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Katherine Ellison won a Pulitzer Prize in 1985, not for science journalism but for coverage of the monetary mayhem perpetrated by Ferdinand and Imelda Marcos on the people of the Philippines. I was nine at the time and have little recollection of the impact of her work, but I will assume that it was meaningful in light of the award. And she went on to win numerous additional accolades for her writing on politics, economics, and human rights.

Her most recent work, “Chiropractic Care Grows, and Gains Acceptance“, will likely not be considered for any journalism awards. The article, published on the New York Times Health and Wellness blog, reveals a terribly flawed understanding of chiropractic practice and philosophy and a preternatural ability to interpret fleecing at the hands of an obvious quack as a positive experience. She displays few if any signs of an ability to think critically when it comes to medicine and gives no indication of having done more than cursory research on the subject of chiropractic.

Sometimes the apple does fall far from the tree

The inspiration for Ellison’s article was a trip to the chiropractor after having injured her tail bone during a spin class. She does this despite having grown up with a surgeon father who apparently did not think highly of “alternative healers,” particularly chiropractors. Right off the bat she brings up the history of the AMA’s stance on the chiropractic profession:

Of course, this was in the 1960s, when the American Medical Association was still waging war on the profession via its Committee on Quackery, which labeled chiropractors as an “unscientific cult.”

And:

The A.M.A.’s Committee on Quackery is long defunct, having gone out of existence after a lawsuit by chiropractors led to a 1987 federal district judge’s ruling that the medical association had tried to destroy the chiropractic profession.

Well, not exactly. The AMA absolutely was vehemently opposed to chiropractic and its practitioners and, as Dr. Harriet Hall describes, they are far from beyond reproach in the methods they used. In fact, I think you would be hard pressed to find anyone that would defend their tactics today. But the Committee on Quackery actually disbanded in 1974, two years prior to the filing of the infamous Wilk v. AMA antitrust lawsuit and at a time when all 50 states were licensing chiropractors. Louisiana, as backwards as my home state can be when it comes to science and medicine, was the last to give in that same year.

Ellison seems to imply, as countless chiropractors have outright claimed, that the final verdict supported the validity of the chiropractic profession and that the goal of the AMA anti-chiropractic efforts was to limit competition for financial reasons. In reality, Judge Getzendanner found that the AMA violated Section 1 of the Sherman Antitrust Act, but not Section 2. Essentially what the AMA did was illegal, but they met the burden of proof for their defense that “the dominant factor was patient care and the AMA’s subjective belief that chiropractic was not in the best interests of patients.” She also clearly stated that the ruling should not be interpreted as an endorsement of chiropractic as a science-based modality.

Ellison continues:

Since then, the number of chiropractors has steadily grown. Today it seems as if everyone I know is seeing one — and not just for the standard hands-on treatment of lower-back pain, but for an expanding range of interventions falling under the rubric of “integrative wellness.”

According to the most recent data on the use of various forms of irregular medicine in the United States, which Jann Bellamy discussed back in February, 8.4% of Americans underwent “chiropractic or osteopathic manipulation” during the previous 12 months. This is actually down a bit from the 2007 data, but it’s close enough to say no growth in my opinion. Even assuming that the vast majority represented visits to the chiropractor rather than a Doctor of Osteopathy, that’s not a huge number. I imagine that confirmation bias is playing a large role in her perception, or perhaps there is some selection bias to acceptance into the Ellison circle of trust.

Chiropractic tries to reach more than the spine

It is absolutely correct that many chiropractic patients are subjected to spinal manipulation geared towards treating or preventing a wide variety of complaints and conditions, not simply lower-back pain. We have documented myriad examples on Science-Based Medicine. But the most common reason overall remains musculoskeletal symptoms, primarily lower back pain.

Claiming to manage non-musculoskeletal conditions is not a new phenomenon. The first condition ever cured by Daniel David Palmer, according to him, was deafness. Today many chiropractors also employ non-manipulative treatments such as vitamins and supplements, conveniently sold at the front desk of course, as well as acupuncture, homeopathy, and reflexology. You can even get an Iridology Analysis Scan from Dr. Nick (not that you should). I wonder if he also treats Bonus Eruptus.

