29 July 2009

Snap, Crackle, Pop

Pharyngula has a great post -- a reprint of the Simon Singh article that got him in so much trouble for exposing chiropractic quackery.  One point worth emphasizing: chiropractic manipulation is not necessarily benign.  Chiropractic stuff is very popular where I live, and in my relatively short career I have seen not one but two vertebral artery dissections and cerebellar strokes that were attributable to chiropractors.  A bigger problem, I think, is that while there are good chiropractors who understand their optimum scope of practice, there are a damned lot of crazy quacks out there.

I have something of a confession: I once visited a chiropractor.  This was quite a while ago; I was playing with first-born son, who was about 18 months old and I had one of those "ouch" moments where my back just went out.  I could not straighten up.  I could tell the pain wasn't radicular.  It didn't feel myofascial either.  Eventually I managed to get vertical, and it was more or less painless unless I bent forward more than about 30 degrees, at which point developed sharp and localized pain and couldn't go any more.  It felt like it just needed to pop.  After a couple of days of it not getting better, I decided to see if a little back-cracking might do the trick.  So I went down to the chiropractor a few blocks from my house.

I didn't tell him what I did for a living.  He asked me what the problem was, and I got about thirty seconds into the story before he cut me off with a question.  That didn't surprise me; doctors are well-known to do that.  But the question surprised me: "When was the last time you had your back x-rayed?"
"Um, never."
"Ohhhhh!" He interjected, with good humor and a touch of bonhomie, "Thought you were gonna get away with something, eh?  Thought you could pull a fast one on me?"
"Um no, but..."
"To the x-ray machine we go!"  And he bustled out of the room, indicating that I should follow.  What the heck, I figured, I'm already down the rabbit hole, let's play the game and see where it goes.  So I followed.  We took an x-ray and I waited in the room until he came back. 

"Looking at your x-ray, you have two problems.  Some degenerative changes in your lumbar spine, and your pelvis is tilted."
I was kind of shocked.  DJD?  At my age?  I was, I think, 32 years old.  Too young for DJD.  "Can I see the x-ray?"
"Oh well, you honestly don't need to..."
"No," I interrupted quite firmly, "I would really like to see the x-ray."
He led me into the next room, muttering something about having trouble with the developer, and showed me the faintest, least diagnostic x-ray I have ever seen in my life.  I examined it closely.  The "degenerative changes" were clearly a figment of his imagination.  He eagerly pointed out to me that the pelvis was "tilted" or, as I would say, rotated.  It was, slightly.  He explained how this meant some malalignment or another.  I pointed out that I just wasn't quite square with the plate when the film was shot.  He assured me that he had made certain that I was square (which I do not think he did).

Either way, he told me, it was clear that I needed some manipulations.  Again, I was shocked.  He had not asked me any questions.  He had not examined me.  He had no idea whether I had symptoms suggestive of nerve pain, or spinal cord injury, or any concept of what the cause of my symptoms might be.  I considered yelling at him, or walking out.  But again, I figured, I wanted some back-cracking, I'll let him give it a go and see if it helps.  I lay on the table and pop-pop-pop, up my lumbar and thoracic spine he went.

And I felt better.

I never went back to him.  The symptoms were resolved, and he was clearly a dangerous quack.  But for my minor problem, on a pragmatic basis, I was prepared to accept that the adjustments had worked.

I should point out that a year or so later, my problem recurred.  I went to see a different chiropractor.  This one was quite different.  He took a careful history and performed as thorough an exam as I would have expected from a physical therapist or physiatrist.  He explained that he thought it was a muscle strain and that I did not need manipulation, I needed stretching exercises, and he gave me a list of some fairly standard exercises.  I came away from that encounter with a solid feeling of respect.

I would not impugn the profession by saying they are all quacks.  The second guy was clearly good and responsible.  I have a sketchy feeling, however, that the first chiropractor may be more characteristic of the norm.  Because it is popular in the neighborhood I live in, many times I have patients ask me whether they think they should see a chiropractor for their problems.  I generally dissuade them, of course.  I refer them to their docs and a physical therapist.  But some folks clearly are bound and determined to see a chiropractor.  That's tough, but I reinforce to them that they should not let the chiropractor touch their neck, and that for most of what I see, the stretching and muscle strengthening exercises are also important.

And just for the record, any chiropractor who thinks that manipulations can improve colic, or ear infections, or asthma is either lying or deluded.

13 comments:

Dr. Bob said...

Unfortunate that this person had a bad experience with a chiropractor. I myself am an emergency physician, and have seen 3 or 4 chiropractors in my lifetime (I'm 46). None of them have been 'quacks'. They have all been educated, professional, and thorough. Too bad that a generalizaton was used to describe them in this person's opinion. Have you looked around the medical profession lately? There are many docs whom I would consider quacks out there, and they do not have D.C. after their name.

Fishpaste said...

I wholeheartedly agree with Dr. Bob. Would you pass judgement on every GP after one bad experience with one of them? There are a damn sight many more crap doctors out there than chiropractors. Their access to some pretty serious drugs also means they can do a lot more damage than a chiropractor ever could. Don't forget that chiropractors are regulated by General Chiropractic Council (GCC) which was created by an act of parliament and functions along exactly the same lines as the GMC, only they seem to really crack down on (pun intended) wayward chiropractors and have a reputation for actually being a bit overzealous. Not like the GMC, who need to be presented with bloody knife and some bad publicity before they'll lift a finger.

ERP said...

I agree. Treatment of back problems should be the extent of their scope of treatment. And cracking a neck is just damn stupid-dangerous.

litbrit said...

