy. He rejected the germ theory and had an aversion to drugs, surgery, and medical diagnosis. Palmer referred to spinal “misalignments” as “luxa- tions.” A few years later a disciple began calling them “subluxations,” a term that became central to chiroprac- tic theory and is still used today. The word “chiropractic” was derived from the Greek words cheir (hand) and praktikos (practice). Soon after his “discovery,” Palmer opened a school to teach his methods to others. The basic entrance re- quirement, as it was in many medical schools around the turn of the century, was the ability to pay tuition.6 One of the first students was Palmer’s son, Bartlett Joshua (“B.J.”), who became chiropractic’s developer. In 1906 D.D. Palmer was convicted of practicing medicine with- out a license and spent 23 days in jail. After his release, B.J. denied him access to the school grounds and wound up purchasing D.D.’s interest in the Palmer School of Chiropractic. At that time about 100 chiropractors were practicing in the United States. Today there are about 65,000. Between 1913 and 1933, 40 states passed laws to license chiropractors; the remaining states gradually fol- lowed suit, with Louisiana being the last in 1974. Chiro- practors have lobbied successfully in most states for laws that force insurance companies to pay for some of their services. In 1972 Congress legislated coverage under Medicare for “treatment by means of manual manipula- tion of the spine to correct a subluxation demonstrated by x-rays to exist.” The International Chiropractors Association states that passage of this bill was spurred by more than 10 million letters received by members of Congress.7 The x-ray requirement was eliminated in 2000. U.S. Census Bureau data indicate that the total re- ported income for chiropractic offices and clinics rose from $6.57 billion in 1997 to $10.06 billion in 2007s.8 Chapter Nine A Close Look at Chiropractic 165 ChiroprACtiC philosophY Chiropractic’s uniqueness is not in its use of manipu- lation but in its theoretical basis for doing so. Jarvis9 describes chiropractic as “a conglomeration of factions in conflict, bound together only by opposition to outside critics.” Philosophy and treatment methods vary greatly from one chiropractor to another, but there are two main types: “straights” and “mixers.” Straights tend to regard “subluxations” as the primary cause of ill health and spinal “adjustments” as the remedy. Some routinely manipulate the neck for complaints in all parts of the body. Many straights disparage medical diagnosis, some even claiming that their sole responsibility is to examine and adjust the spine. Mixers, who are more numerous, acknowledge that germs, hormones, and other factors play a role in disease; however, they tend to regard mechanical disturbances of the nervous system as the underlying cause (through lowered resistance). In ad- dition to spinal manipulation, they may use measures that are standard in physical therapy as well as a wide spectrum of questionable nonmedical approaches. Mix- ers are more likely to diagnose medical conditions in addition to spinal abnormalities and to refer patients to medical practitioners for treatment. Figure 9-1 illustrates chiropractic’s tendency to overclaim. Both straights and mixers may claim that the nervous system is the master of all body functions, regulating everything from major organs to intricate cellular activi- ties. This statement is untrue. However, charts and other materials relating the spine to the full range of illnesses can still be found in many chiropractic offices and online (Figure 9-2). Thus, even though nearly all chiropractors manipulate the spine as their primary treatment method, their rationales and techniques vary considerably. Many chiropractors detect “subluxations” in healthy individuals. A small percentage of chiropractors reject the subluxation concept and limit their practice to short- term treatment of musculoskeletal conditions using evidence-based procedures similar to those of physical therapists and osteopaths. Chiropractors also differ greatly about how treatment should be done. More than 200 “technique systems” have been advocated. In 1996, Thomas F. Bergmann, D.C., who edited the journal Chiropractic Technique, stated: A challenge for the future is to classify and place all chiroprac- tic techniques into a framework that allows determination as to whether any of them has a basis in fact. . . . Studies designed to compare effectiveness . . . have not been done. . . . No technique system has been demonstrated to be more or less effective than any other for any condition.10 In 2011, Bergmann acknowledged that chiropractic research had not yet solved any these problems.11 Figure 9-2. Chart from a chiropractic brochure. Many chiropractors use such charts to reinforce the idea that spinal problems are a major cause of disease. This