“Complementary and alternative medicine,” as pediatrician and fellow blogger John Snyder aptly stated in a recent journal article on CAM and children,
is a term used to describe a disparate, poorly defined set of practices and treatment modalities presumed to be distinct from so-called ‘conventional medicine’.
As we have discussed here at Science-Based Medicine, this amorphous concept facilitates a convenient fluidity in delineating the parameters of CAM. Without a clear definition, CAM (and integrative medicine) proponents are able to rebrand plausible and evidence-based practices such as diet, exercise and relaxation as CAM, a tactic we at SBM call “bait and switch.” This results in inflation in the figures of CAM use (important because CAM is all about popularity) and claims that CAM “works.”
Manipulating a term
Yet another example of CAM’s claiming “conventional” medicine as its own appeared in the form of NCCAM’s most recent Clinical Digest, which discusses CAM treatments for pain and mischaracterizes spinal manipulation as CAM.
(FYI, this edition of Clinical Digest also promotes acupuncture for pain, even though it doesn’t work, and co-opts exercise (Tai Chi) and relaxation as CAM, even when they aren’t.)
NCCAM’s categorization of spinal manipulation as CAM would surely come as a surprise to the orthopedic surgeons who prescribe it, the physical therapists who carry out those orders, and the M.D.s and D.O.s who themselves perform it. Spinal manipulation is a physical therapy employing a high velocity, low thrust technique whereby a joint (such as a spinal vertebra) is moved beyond its normal physiological range of motion. The primary purpose of the therapy is to create mobility in an otherwise tightened joint. While its mechanism of action is not fully understood, it is biologically plausible and has some evidence of effectiveness for certain types of back and neck pain. It is “conventional” medicine.
A likely source of NCCAM’s confusion is chiropractors’ use of the term “spinal manipulation.” Some chiropractors employ manipulation in the same way physical therapists, MDs and DOs do – as a physical therapy for patients with back or neck pain who have been conventionally diagnosed and found to be appropriate candidates for this therapy. However, chiropractors also use the term “spinal manipulation” as a synonym for “spinal adjustment” which, in their unique vocabulary, is a treatment for the ubiquitous and nonexistent subluxation. Only chiropractors use the term in this manner because only chiropractors believe the chiropractic version of the subluxation exists. There is an excellent discussion of this distinction by Sam Homola, himself a chiropractor, on SBM and NCCAM’s staff would do well to review it.
(By way of background, to a physician, nurse, physical therapist and other science-based health care providers, a subluxation is a partial dislocation, as of a joint. Chiropractors have their own vocabulary which includes terms defined differently than, or not used in, the common lexicon of other health care providers.)
The chiropractic subluxation has been addressed a number of times here at SBM, but briefly the subluxation is an ill-defined, unproven spinal pathology of no known clinical significance. It was invented out of whole cloth in 1895 by a self-styled “magnetic healer” who had no medical education or training. Despite efforts by chiropractors to backfill a scientific explanation into this preconceived notion, there is no plausible scientific evidence that the chiropractic subluxation exists.
Not surprisingly, chiropractors cannot agree on a definition for their subluxation, how to diagnose one, or its clinical significance. They can’t even agree on a name for it – it’s variously called the vertebral subluxation complex, manipulable lesion, spinal lesion, joint dysfunction, and so on. Nor can they agree on its role in chiropractic – large and unremitting intramural battles have been fought over the subject. Nevertheless, chiropractors daily tell patients that they are suffering from subluxations which must be corrected at the risk of ill health. Again, one means of correction is the chiropractic “adjustment,” which chiropractors also refer to as “manipulation.”
If chiropractors are this confused, then one can well understand how the writers and editors of NCCAM’s website could be confused, but it’s time to set the record straight. The correction of subluxations via a spinal adjustment/manipulation is not the same as the use of spinal manipulation by physical therapists and other health care providers as a means of alleviating back or neck pain. While it is true that a chiropractor might “find” a subluxation and claim it is the cause of a patient’s pain, this is not a legitimate diagnostic method nor is its correction via an adjustment/manipulation a legitimate therapy for the patient’s pain.
NCCAM does its readers a real disservice in failing to explain this critical difference. As it stands, readers may be left with the incorrect assumption that a chiropractor’s use of adjustments/manipulations to correct subluxations is a useful therapy for neck or back pain. This is especially important because some chiropractors have intentionally tried to exploit the efficacy of manipulation for back pain as proof that chiropractic “works.” They have also falsely claimed that they are more proficient at, and safer in performing, spinal manipulation than other practitioners, to the point of trying to use the political process to prohibit physical therapists from employing manipulation.
But wait, it gets worse
To confound the problem, NCCAM’s discussion of manipulation as a pain therapy refers readers to its information on chiropractic, the very practitioners who may subject them to the ineffectual adjustment/manipulation for pain. And while NCCAM’s confusion over conventional manipulation versus chiropractic manipulation for subluxations might be understandable, any sympathy should end at this reference. As David Gorski pointed out, NCCAM discusses CAM practices in a “weaselly, wishy-washy way,” and chiropractic is no exception:
Chiropractic is a health care profession that focuses on the relationship between the body’s structure—mainly the spine—and its functioning. Although practitioners may use a variety of treatment approaches, they primarily perform adjustments (manipulations) to the spine or other parts of the body with the goal of correcting alignment problems, alleviating pain, improving function, and supporting the body’s natural ability to heal itself.