Oh dear.

I crack a lot of my own bones, something I learned to do--for better or worse--in ballet. For minor back stiffness, I cross my arms, breathe out, and get Robert to bear-hug me from behind while lifting me a couple of feet off the floor and shaking me--sounds extreme, but damn it feels wonderful, like you've just grown an inch or two. Yeah, I even crack my own neck, something that freaks people out because it looks as though you're going to twist your head right off your shoulders, but when I feel a tension headache starting up, a good neck-crack can stop it cold. (Why is that?)(Is it really dangerous?)

No, I've never seen an actual chiropractor.

Zeke said...

But then again, I had a similar experience with two bona fide MDs over the diagnosis of severe, radiating pain from the left side of my chest and down the left arm, especially during exertion or stress. Since I was in my early '30s, vegan and very athletic, it was "diagnosed" w/o physical exam or other diagnostic as "muscle strain" or a "nerve pinch". The script pads were whipped out and the appropriate blockbuster pain meds were duly prescribed and referrals made to orthopeds (with the several month delay awaiting insurance company approval). After 2 years of this the problem was finally diagnosed as severe CAD after a MI.

Quacks come with all sorts of degrees.

alexandralynch said...

I find that seeing one regularly helps with the issues I have left over from a car wreck and childbearing regarding my lumbosacral area. Indeed, one kept me able to walk while pregnant.

But on the other hand, I also think that the impact that has on my fibromyalgia is just that I got to relax for forty minutes and had some reduction in something that hurt, so it's not there for the fibro to amplify any more.

Mine told me there is nothing we can do except try to maintain until I get more surgery on my foot, which I thought was refreshingly honest.

Kipper said...

I had a brush with chiropractic in my 20s after my cholecystitis was misdiagnosed as back pain (I think my GP just wanted me out of her office, honestly, and figured she'd foist me off on the premier attendants to the worried well). My observation was that the chiropractor never did anything to me that I can't do for myself with simple stretches (and, of course, did no good whatsoever for the cholecystitis). It's hard to say whether someone who hasn't had a history of stretching regularly could do the same. I assume so, although there might be a bit of a learning curve.

Gene said...

I've visited a few in my 53 years, mostly after a fall backwards out of a "bread-truck' van. The first thing I look for when I walk in is any kind of brochure or pamphlet that says something like, "Chiropracty and Appendicitis" (I've actually seen that one). If I see that, I leave. These are glossy, professionally produced "publications" and therefore there is obviously a large enough market for someone to make money printing them. Go ahead, do your own Bing search, I'll wait.

Back? Here's a quote from B.J. Palmer, the son of the founder of chiropractic "medicine":
"We CHIROPRACTORS work with the subtle substance of the Soul.

We release the prisoned impulse, the tiny rivulet force that emanates from the mind and flows over the nerves to the cells and stirs them into life.

We deal with the magic power that transforms common food into living, loving, thinking clay; that robes the earth with beauty, and hues and scents the flowers with the glory of the air.

In the dim, dark, distant long ago, when the sun first bowed to the morning star, this power spoke and there was life; it quickened the slime of the sea and the dust of the earth and drove the cell to union with its fellows in countless living forms.

Through eons of time it finned the fish and winged the bird and fanged the beast.
Endlessly it worked, evolving its forms until it produced the crowning glory of them all.
With tireless energy it blows the bubble of each individual life and then silently, relentlessly dissolves the form, and absorbs the spirit into itself again.

And yet you ask, “Can Chiropractic cure appendicitis or the ‘flu’?”

Have you more faith in a knife or a spoonful of medicine than in the Innate power that animates the internal living world?"

ANd here's what his dear old dad had to say, "A subluxated vertebra… is the cause of 95 percent of all diseases. …The other five percent is caused by displaced joints other than those of the vertebral column."

Chiropracty is no more medicine than Homeopathy.

AmyPinSeattle said...

Never saw a chiropractor till a few years ago. It's amazing how great my midback feels after a visit. My neck too...it's like it gets "stuck" and the release makes it easier for it to turn again.

This is after I tried PT for 4 years to no success with resolving them.

I just wish it would last longer!! So what's the concern about the neck adjustments?

wrin said...

I saw a chiropractor for back pain. He did solve my back pain. He happened to be one of the ones big on the "allopathy is baaaaad" market (including power point presentations on televisions strategically placed throughout the office, encouraging you to distrust your Western medicine.) I made the mistake of telling him I was asthmatic. He then insisted he could cure my asthma with chiropractic, and began attempting ribcage manipulations.

He'd say the reason I'm still asthmatic is because I quit going to him. I think I'm still asthmatic because asthma is ... a chronic illness.

Anonymous said...

I have gone to two very good chiropractors. I have spondo-what-ever-you-call-it when the vertebrea are not aligned. Both never touched it. But when I am sore....it tends to domino up the whole back. They make me feel better.

Anonymous said...

What about DO's? Have you ever had any experience with osteopathic medicine? I realize that not too many use manipulation anymore, but I was just curious of your thoughts..

Sarah said...

That's funny - I'm a chiropractic intern and my latest experience with an orthopedist sounds a hell of a lot like your first experience with a DC - no exam, didn't once lay a hand on me, shoddy job reading my imaging, and immediate referral for his specialty (in my case femeroacetabular labral debridement). I don't hold it against him or the profession, it's just a funny coincidence.

That being said, thanks very much for your fair, honest and respectful discussion of chiropractic. Whether or not you agree with what I do (and no, I do not claim to "cure" or even treat visceral problems), I appreciate the way in which you're going about it.