one claims that “spinal misalignments” can cause more than 100 health problems, including allergies, amnesia, crossed eyes, deafness, gallbladder conditions, hernias, jaundice, and pneumonia. Other charts showing how nerves connect from the spine to the body’s organs are used to persuade patients that regular spinal care is essential for good health. Figure 9-1. Portion of a chiropractic newspaper ad from the 1970s that illustrates chiropractic’s tendency to overclaim. Part Two Health-Care Approaches166 The two largest chiropractic organizations are the American Chiropractic Association (ACA, mixers) and the International Chiropractors Association (ICA, straights). Judging from their income tax returns and dues structures, the ACA appears to have about 8000 members (not including students) and the ICA has about 2500. The two groups have considered merging, but they are unable to agree on the definition and scope of chiropractic. The World Chiropractic Alliance, which has about 900 members, states that its mission is “promoting a subluxation-free world.” A small network of faculty members at some of the chiropractic colleges is attempting to place chiropractic on a scientific basis by determining which practices are valid and which are not. In 1995, Magner12 noted that negative research findings appeared to have little effect on what most chiropractors do. That is still true today. The Elusive “Subluxation” Medical doctors and chiropractors use the word “sublux- ation” differently. The medical meaning is incomplete or partial dislocation—a condition, visible on x-ray films, in which the bony surfaces of a joint no longer face each other exactly but remain partially aligned. Most partial dislocations occur in areas other than the spine and are the result of injury. Spondylolisthesis, a partial dislocation of a spinal bone, usually is congenital and causes no symptoms. Because the ligaments connecting the spinal bones are quite strong, vertebral dislocations rarely occur after birth and are unlikely without severe injury that would require surgical treatment, not chiro- practic treatment. Chiropractors disagree on how their “subluxations” should be defined. Some describe them as “bones out of place” and/or “pinched nerves,” some speak of “fixations” and/or loss of joint mobility, some occupy a middle ground that includes any or all of these ideas, and a few renounce chiropractic’s subluxation concepts completely. Figure 9-3 shows a children’s storybook used to promote the notion that correcting subluxations promotes general health. Figure 9-4 shows a poster that has been used for more than 20 years to suggest that chiropractic care is necessary. Chiropractors also disagree on whether their “sub- luxations” are visible on x-ray films. Those who claim that “nerve interference” results in too much or not enough “nerve energy” have never specified how this could be measured by scientific instruments. Chiropractors also differ among themselves about whether specific patients have subluxations and what to do about them. Several investigations in which many chiropractors have examined the same patient have found that the diagnoses and proposed treatments differed greatly from one practitioner to another. The Personal Glimpse Box on the next page includes the results of five such investigations. Some physical therapists, athletic trainers, osteo- pathic physicians, and medical doctors use manipulative Figure 9-3. Chiropractic story- book. After a chiropractor told a little girl that she had a sub- luxation, she searched in vain under her bed and in her toybox to find it. She finally learned its location when the chiropractor said it was a bone in her neck that was “not lined up with the other ones.” The chiropractor explained: “Subluxations make your body sick. Each time I push on your back, the bones are adjusted closer to their normal position. This opens up the pathways, so that your brain may talk properly with your body. As your subluxations are corrected, you become healthier.” The booklet was marketed by a practice-building firm that promoted “chiropractic pediatrics.” Figure 9-4. Poster for chiropractic offices. A distributor calls it “the most powerful single visual aid available.” Chapter Nine A Close Look at Chiropractic 167 s Personal Glimpse pinched nerve in the boy’s neck. Another said his left leg was shorter than his right. Another said his right leg was shorter than his left. Another diagnosed zinc deficiency. Another chi- ropractor blamed the boy’s ear problems on “food sensitivi- ties” and advised avoiding corn, cow’s milk, and white flour. Another gave similar dietary advice but said that the main diagnosis was a “subluxation” in the top vertebra. Another said the boy didn’t have an ear problem but had scoliosis—a diagnosis disputed by a pediatrician and a radiologist who reviewed this chiropractor’s