For the uninitiated, let’s decode these weaselly words. “Focuses on the relationship between the body’s structure – mainly the spine – and it’s functioning” is a reference to chiropractic belief that there is a spinal pathology (the subluxation) they can detect and that it has some effect on bodily function. The putative effect of this putative pathology is sometimes described simply as a “misalignment” blocking “nerve flow” and at other times more elaborately (and equally nonsensically) as “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 . . . .” The reference to “adjustments (manipulations)” is an unintentional acknowledgement of my point that chiropractors use the terms interchangeably and describes their unproven therapy for their unproven condition, which “correct[s] alignment problems, i.e., subluxations. “Supporting the body’s natural ability to heal itself” is a reference to the chiropractic belief in vitalism, their version of which is “Innate Intelligence.”
The quoted description – indeed the whole of NCCAM’s page on chiropractic – doesn’t mention by name what even chiropractors themselves describe as its core concept: the subluxation. A consumer reading this page would have absolutely no clue that going to a chiropractor might subject him to a phony diagnosis of “subluxations” and phony treatments to “correct” them. There is also a mention that chiropractors use x-rays as a diagnostic tool, without telling the reader that a chiropractor may well use x-rays to detect the nonexistent subluxation.
Criticism of this sort of thing was raised by Steve Novella, David Gorski and Kimball Atwood at their visit with NCCAM’s director over two years ago. As Dr. Novella said then, “the pattern of information is consistent – NCCAM staff talk about a strict adherence to evidence-based medicine and science being neutral, but interspersed with this is an uncritical presentation of ancient superstition as if it were science . . .” There he was discussing acupuncture. The only difference here is that NCCAM is uncritically presenting a superstition of more recent origin, in the form of belief in “Innate Intelligence” and resulting pseudoscientific diagnostic methods and treatments.
NCCAM also advises readers to
Tell the chiropractor about any medications (prescription or over-the-counter) you take. If the chiropractor suggests a dietary supplement, ask about potential interactions with your medications or other supplements.
“If the chiropractor suggests a dietary supplement” the patient would be well advised to ask exactly why it is being prescribed, given the paucity of evidence for the safety or benefit of dietary supplements, and to be especially suspicious if the chiropractor sells the supplement, an inherent conflict of interest. And the patient should not rely on a chiropractor to know about “potential interactions with . . . medications or other supplements.” The patient should ask someone with sufficient training in pharmacology for that advice, such as a pharmacist or M.D.
As well, NCCAM advises,
Mention any medical conditions you have, and ask whether the chiropractor has specialized training or experience in the condition for which you are seeking care.
NCCAM is apparently unaware of the dubious system of chiropractic “specialization” which results in “specialties” like chiropractic neurology, chiropractic pediatrics, and chiropractic family practice. At least I hope the writer was unaware and would not knowingly recommend these “specialists.”
Perhaps the most egregious failure, however, is the failure to warn consumers about the risk of stroke following cervical manipulation. Here is what NCCAM says:
A 2009 study that drew on 9 years of hospitalization records for the population of Ontario, Canada analyzed 818 cases of vertebrobasilar artery (VBA) stroke (involving the arteries that supply blood to the back of the brain). The study found an association between visits to a health care practitioner and subsequent VBA stroke, but there was no evidence that visiting a chiropractor put people at greater risk than visiting a primary care physician. The researchers attributed the association between health care visits and VBA stroke to the likelihood that people with VBA dissection (torn arteries) seek care for related headache and neck pain before their stroke.
Yes, it’s the infamous Cassidy study, a subject we’ve addressed before at SBM. Now, I suppose it is correct that the study showed that “visiting a chiropractor” did not put people at greater risk than “visiting a primary care physician” if by “visiting” you mean walking in the door and having a seat in the waiting room. The study did not look at what treatment (if any) the patients received so it cannot legitimately claim to answer the question whether actually being treated by a chiropractor puts one at greater risk than being treated by a primary care physician. And it certainly does not answer the question whether cervical manipulation puts one at risk of stroke. As Mark Crislip pointed out in his analysis of the study, that last sentence is a hypothesis created by the authors of the study, it is not a statement supported by the study’s data.
Of course, the layperson might well be left with the impression, completely false, that cervical manipulation does not put one at risk of stroke. In fact, vertebral artery dissection and stroke following chiropractic cervical manipulation continues to be reported in the medical literature and no one besides chiropractors seems to think the Cassidy study settled the question. As a recent article in the Journal of Neurosurgery plainly states
Chiropractic manipulation of the cervical spine can injure the vessels of the head and neck and produce stroke and other debilitating symptoms.
Why is this not part of the “evidence-based information” NCCAM says it is committed to?
In sum, where’s the science?
NCCAM’s supposed dedication to “rigorous science” is not in evidence in its advice to consumers about chiropractic and spinal manipulation. NCCAM’s presentation fails to live up to its promise to “maintain a strong commitment to providing objective and authoritative evidence-based information to the public and health care professionals.”