NY Times response


Chiropractic Care Grows, and Gains Acceptance




Katherine Ellison, New York Times, October 5, 2015


[See comments by JCS in red.]

After injuring my tailbone in an ill-advised spin class, I made my first appointment with a chiropractor.

I did so with some trepidation: I’d grown up hearing my father, a surgeon, cast aspersions on all sorts of alternative healers, from acupuncturists to osteopaths, always reserving a special aversion for chiropractors. 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.”

[Ms. Ellison admits being chirophobic and this attitude reveals itself later in her article. It’s sad we can’t find a ‘fair and balanced’ reporter rather than a biased one.]

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. 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.” [Okay, what does this mean?]

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. 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 mention of the recent Gallup/Palmer survey?]

Many insurance plans now reimburse patients for basic chiropractic care for back and neck pain. Kaiser Permanente and the Department of Veterans Affairs, for example, have provided such care for many years now, while companies like Google and Cisco have offered chiropractors’ services more recently as a coveted employee perk.

“It’s mainstream because it works,” said Leonard Stein, the former team chiropractor for the National Basketball Association’s Golden State Warriors and now the chiropractor for the San Francisco Ballet. [Why didn’t she use Dr. Stein to treat her sacral pain instead of the DC she later criticized so badly? Was she looking for a punching bag or what?]

A growing number of physicians agree. Dr. Alan Hilibrand, a professor of orthopedic surgery and neurosurgery at Thomas Jefferson University in Philadelphia and a spokesman for the American Academy of Orthopedic Surgeons, said, “At least as far as low-back pain is involved, it poses very little risk, and there are a lot of real advantages to it in this world of more and more medicine, and more and more opiate addiction.” [Yeah, an honest orthopedist!]

Dr. Richard Deyo, the Kaiser-Permanente endowed professor of evidence-based medicine at Oregon Health and Science University and the author of “Watch Your Back!” called chiropractic care for lower-back pain “a reasonable alternative for people who would prefer to avoid medication or high-tech intervention.” He said more doctors were referring patients to chiropractors and more insurance plans were covering them for reasons that included “growing evidence that chiropractic care may be approximately as effective as conventional care, at least for back pain; successful lobbying by the chiropractic profession; and at least some evidence that for back pain, chiropractic care may be cost neutral rather than adding to costs of care.” [Again, Deyo’s lukewarm appraisal of our profession ignores more positive studies. I reviewed his book earlier this year.]

review of available evidence from the Cochrane Collaboration, a global network of researchers, concluded that “combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute/subacute low-back pain.” And other studies have shown that chiropractic treatment or exercise may be more effective than painkillers for the relief of neck pain. Yet the Cochrane reviewers pointedly added that there was “no evidence” that chiropractors “provide a clinically meaningful difference for pain or disability” for lower-back pain “when compared to other interventions.” [That review flies in the face of numerous studies (AHCPR, Manga, Optum) and was debunked by many medical experts, such as Roger Chou who said “it is not a game-changer.” Indeed, Ms. Ellison dug deep to find anything critical rather than mentioning the positive studies.]

Dr. Deyo said the mechanism of how chiropractic care might help still isn’t well understood  (by him, at least), although he speculated that a combination of factors might be responsible, including some muscle relaxation, possibly “a realigning of the facet joints on vertebrae that help maintain alignment,” and a powerful placebo effect conveyed by the hands-on treatment. [Deyo is an internist/family practitioner who apparently is out of his area of expertise.] Yet another factor might be the simple passage of time, he said, adding that “most people with back problems seek treatment when they’re at their worst. They’re probably going to get better on their own, with or without care.” [Ignoring back pain is like ignoring a toothache or chest pains—it may subside, but the underlying problem did not go away. Again, Deyo ignores joint dysfunction as a main  cause of LBP. As a panelist of the AHCPR study, I find his omission shocking.]

There’s a case to be made for patience, given that the basic procedure is not without some documented dangers, particularly when it comes to the treatment of neck pain. [Here we go on her Chicken Little witch hunt.]

Last year, the American Heart Association urged practitioners to inform patients of a possible association between neck manipulation and the risk of a tear in the artery walls in the neck that could result in a stroke, although it noted that “it cannot be said with certainty that neck manipulation causes strokes.” A 2007 report in the journal Spine estimated that the risk of any “seriously adverse effect” of cervical spine manipulations, including a serious worsening of pain or “persistent or significant disability/incapacity” was at worst six per 100,000 treatments.[Too bad she didn’t read my analysis of this stroke slander before posing as another medical shill taking a cheap shot.]