findings. In 2001, a healthy 11-year-old girl was taken by her uncle (a reporter) to five chiropractors in Toronto, Canada, for a checkup. The chiropractors were told the child was gener- ally in good health but suffered from a few earaches, some mild headaches, and a few signs of allergy symptoms. The chiropractors were also told that the girl’s mother was worried about the possibility of asthma and had heard from neighbors that chiropractic care could be beneficial for children. Four of the chiropractors found different subluxations and said that the girl needed chiropractic adjustments to get healthy. The methods they used to locate the alleged subluxations included spinal palpation, thermographic scans (looking for heat differences), and surface electromyography (SEMG), which merely measures muscle electrical activity. Among other things, the chiropractors said the child had one shoulder lower than the other, one leg longer than the other, one hip higher than the other, one ear lower than the other, something called “anterior head carriage,” scoliosis, early osteoarthritis, and numerous subluxations, all of which could cause earaches, headaches, allergies, asthma, arthritis, learning problems, and more serious problems later in life, including digestive and reproductive problems. In 2004 a team of high school students contacted chiro- practic offices in metropolitan Portland, Oregon, and found evidence of unscientific practice in every one. Following a script, they posed as a prospective patient and telephoned 42 local offices. All questions were answered by a member of the chiropractor’s office staff, who sometimes consulted with the chiropractor. The students reported that all routinely or usually took x-rays during the first visit, 40 said they treated “subluxations,” 41 recommended “maintenance” adjust- ments, 38 offered craniosacral therapy, 37 recommended treatment for newborn infants, 29 treated newborns, and at least 28 did not recommend routine vaccination for children. Undercover Investigations of Chiropractors13 In 1989 Dr. William M. London visited 23 chiropractors in Ohio and Florida who had advertised free consultations or examinations. Each one espoused subluxation theory either during the consultation or in waiting room literature, and all but two recommended periodic preventive maintenance. Seventeen performed examinations. Of these, three identi- fied subluxations (at differing locations), three said his left leg was shorter than his right leg, and two said his right leg was shorter than his left. Seven recommended treatment, and one treated him with a motorized roller device before examining him. In 1994 ABC’s “20/20” reported on visits to 17 chiro- practors who had made it known through advertising or other means that they treated children. In one segment, an infant named Blake was taken by his mother to 9 chiropractors in the New York metropolitan area, accompanied by a “friend” who was carrying a hidden camera. Blake had experienced recurring ear infections, a problem that a pediatrician said could be managed with antibiotics and would eventually be outgrown. Every chiropractor found a problem, and all said they could help and recommended care ranging from several weeks to a lifetime. The first found “a misalignment between the second and third bones in his neck.” The second said it was “on the right side of his neck between the first and second bones.” The third, using muscle-testing, found “weakness in the adrenal glands.” The fourth said there was a subluxation because one of Blake’s legs was shorter than the other. The fifth claimed he could diagnose the boy’s problem by pulling on his mother’s arm while she touched the boy on the shoulder. The sixth chiropractor did a similar test by pulling on the mother’s legs while Blake lay on top of her back. After diagnosing “jamming of the occiput (the back bone of the skull),” the chiropractor said he corrected it by “lifting” Blake’s occiput with his thumbs. He also said (a) Blake needed work on his immune system, (b) a learn- ing disorder might be a problem, (c) both mother and son had “eyes that don’t team too well,” and (d) the cameraman, whom the chiropractor incorrectly assumed was the boy’s father, had the same eye problem. The same program also reported on visits to eight Wis- consin chiropractors by a 5-year-old boy with chronic ear infections so severe that medical doctors wanted to insert tubes in his ears to drain them. All eight chiropractors found problems, but not usually the same ones. One diagnosed a techniques. However, their intent is never to correct subluxations; it is to relieve pain and secondary muscle spasm by restoring the mobility of joints that have a mechanical malfunction. The notion that nerve interference is a major cause of disease clashes with established anatomic facts. During the early 1970s Dr. Edmund Crelin, a