The more recent development is the use of terms like “integrative wellness.” The concept of integrating unscientific testing and treatments with science-based medicine, like mixing cow pie into your apple pie in the hope of improving the flavor, is primarily a marketing strategy cleverly designed to serve as a spoonful of sugar to help quackery go down the gullets of as many people as possible. It has worked spectacularly, even convincing leading academic medical facilities of the miracles of chiropractic. David Gorski’s recent post on the evolution of the NCCIH covers this in detail. But to be clear, the “expanding range of interventions” of which she speaks are those which have not been shown safe or effective, and are thus not part of the consensus standard of medical care.

Argument from Employment Opportunity: A new fallacy

Ellison digs her hole a little deeper:

The American Chiropractic Association estimates that there will be 80,000 chiropractors in the United States by 2020, up from 58,000 in 2010, with chiropractic colleges graduating about 3,000 new practitioners each year.

Even if true, so what? An Argument from Employment Opportunity doesn’t support safety or efficacy, but it does help put paying students in the chiropractic colleges. I’m sure that their practice building firms wouldn’t disagree considering that more chiropractors means more need for their services.

A 2007 study found that more than 18 million Americans had been treated with spinal manipulation, the core of chiropractic practice, during the previous year, a number that has likely increased since then.

No need to guess. It hasn’t. I already linked to the updated NHIS survey released several months ago which showed no increase in chiropractic care since 2007. I guess her “research” missed that. And don’t forget, some of those manipulations were provided by an osteopathic doctor rather than a chiropractor.
Increasingly, spinal manipulation is being offered by physical therapists without all the baggage. Spinal manipulation, primarily for acute lower back pain of less than 6 weeks duration, does have an evidence base. But what chiropractors do that might provide benefit isn’t unique to chiropractic, and what is unique provides no benefit beyond the illusion of placebo.

The “experts” weight in

Ellison quotes a few believers in chiropractic, but after a nebulous assertion of efficacy (“It’s mainstream because it works”) by the former team chiropractor for the Golden State Warriors, the others are hardly ringing endorsements. A spokesman for the American Academy of Orthopedic Surgeons admits that chiropractic is fairly low risk if used for low-back pain, and implies it might help decrease the need for opioids. This is probably true in some situations as some chiropractic techniques are about as good as doing physical therapy or taking ibuprofen.

Dr. Richard Deyo, a professor of evidence-based medicine at Oregon Health and Science University describes chiropractic as “a reasonable alternative” to conventional medical care for back pain because it “may be approximately as effective.” He cites this and successful lobbying as reasons for increasing referrals from medical doctors. Deyo’s explanation for how chiropractic might help back pain primarily involves relaxation and placebo effects, including simple regression to the mean and the self-limited nature of back problems.

Deyo, who is clearly the only voice of reason involved in the piece, does comment on chiropractic management of conditions other than back pain, including diabetes and thyroid disease. He’s skeptical. But Ellison, even after confirming that “some chiropractors claimed to offer such therapies as pendulum divination, biological terrain assessment and herbal crystallization analysis,” doesn’t appear to be.

After handwaving the risk of vertebral artery dissection and stroke associated with manipulation of the cervical spine, Ellison quotes the president of a chiropractic college on their educational standards:

The standard is four to five years of postgraduate study at a chiropractic college and at least one year of supervised patient care. Before chiropractors can practice, they must also pass a national exam and be licensed by their state. The American Chiropractic Association says the training is similar to that at medical school.

The subject of chiropractic education has come up numerous times on Science-Based Medicine because of claims such as this that are often made to support the treatment of non-musculoskeletal conditions. Or even in defense of chiropractors’ attempts to become primary care practitioners, something which truly frightens me. Chiropractic education’s only similarity with that of medical education is the total number of hours and the names of a few classes. And the “national exam” is designed within the profession. It isn’t as if the American Academy of Pediatrics signed off on their competence in pediatric care.

