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There is a bill before the Oregon Legislature, Senate Bill 1535, that:

Allows chiropractic physicians and naturopathic physicians to provide release for athlete who sustained concussion or is suspected of sustaining concussion.

Unfortunately, the Oregon legislature has already granted naturopaths primary care physician status, so I expect this may well pass, despite the fact neither chiropractors nor naturopaths have much reality-based education and training in medicine.

You may wonder, why you should care about what is going on in Oregon? Well, it is likely similar laws are being considered in your state. You might be surprised at the shenanigans going on in your legislature. I was when I looked. To keep informed, go to Legislative Update at the Society for Science-Based Medicine for weekly updates.

Let’s go through the issues: why is it a bad idea for the athletes of the state, most of whom will be children, to be cared for by NDs and DCs?

What a concussion is

A concussion is a form for trauma, an injury to the brain. The brain floats in cerebral spinal fluid, which acts as a cushion. If the skull hits something, or is hit, hard enough by a fist or a football helmet or a wall, the cushion fails and the brain smashes into the skull. Trauma results.

The patient can then have a headache, confusion, ringing in the ears, seizures, double vision, and other neurologic symptoms. The number and severity of the symptoms depends on what part of the brain is injured, and the severity of the injury.

Treatment is resting the body and the brain and avoiding re-injury. There may be long-term sequelae to concussions, especially repeated concussions, such as depression, dementia and Parkinson’s. The brain is not physically, emotionally, or spiritually forgiving when injured.

It is a huge problem, with 300,000 sports related concussions a year in the US, and this only counts concussions that led to a loss of consciousness, perhaps 10% of the total. Children are both more prone to concussion and, perhaps, long term sequelae.

So concussion is a serious and widespread medical problem. It may not be an optimal approach to have those with little or no education, training or experience in medicine care for children with concussion. Except, probably, in Oregon.

Education

Chiropractors and naturopaths like to pretend that their ‘medical’ education is equivalent to medical school. Nothing could be further from the truth.

Chiropractic education

During the public hearing it was offered that the education of a chiropractor is equal to that of an MD. While there are superficial similarities, the whole of chiropractic education is through the lens of chiropractic theory: that there are misalignments of the spine, subluxations, that block that body’s ability to heal, and that chiropractors can identify and adjust these subluxations to restore health.

The whole underlying concept of chiropractic is a pseudo-science, with no basis in anatomy, physiology, or reality. As one review notes:

Chiropractic and allopathic medicine differ the greatest in clinical practice, which in medical school far exceeds that in chiropractic school. The therapies that chiropractic and medical students learn are distinct from one another.

Medical education is grounded in reality; chiropractic education is grounded in the fantasy of innate intelligence, subluxations, and spinal adjustments.

Naturopathic education

Naturopathic education also appears to be superficially similar in the number of hours devoted to the basic sciences. When compared to the education of a Family Practice Physician, it is clear that ND’s have a fraction of the training required to become and MD/DO.

Doesn't look so good, does it?

Doesn’t look so good, does it?

It is more than the quantity of hours in education and training that makes a physician, it is also the quality of the content. ND curriculum is even more focused on pseudo-science than chiropractic: homeopathy, hydrotherapy, acupuncture, energy therapies, and more make up a significant portion of the naturopathic education. Time spent studying pseudo-science and pseudo-medicine is time not spent studying and understanding reality-based medicine. Those educated in the care and feeding of unicorns are not qualified to care for horses.

The naturopaths testifying at the hearing suggest that since they have been given primary care designation they should be allowed to diagnose and manage concussion as well. I would suggest that two wrongs do not make a right.

Post-education training

No MD or DO is even remotely ready for independent patient care upon graduation from medical school. After graduation MDs and DOs have a residency to learn their specialty. Internal Medicine, Family Practice, and Neurology residencies are three years; neurosurgery takes 7 years. It is the residency, practicing under the guidance of senior physicians, where doctors really learn their profession.

Neither naturopaths nor chiropractors have a residency; they usually go straight from school and into practice. The few that do complete a residency do so in the field of naturopathy or chiropractic, further reinforcing their pseudo-medical training.