prominent anato- mist at Yale University, subjected subluxation theory to an actual test.14 After collecting the spines of six people who had died a few hours earlier, he twisted them with instruments and observed the spaces between the verte- brae through which the spinal nerves passed. No nerve Part Two Health-Care Approaches168 compression occurred, regardless of the force applied. In a later memorandum he commented further: Only 24 of the 43 pairs of nerves that pass from the brain and spinal cord to various parts of the body could ever be impinged upon in the [vertebral openings] by the excessive displacement of vertebrae. Why these 24 pairs should be causing disease, exclusive of all the others, defies a rational explanation. . . . Complete severance of spinal nerves to the heart, glands (salivary, thyroid, liver, pancreas, etc.) and smooth muscles of the lungs, stomach, intestines, etc., has only transient effects. The gland cells and smooth and cardiac muscles not only survive, but function normally. They surely do not become diseased.15 Despite the unscientific nature of the subluxation concept, a cross-sectional survey16 of North American chiropractors conducted in 2002 found that (a) 88.1% thought that the term vertebral subluxation should be retained, (b) 89.8% thought that spinal adjustment should not be limited to treating musculoskeletal conditions, and (c) 62.1% rated the subluxation as a significant contributing factor in visceral conditions (diseases of the internal organs), and (d) 76.5% taught patients about a relationship between subluxations and visceral health. Mainstream chiropractic organizations are also strongly tied to the subluxation concept. In 2000, the ACA House of Delegates reaffirmed its core principle of subluxation by passing this resolution: The ACA will strive to reiterate this principle and further state that the core treatment of chiropractic is manual manipulation/ adjustment of the articulations, both spinal and extra-spinal, to reduce subluxations, when called upon in relation to Federal legislative efforts, in addition to full scope of practice as al- lowed by state law. References to subluxation and chiropractic adjustments/manipulation should be made in ACA releases, whenever possible. In 1996, in an attempt to unify the profession, the Association of Chiropractic Colleges (ACC)17 adopted a subluxation-based “chiropractic paradigm” statement that contains this definition: A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed and managed through the use of chiropractic procedures based on the best available rational and empirical evidence. In 2005, the World Federation of Chiropractic, an association of chiropractic organizations in 85 countries, adopted an “identity statement” based on a survey in which thousands of chiropractors were asked how the public should perceive them. The survey found that 65% of respondents said that the phrase “management of vertebral subluxation and its impact on general health” fits chiropractic “perfectly” or almost perfectly.18 Subluxation theory is not only entrenched in the practices of chiropractors; it is also embodied in all 50 of the state laws that govern chiropractic regulation. Twenty-states authorize chiropractors to treat sublux- ations, 25 authorize them to treat purported vertebral malpositions that interfere with nerve flow (or similar wording), and five authorize the use of whatever is taught at chiropractic colleges.19 As a result, all states permit chiropractors to treat all or most diseases by adjusting subluxations to improve nerve flow. ChiroprACtiC eduCAtion In 1973 the U.S. Office of Education approved the Council on Chiropractic Education (CCE) to accredit chiropractic schools. In 2007, the requirements for ad- mission to a CCE-accredited school included 90 credit hours (about 3 years) of prechiropractic college educa- tion with at least a 2.5 (out of 4.0) grade-point average.20 To receive the doctor of chiropractic (D.C.) degree, students must complete at least 4200 hours of study over a 4-year period. Courses include anatomy, biochemistry, microbiology, pathology, public health, diagnosis and x- ray examination, related health sciences, and chiropractic principles and practice. Seventeen chiropractic programs in the United States have CCE accreditation. In 1968 a comprehensive study by the U.S. Depart- ment of Health, Education, and Welfare concluded that chiropractic education did not prepare its practitioners to make an adequate diagnosis and provide appropri- ate treatment.21 Chiropractic colleges have improved considerably since that time. However, all still discuss subluxations in their philosophy courses, some consider subluxations to be real entities, and a few still encour- age students to treat “subluxations” rather than diseases or “conditions.”22 The ACC paradigm statement