The manipulation begins

Ellison’s trip to the chiropractor, encouraged by one of her aforementioned friends, is a complete disaster from beginning to end. She admits to being surprised by the fact that she has to pay cash, because many chiropractors don’t want the hassle of dealing with insurance companies, and then to “stunned acquiescence” when put through a “three-hour wellness exam, with more than $300 in extra charges.” In a classic bait-and-switch scam, she had been told by the receptionist that the visit would only cost $125.

The chiropractor evaluated Ellison with “various instruments,” discovering a litany of classic bogus diagnoses including chronic Lyme disease and candida infection. If she really does have thrush, she has a lot more to worry about than her tail bone. He apparently also practices iridology as he was worried about a “brown spot” on her right eye. Also among the possible conditions she was suffering from was a loss of bone density. Remember that one.

Ellison jokes about the tail bone, where her actual symptoms are, being connected to the “smile bone” because she was told that she had an asymmetrical smile. It’s almost as if on some level she gets how utterly ridiculous her encounter is. She then botches a brief summation of the origin of chiropractic, simply describing it as the theory that “everything is connected,” and that impairment of the nervous system can cause a variety of health problems. She clearly did a very shallow dive into these murky waters and I don’t think she can even swim.

Here is where I kind of feel sorry for her, where it becomes truly clear how she is a victim in all of this. She describes having identified as a generally healthy older woman prior to the encounter, but left the visit feeling vulnerable, like “a walking time bomb” with a host of newly discovered health problems to worry over. This anxiety played a role in her agreeing to expensive and almost certainly unnecessary x-rays, although she found the resolve to turn down a selection of his exclusive vitamin supplements. After all of this she undergoes a brief manipulation of the tail bone, and probably unnecessary ultrasound therapy which added $70 dollars to her bill without her knowledge.

The verdict is in

Ellison, despite leaving the unnamed chiropractor’s office having been misled, robbed of hundreds of dollars, and still suffering from her coccydynia, draws no firm conclusions. She believes that the jury is still out. After weeks pass and her pain finally subsides, as is the natural course in many cases with conservative management, she wonders if “that 15 minutes of touch and heat” may have played a role in her recovery.

She bends over backwards to find something positive to attribute directly to the chiropractor, giving him credit for discovering her decreased bone density. But did he? Roughly a third of post-menopausal women have decreased bone density, and if she happens to have a family history of osteoporosis, and mentioned that, his odds of guessing correctly would be even higher.

Ellison describes being tested with “various instruments” that also raised concerns for candida infection in her mouth and muscle atrophy in her extremities. Only extremely dubious diagnostic devices are used to make such diagnoses. It is possible, if not extremely likely, that he simply mixed in a high probability guess along with the usual bogus maladies.

She was urged to have her bone density tested at a specialist lab, whatever that means, and was found to have osteoporosis. Someone, likely a qualified medical professional, prescribed an actual medication for the condition. I don’t believe that any credit should go to the chiropractor for discovering her osteoporosis, and certainly not for the eventual resolution of her initial complaint of tail bone pain. Ellison on the other hand, citing her research on the subject of “integrative wellness,” would use the services of a chiropractor for future occurrences of serious low back pain. And she plans to encourage her primary care physician to perform “periodic, thorough checkups.”

Ellison claims to have expertise in neuroscience, and has written a book on ADHD that will be on shelves next month. Her current New York Times blog post does not inspire confidence in her ability to communicate such a complex condition to the public. ADHD is a common focus of practitioners of medical pseudoscience and I can’t help but wonder what her research on the subject will uncover. I also can’t help but wonder about the quality control at the New York Times.


Mark Crislip also commented on Ellison’s New York Time blog article over at the Society for Science-Based Medicine’s website.

 

 

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician practicing at Newton-Wellesley Hospital in Newton, MA, and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @skepticpedi and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey.

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