There is no subspecialty naturopathic training in neurology; chiropractors can be certified as a chiropractic neurologist in 40 days of internet classes, or 300 classroom hours. Compare that to the over 8,000 hours (assuming a mythical 8-hour workday) it takes to be a real neurologist, much of which is spend in direct patient care. This is why Dr. Steven Novella, a Yale neurologist, says:

Chiropractic neurology appears to me to be the very definition of pseudoscience — it has all the trappings of a legitimate profession, with a complex set of beliefs and practices, but there is no underlying scientific basis for any of it…Chiropractic neurology does not appear to be based on any body of research, or any accumulated scientific knowledge.

Evaluating their education, training and practice, I would suggest that chiropractic and naturopathy are to real neurology and medicine what Guitar Hero is to Jimmy Page.

The medical literature

A search of the medical literature on PubMed for “naturopathic medicine concussion” yields zero publications. There are no trials to suggest that the pseudo-medical practice of naturopathy can be applied to brain injury. Or any other real disease for that matter.

For “chiropractic concussion” there are 19 hits on Pubmed, out of the 7,511 medical publications on concussion. None of the articles concern the competency or efficacy of chiropractors in the diagnosis and treatment of concussion.

There are no clinical trials demonstrating efficacy of chiropractic or naturopathic treatments for concussion. And there is no reason, based on known anatomy and physiology, to suspect that either pseudo-medicine would have benefit in the diagnosis or treatment of concussion.

Dangers of chiropractic treatment

The Palmer School of Chiropractic recommends manipulation of the cervical spine for concussion.

There is an association with cervical spine manipulation in the young and vertebral basilar artery stroke:

Results for those aged 45 years showed VBA cases to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA (95% CI from bootstrapping, 1.32 to 43.87). Additionally, in the younger age group, cases were 5 times as likely to have had ≥3 visits with a cervical diagnosis in the month before the case’s VBA date.

The association between cervical spine manipulation and stroke is consistent enough that the American Heart Association and the American Stroke Association have released a scientific statement suggesting:

Although current biomechanical evidence is insufficient to establish the claim that cervical manipulative therapy (CMT) causes cervical artery dissections (CD), clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and vertebral artery dissection stroke in young patients.

Complications fortunately are rare, as “Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the Literature” showed:

Thirty-one articles met the selection criteria. A total of 12 articles reporting 15 serious adverse events were found. Three deaths occurred under the care of various providers (1 physical therapist, 1 unknown practitioner, and 1 craniosacral therapist) and 12 serious injuries were reported (7 chiropractors/doctors of chiropractic, 1 medical practitioner, 1 osteopath, 2 physical therapists, and 1 unknown practitioner).

But for an intervention that has no benefit, the risk should be zero. Young people have died after chiropractic manipulation, perhaps including the recent death of the “Queen of Snapchat,” Katie May.

And children are injured by manipulation when the correct diagnosis is missed:

Other (serious adverse events) leading to permanent neurological consequences have been reported. However all of these were attributable to a misdiagnosis leading to the inappropriate application of SMT with unfortunate consequences.

Yes. A child crippled by a useless intervention for the wrong reason is an “unfortunate consequence.” Given the lack of medical training by DCs and NDs, further unfortunate consequences would seem inevitable.

If stroke were due to a medication, the medication would receive a black box warning at a minimum or be pulled from the market. The major chiropractic organizations deny that chiropractic can cause strokes and continue to snap the neck, which can result in the same forces and injury as a hanging. But that is typical of pseudo-medicines: they never recognize that their interventions could be dangerous and alter or abandon practice accordingly.

The data suggesting a link between chiropractic manipulation and stroke is complicated and incomplete. However in medicine, but not chiropractic or naturopathy, the precautionary principle is applied:

if an action… has a suspected risk of causing harm to the public, in the absence of scientific consensus that the action or policy is not harmful, the burden of proof that it is not harmful falls on those taking an action.

And the action avoided.

The majority of chiropractors are of the opinion that spine manipulation is a treatment for concussion, even though the brain is distant from spine:

Most respondents agreed or strongly agreed that manual therapies may be appropriate in certain circumstances in adults (80%) and minors (80%).

When all you have is a hammer, everything is a nail.

While there is no naturopathy-specific treatment for concussion, naturopaths do have their own naturopathic manipulation.

Bill 1535 should not pass

It should give anyone concerned with the health of children a frisson of terror at the thought of concussed children being evaluated and managed by naturopaths and chiropractors.

Naturopaths and chiropractors lack the education, the training, and the understanding of medicine and neurology to diagnose and treat concussion. Their therapies are at best useless and can result in strokes in one of our most vulnerable populations, children.

Senate Bill 1535 should not pass.

 

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.

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