says, “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.”17 The statement was signed by all of the U.S. chiropractic college presidents in 1996 and is still considered current. In 2011 Mirtz and Perle23 reported that all but three of the chiropractic colleges in the United States and Canada mentioned “subluxation” in their catalogs and that the average number of course descriptions using the term ranged from 1 to 24, with an average of 5.2. Chiropractic colleges do not provide the depth of diagnostic and therapeutic training that physicians Chapter Nine A Close Look at Chiropractic 169 receive. Whereas most medical school faculties are large and contain experts in every aspect of medical practice, chiropractic colleges have few or no physicians on their faculty. Whereas the patients studied by medical students encompass the full range of disease, the vast majority seen by chiropractic students seek help for musculoskel- etal problems. Although many of their courses are based on standard medical textbooks, chiropractic students lack much of the experience needed to make the information meaningful.24 Some chiropractors try to downplay their lack of clinical experience by claiming that they spend more hours than medical students do in one subject or an- other. These claims are misleading because nearly all medical doctors undergo at least 3 additional years of full-time clinical training before going into practice, whereas nearly all chiropractors enter practice directly after graduation from their 4-year program. Moreover, in chiropractic colleges, instruction in many subjects, including pediatrics, obstetrics, and gynecology, is confined to the classroom, with little or no actual patient contact and no experience with hospitalized patients.24 A team of research-oriented chiropractors recently stated: There is a tremendous void in how chiropractic graduates develop any meaningful hands-on clinical experience with real patients in real life situations. The chiropractic profession has an obligation to actively divorce itself from metaphysi- cal explanations of health and disease as well as to actively regulate itself in refusing to tolerate fraud, abuse and quackery, which are more rampant in chiropractic than in other health- care professions.”25 Critics also note that because much of chiropractic is based on a false premise, neither length of study nor accreditation of its schools can ensure that those who graduate will practice competently. Practice-Building Techniques After graduation many chiropractors take courses to help build their practices. These courses teach efficient office management, but some have taught unethical methods of recruiting and retaining patients. For example, one practice-building manual provided detailed instruc- tions for persuading all comers to have monthly spinal examinations.2 Another suggested telling patients that “the best health insurance you’ll ever buy is regular adjustments of your spine, releasing nerve pressures.”26 Both of these books were authored by chiropractic col- lege presidents and widely used for more than 30 years. Although neither book is still published, most current practice-builders teach the same techniques and thou- sands of chiropractors use them. A 1986 report by the Office of the Inspector Gen- eral (OIG)27 concluded that “practice-building courses, popular with many chiropractors, advocate advertising techniques which suggest the universal efficacy of chi- ropractic treatment for every ailment known to humans.” It also concluded that despite evidence of an increased emphasis on science and professionalism in the training and practice of chiropractors, “there also exist patterns of activity and practice which at best appear as overly aggressive marketing—and, in some cases, seem de- liberately aimed at misleading patients and the public regarding chiropractic care.” A subsequent OIG report noted that the two most common reasons for disciplinary actions by state chiro- practic boards are billing abuses (relating to utilization or fees) and advertising abuses.28 Figure 9-5 shows two types of stickers chiropractors use to promote their practices. reseArCh Findings Many studies have examined whether spinal manipu- lation can relieve back pain. Relatively few studies have looked at whether manipulation could help other problems. In properly selected cases, manipulation may relieve low-back pain of musculoskeletal origin. How- ever, there is little evidence that it is effective for other Figure 9-5. Chiropractic promotional materials. Many chiropractors use messages that reinforce the idea of a special bond between themselves and their patients. The bumper sticker was distributed by the American Chiropractic Association. The heart sticker is from a company that sells novelty items to chiropractors. Several companies sell birthday cards and other greeting cards with chiropractic themes.

