Sisyphus, our enervating mascot.  Join us!  We're tired.

Sisyphus, our enervating mascot. Join us, we’re tired!

Over at the Society for Science-Based Medicine we have Sisyphus as the logo on the website. Sisyphus, as you may know, is the Greek who had to push a boulder up a hill every day, the archetypal metaphor for futile labor. It was meant to be a bit tongue in cheek, but only a bit. As quackademia proudly expands I sometime feel we were overly optimistic. Perhaps it should have been Prometheus

But if SBM has it tough, it pales next to the work of Bruce Walker DC, an Australian chiropractor who is calling for The new chiropractic.

His goal is to remake chiropractic, turning it into an evidence-based spine specialty, abandoning all the pseudo-scientific baggage.

I wish him luck. He will need it.

Follow the bouncing ball…er boulder

First, he believes in the benefits of chiropractic.

The “good” can be summed by recognising over a century of improvement to public health by improving pain and disability in countries where chiropractic is practised. It can be asserted that this has provided significant economic savings and improved productivity.

I wonder if this is true. It is of interest that he is the author of a reasonably well done study that demonstrated the worthlessness of spinal manipulative therapy for thoracic pain:

no difference in outcome at any time point for pain or disability when comparing SMT, Graston Technique® or sham therapy for thoracic spine pain, however all groups improved with time.

A result mirrored in a Cochrane review:

Combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute/subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions.

Although like much of the medical literature Newton’s third law applies, for every meta-analysis there is an equal and opposite meta-analysis. If chiropractic manipulation has any unique and reliable effects on pain and disability, it is lost in a sea of poorly done studies. SMT is certainly not at the level of, say penicillin for Streptococcal endocarditis.

He can assert the benefits of chiropractic, but not prove it, and medicine ought not be the same geometric assumptions. His assertion is the one unreferenced statement in the paper and for good reason. That there has been ‘good’ from chiropractic is in the eye of the beholder; I would need a much better lens prescription from my ophthalmologist before I could see it.

Then he lists the “Aberrant practices that cause significant reputational damage to the profession”, which he appears to ascribe to a minority of the field.

  • Adherence to a flawed chiropractic ideology centring on innate intelligence and vitalism
  • Claims of cures for visceral and other non-musculo-skeletal conditions
  • Anti-vaccination propaganda
  • Anti-drug and anti-medicine propaganda
  • Anti-physiotherapy sentiments
  • Misleading and deceptive advertising
  • Open plan clinics where multiple people are treated in the same room fully dressed
  • Unscrupulous contracts of care
  • Over-servicing
  • Obligatory full spine x-rays
  • Use of the term “subluxation” as a valid diagnosis
  • Unnecessary treatment of babies
  • Biologically implausible diagnostic tests and therapies
  • Unfounded claims of decreased immunity from “subluxation” and increased immunity from chiropractic treatment
  • Life time chiropractic care in the name of “wellness”
  • An unhealthy disregard of clinical research, evidence based practice, and non-specific treatment effects including natural history and the placebo effect.

And I would add an

  • unhealthy disregard for patient safety and the potential complications of SMT.

The above list is why this site has so many articles on chiropractic. I can find no information to suggest these are the aberrant practices of a minority. The first three hits on google? One, two, three aberrant practices. The whole profession is a cluster-something-or-other. Cluster-jam. Yeah. That’s the word I was looking for. I think these aberrant practices define chiropractic practice as well as chiropractic educational and professional organizations.

The author would like to make chiropractic a legitimate healthcare partner, making chiropractors musculoskeletal practitioners with an emphasis on skeletal pain. Doing what exactly for patients, since their bread and butter, SMT, has little, if any, meaningful effect on skeletal pain. Or anything else. To paraphrase someone, the good things about chiropractic practice are not unique, the unique things about chiropractic are not good. Once the aberrant practices (I love that term; it would make a great punk band name) are removed what is left? One might as well have a physical therapist, at least one that doesn’t use dry needling.

He does have a 10 point plan for improving the field. All his ideas are excellent until you realize how they have to be applied. Silk purse, sows ear and all that.

Bruce Walker’s ten-point plan

1) He wants a better pre DC education. Not a bad idea. The GPA for chiropractic school in the US is 2.5. C+. The best and the brightest are not becoming DC’s. And what bright student would want to be a chiropractor, new or otherwise? Might as well become a real healthcare provider.