William Meeker, president of the Palmer College of Chiropractic-West Campus in San Jose, Calif., maintained that the risk of a chiropractic adjustment causing “morbidity or mortality” was a fraction of the risk of taking a course of aspirin. [You give her hell, Bill.] He said chiropractors were generally better trained than ever, minimizing the risk of harm from such procedures. 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. At the same time, Dr. Deyo and other experts have expressed concern about the tendency of some members of the profession to dabble in a widening variety of medical realms, in a kind of mission creep. “I’ve spoken with chiropractors who assert they treat diabetes and heart disease and thyroid problems, and I have to say I’m skeptical,” Dr. Deyo said. [Obviously he fails to understand the concept of neurophysiology.] A brief Internet search confirmed that some chiropractors claimed to offer such therapies as “pendulum divination,” “biological terrain assessment” and “herbal crystallization analysis.” [Why is it I’ve never met any DC who professes these “mission creeps”? Again, is Ms. Ellison looking for any outlier she can find to cast aspersion upon our entire profession, just as she admits her father did?]

I can only imagine what my dad would have said. [The same thing she’s alluding to!]

I got a front-row-seat view of the industry’s holistic possibilities a few minutes into my appointment with a chiropractor who had been so highly recommended by a friend that I rashly didn’t check beforehand if he had contracted with my insurance plan. (Turns out he hadn’t: Despite all that lobbying, many chiropractors would rather not deal with insurance.) [Sounds exactly like most MDs, too.]

To my surprise, and temporarily stunned acquiescence, what I’d imagined would be a brief encounter resulting in a soothed tailbone for $125 (the fee quoted by the receptionist) turned into a three-hour “wellness” exam, with more than $300 in extra charges. [Okay, apparently she got involved with  some “practice-manager” devotee who ran up her bill.]

Long before he looked at my spine, the chiropractor inspected the rest of me with various instruments, alerting me — by dictating loudly to his assistant, who scribbled on a pad — that I was suffering, among other things, from a potential Candida infection in my mouth, a slight tremor and muscle wasting in my hand, possible Lyme disease, bone-density loss, mismatched leg lengths, a worrisome “brown spot” on my right eye and an asymmetrical smile. [Did this DC ever find any vertebral subluxations or is he a ‘medipractor’?]

The founding theory of the chiropractic profession, dating back to 1895, is that everything is connected, and that harm to the nervous system caused by a skeletal misalignment can lead to a gamut of health problems. But who knew the tailbone was connected to the smile bone? [“Smile bone”? Here comes her cynicism.]

I’d entered that office considering myself a relatively healthy, if aging, woman, but left feeling like a walking time bomb. I couldn’t have foreseen there’d be so many completely new things to worry about. This may explain why I worriedly ended up agreeing to a supposedly essential set of X-rays for $165, although I managed to decline the offer of proprietary vitamins for sale at the front desk. [I don’t blame her on that.] Only in the last 15 minutes of the appointment did the chiropractor manipulate my tailbone — for less than five minutes — after which his assistant deployed what she told me was ultrasound therapy, for an extra $70 that was disclosed only when I was handed the bill. [Definitely bad patient management by the DC.]

The jury is out as to whether any of it helped, since my tailbone didn’t stop hurting for another couple of weeks. Was it merely the passage of time, as Dr. Deyo had suggested, or did that 15 minutes of touch and heat — and maybe some placebo effect — do the trick? [Why didn’t the DC suggest it may take more than one adjustment to stabilize her pelvic problem?]

My chiropractor did do me a service by urging me to get my bone density checked — which I did, at a specialist’s lab, resulting in a diagnosis of osteoporosis (sigh) and a prescription for Fosamax. While, after all my research, on balance I’d be willing to visit a chiropractor again for serious lower-back pain, I plan to pursue “integrative wellness” at least in the near future by nudging my primary care doctor for periodic, thorough checkups. [What does a PCP know about wellness—more drugs?]

The next time I see him, I’ll ask if I should worry about my crooked smile. [Okay, she’s allowed a cheap shot after what she went through.]

Katherine Ellison is the author of several books, including the forthcoming “ADHD: What Everyone Needs to Know,” written with Stephen P. Hinshaw, vice chairman for psychology at the University of California, San Francisco.

Postscript by JCS

Sadly, this article had the makings of a good article until the writer soured after her visit with a DC using marginal methods. She seemed bent on finding the extraordinary elements in our profession and regrettably stumbled into a practice that was, indeed, quite extraordinary in suspicious ways. Methinks her chirophobic father had instilled in her a bias that she could not overcome in the end.

She never did mention the Gallup/Palmer survey or the many studies supporting SMT.

She also totally ignored the massive criticism of medical spine care—opioid painkillers, ESI never approved by FDA for LBP, and the debunking of the ‘bad disc’ premise for spinal fusions. Apparently her focus was solely on chiropractic and to nit-pick on her experience with one DC who obviously is not mainstream.

So, another golden opportunity in The New York Times goes down the PR toilet.