MY CHIROPRACTOR

LOVES ME

Part Two Health-Care Approaches170 musculoskeletal conditions and no evidence that it is effective for nonmusculoskeletal conditions. Homola29 has noted that “chiropractic research has yet to pinpoint what chiropractors do that is beneficial.” During the early 1990s, manipulation received considerable publicity after reviews by the RAND Cor- poration30 and the Agency for Health Care Policy and Research (AHCPR)31 concluded that manipulation was effective for acute low-back pain in patients with no signs of lower-limb nerve root involvement. Although chiropractors promoted these reports as endorsements of chiropractic, they were not. They merely supported the use of manipulation in carefully selected patients. Only a few of the studies on which their conclusions were based involved manipulation by chiropractors; most were done by medical doctors and physical therapists whose practices were not identical to those of chiropractors.12 Since that time, there have been many more studies and many more reviews. In 2003, a team that included RAND’s project leader concluded: “There is no evidence that spinal manipulation is superior to other standard treatments for patients with acute or chronic low back pain.”32 In 2005, after looking at 19 reviews related to back pain, Canter and Ernst33 concluded that “those authored by chiropractors tended to generate positive results, whereas the others failed to demonstrate effectiveness.” In 2006, Ernst and Canter34 reported on 16 systematic reviews of clinical trials of spinal manipulation published between 2000 and May 2005 on back pain, neck pain, headache, non-spinal pain, menstrual pain, infantile colic, asthma, allergy, neck-related dizziness, and medi- cal problems in general. They concluded: These reviews were largely negative, except for back pain where spinal manipulation was considered superior to sham manipulation but not better than conventional treatments. . . . Collectively these data do not demonstrate that spinal manipu- lation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment. A recent Cochrane35 review examined the effect of manipulation plus other modalities on low-back pain. The other modalities were heat and cold therapy, electro- therapy, mechanical devices, exercise, nutritional advice, orthotics, lifestyle modification, and patient education. The reviewers concluded that although combined chi- ropractic interventions slightly improved pain and dis- ability in the short term and pain in the medium term for acute and subacute low-back pain, “there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain.” A subsequent review drew similar conclusions for chronic low-back pain.36 probleMs For ConsuMers Although some research on the use of spinal manipula- tion is favorable, the situation faced by consumers is actually worse than these studies might seem to indicate. Most research on spinal manipulation is done in studies where the patients are appropriately screened and the treatment is limited by the experimental protocol. In the real world, however, the odds of getting appropriate treatment are much lower because the following prob- lems are widespread. Exaggerated Scope Many chiropractors exaggerate what they can achieve. Tedd Koren, D.C., publishes many brochures and other practice-building supplies, one of which states: Nearly every condition to which the flesh is heir has responded to chiropractic, including ear infections, asthma, allergies, colic, bedwetting, hearing problems, skin conditions, diges- tive and menstrual problems, infertility, spine and nerve pain, colds and flu, headache, sciatica, emotional and neurological conditions and many others.37 Figure 9-6. “Danger signal” ad from phone directory. The ad is misleading because (a) most of the listed symptoms are unlikely to be caused by pinched nerves, (b) most cases involving these symptoms are not serious, and (c) some of the symptoms (such as difficult breathing) are far more likely to be appropriate for medical rather than chiropractic evaluation. Contour analysis has no diagnostic value. Chapter Nine A Close Look at Chiropractic 171 Koren also advised chiropractors they could double their practice “practically overnight” by having patients read one of his lists of conditions treated and asking: “Do you know of any children, perhaps your own, or those of relatives or friends, that have any of the problems in this list?”38 A recent survey found that unsubstantiated claims are very common among chiropractic Web sites. In the fall of 2008, the researchers looked at the sites of 200 chiropractors and 9 chiropractic associations in Austra- lia, Canada, New Zealand, the United Kingdom, and the United States. Each site was examined for claims which suggested that chiropractic treatment was appropriate for asthma, colic, ear infection/earache/otitis media, neck pain, whiplash, headache/migraine, and lower back pain. The study found that 95% of the surveyed sites made unsubstantiated claims for at least one of these conditions and 38% made unsubstantiated claims for all of them. The authors concluded39: The majority of chiropractors and their associations in the English speaking world seem to make therapeutic claims that are not supported by sound evidence, while only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue. Patients who rely on exaggerated chiropractic claims may delay obtaining more appropriate care. Modde40 highlighted this problem when he said that “malpractice is an