He also thinks that chiropractic colleges should not be accredited if the teach subluxation. Whoa. Good luck with that. It would be like asking Christian Scientists to give up prayer.

2) Become “solely musculoskeletal practitioners with a special emphasis on spinal pain.” Nice in theory. Kind of like podiatrists of the spine, and I value podiatrists.

But do the math. There are 44,000 DCs in the US (and a little over 7,000 infectious disease physicians). Let’s say about 65,000,000 people have back pain at any given time (one of many estimates I found on the interwebs). That’s about 1,400 back pain patients per chiropractor at any given time. If they all go to a DC, that’s about 6 patients a day, about a third needed to support a full time practice. The only option is to get rid of about 2/3 of the chiropractors in the US and most of the chiropractic schools as well since they are pumping 2,900 new graduates a year into the economy (as compared to 218 new ID docs a year). It would be a good start.

With supply vastly outstripping demand, I suspect there are compelling financial reasons for chiropractors to continue income-generating aberrant practices.

3) Chiropractic needs to develop a specialized knowledge outside of chiropractic, a “special interest that sets us apart as experts in a distinctive area.”
Perhaps. But first they need to do the same within their field, which is sadly lacking in any specialized knowledge once subluxations and their correction are removed.

My warning. Swallow any milk or coffee before proceeding; laughter with a mouthful of liquid can damage your computer.

4) Marginalization of the nonsensical elements within the profession. As professionals chiropractors should not tolerate colleagues or leadership in the profession who demonstrate aberrant ideas.

Good luck with that. Aberrant ideas are what define the profession. The majority of chiropractic schools, for example, endorse aberrant ideas as their raison d’être.

More than half of the chiropractic colleges in Canada and the United States make unsubstantiated claims for clinical theories or methods on their Web sites. This behavior likely reflects what is taught in the schools. Chiropractors’ quest for greater legitimacy and cultural authority is retarded by this tendency.

5) Be pro-public health: as in pro-vaccination and stop diagnosing babies.

Like the American Chiropractic Association?

The ACA is supportive of a conscience clause or waiver in compulsory vaccination laws thereby maintaining an individual’s right to freedom of choice in health care matters and providing an alternative elective course of action regarding vaccination

6) Support chiropractic organizations that espouse these principals. Such organizations do exist. Much like, I suppose, Latinos for Trump. I suspect they are not representative.

7 & 8 & 9) Are the variations on applying evidence-based practice to improve the profession at all levels.

The problem, of course, is that to apply the evidence for chiropractic, from basic principles to clinical practice would lead to the death of the profession.

And last is the call for chiropractors to grab the bull by the horns and apply these ideas in their own lives.

Sound principles, unlikely in practice

An admirable list of goals. Good luck as their application will be close to impossible. DO schools in the US are now no different than MD schools in the physicians they produce and osteopathic manipulative therapy is fading into the used needle container of history. So I suppose it is possible to make a new chiropractor, much like the New Soviet man. We know how well that worked.

There may be the odd chiropractic gadfly and reformer, but as a connoisseur of pseudo-medicine I just do not see that the field as a whole has what it takes to change for the better.

And it is not like science-based medicine has a snowball’s chance in hell of altering the course of the current quackademic tsunami. Aberrant practices bring in the bucks from Stanford to Harvard and points in between. Medicine doesn’t marginalize the nonsensical elements within the profession and tolerates colleagues or leadership who demonstrate aberrant ideas. In medicine aberrant practices get academic appointments in the division of Integrative Medicine. Pot? Meet kettle.

“Oho!” said the pot to the kettle;
“You are aberrant, unscientific and quack!
Sure no one would think you were rational metal,
Except when you’re given a crack.”

“Not so! not so!” kettle said to the pot;
“‘Tis your own aberrant image you see;
For I am so scientific – without blemish or blot –
That your quackery is mirrored in me.

If reality-based medicine is embracing aberrant practices, can chiropractic ever make the same shift, much less in a generation? I hope so, but I just do not see even the hint of a suggestion of a possibility that in the US chiropractors are adhering to the wisdom of 1 Corinthians 13:11

When I was a chiropractor, I spoke as a chiropractor, I understood as a chiropractor, I thought as a chiropractor; but when I became an evidence-based practitioner, I put away chiropractic things.

 

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.