inevitable result of chiropractic philosophy and training.” Unnecessary Treatment Many chiropractors claim that treating subluxations improves general health and is important throughout life. For example, in 1995 an ACA board member stated: “I treat my patients as if each spinal adjustment has a virtually unlimited potential in improving their health. My father adjusted me on the day that I came home from the hospital, and I did the same with my children.”41 Many chiropractors suggest unnecessary “spinal adjustments” for “preventative maintenance” or for treating nonexistent conditions. Maintenance care is typi- cally promoted with claims that undetected subluxations pose a serious health threat. A 2009 Koren pamphlet, for example, states: “Subluxations are sometimes referred to as ‘silent killers’ because they can slowly eat away at your health and vitality for years without your knowing it.”42 Figure 9-4 shows a poster used to reinforce this idea. Many chiropractors offer free evaluations with the hope that takers will contract for long-term care. These offers may be communicated through mall exhibits, free dinners, newspaper advertising, and various other channels. Figure 9-6 provides an example. The in-office sales pitch typically includes a recommendation for 50 to 100 visits over a 6- to 12-month period to promote wellness and/or prevent spinal degeneration. To increase compliance and discourage patients from stopping if their initial symptoms resolve, patients are offered a discount for advance payment. The Personal Glimpse box about “discount plans” describes what happened when a patient stopped coming because the treatment was not helpful. s Personal Glimpse West signed said that if she stopped before the 100 visits were completed, she would be charged at a nondiscounted rate for the visits she had and an additional 10% “admin- istrative fee.” However, the judge ruled that the penalty clause was “unconscionable” and that West had been misled and was entitled to a full refund. A small claims appeal judge reduced the award to $4589 but agreed that the contract was unreasonable. Chiropractors who offer “discount” plans should be avoided because such plans are a sign of overselling. Even when chiropractic treatment can be helpful, it is not possible to know in advance that a large specified number of visits will be needed. Be Wary of Discount Plans In 2008, in response to an advertisement, Gertrude West, a 76-year-old retired attorney, sought help from a chi- ropractor for knee pain. The chiropractor performed a cursory examination, some diagnostic tests, and an x-ray examination and advised West that she had “subluxation degeneration” that would worsen without intensive chiro- practic care. The chiropractor’s written report of findings called for 100 visits at a total cost of $7080, but if she signed a contract and paid in advance the price would be discounted (15%) to $6354. After 49 visits over a 4-month period, West concluded that she was not being helped and asked that payment for the unused visits be refunded. When the chiropractor refused, she sued him in small claims court. The contract Part Two Health-Care Approaches172 Some patient-recruitment programs have been packaged as an opportunity to participate in research. In 2008, for example, several chiropractic Web sites began advertising for “research volunteers” who would be evaluated free of charge. After the evaluation, they would then be invited—as paying patients—to “com- mit to a 24-visit cycle, and continue coming until they reach their maximum potential.” The ads are part of a practice-building program offered by Research & Clini- cal Science (RCS), which promised chiropractors that it would tabulate data that would ultimately pinpoint “exactly what impact subluxations have on the body, and what benefits chiropractic might offer to people of various ages and health levels.” RCS also promised that its program would generate between 10 and 25 new patients a month and promote long-term wellness and compliance among existing patients. To join the pro- gram, chiropractors would pay $7384 in advance or up to $8384 for an installment plan. In return, RCS provided the training, research technology, wall plaque, brochures, and other materials needed to represent themselves as “RCS Authorized Clinical Investigators.”43 Dubious Practices and Procedures Many chiropractors use leg-length measurement, ther- mography, surface electromyography, or other dubious methods to detect alleged subluxations. The Chirobase Web site (www.chirobase.org) has detailed reports on these methods. Many chiropractors use applied kinesiology muscle- testing, hair analysis, or other dubious methods as a basis for prescribing unnecessary vitamins, irrational “dietary supplement” formulations, herbs, and/or homeopathic products, most of which are sold to patients at two or three times their wholesale cost. Unsound uses of dietary supplements and herbs are discussed in Chapter 11 of this book. Homeopathy is covered in Chapter 8. Many chiropractors x-ray most or all of their patients to look for “subluxations.” About 10% of chiropractors still obtain 14 x 36-inch full-spine x-ray films, which yield little or no diagnostic information and involve relatively high levels of radiation. A 2003 survey by the National Board of Chiro- practic Examiners45 found that 89% of 2167 full-time practitioners who responded said they had used “nutri- tional counseling, therapy or supplements” within the previou

[TRUNCATED]