The recent uproar about the chiropractor who was accused of breaking an infant’s neck has provoked renewed discussions about the role of chiropractors, not only in the care of children, but in general. We have addressed chiropractic many times on this blog. While spinal manipulation therapy (SMT) is an effective option for treating certain types of low back pain, chiropractors typically do a lot of other things that are not evidence-based, can be dangerous (strokes from neck manipulation), and are often outright quackery like applied kinesiology. Chiropractic treatment of children has been called child abuse, and even some chiropractors have spoken out against it.
Chiropractors have protested in the comment threads that we have an outdated, biased view of chiropractic, and that modern chiropractic practice is very different. They claim that they have rejected the original basis of chiropractic (the subluxation/nerve interference/innate paradigm), that they reject all forms of quackery, that what they do is based on scientific evidence, and that they have an important role to play in modern health care. We think that “reformed” attitude is rare. We would love to know what percentage of chiropractors fall into the “reformed” category, but no studies have been done to answer that question. Now there is a new study from Australia that provides important information about the state of chiropractic practice in that country. While it can’t answer the question about the number of “reformed” chiropractors in the US, it does shed some light on the subject.
The broken neck accusation: Unanswered questions
First, a brief review of the broken neck accusation. A chiropractor treated a 4-month-old baby with torticollis (wry neck), the baby developed a loss of head control after the treatment, and a subsequent x-ray was interpreted as showing a “hangman’s” fracture. A review commissioned by the Australian Health Practitioner Regulation Agency (AHPRA) and carried out by the Chiropractic Board of Australia (CBA) found that the baby did not have a broken neck, but rather a congenital defect called spondylolysis, where certain areas of the vertebral arch are absent, leaving a defect that can look similar to a fracture. The review found that the chiropractor did not cause a fracture, but it found other problems with his history-taking and examination of the child and with his record-keeping. The case against the chiropractor was closed after he agreed to get further education. No explanation was ever offered for the baby’s loss of head control; the chiropractor who wrote the report thought it was unrelated to the treatment.
Here the story gets murkier. The pediatrician who treated the infant stood by his original diagnosis. He said that the baby had both a fracture and a congenital defect (that the chiropractor had overlooked), that the congenital defect put the child at greater risk of fracture and complicated the baby’s treatment for the fracture, and that a follow-up CT scan done 6 months later showed new bone formation that confirmed the diagnosis of a healing fracture. The AHPRA report and a later review by an unnamed “internationally renowned” radiologist insisted that no fracture had occurred. But apparently the consensus of the baby’s doctors was that it had, since last week the Friends of Science in Medicine newsletter reported that the baby spent six months in a neck brace.
Michael Vagg wrote an account of the whole kerfuffle. The AHPRA report was inappropriately leaked to the public. This was a massive failure on the part of the CBA, which must maintain confidentiality in order to protect the integrity of future investigations. The Chiropractor’s Association of Australia (CAA) protested loudly, demanding retraction of the news story and claiming that no child had ever been injured by chiropractic (a demonstrably false claim).
With no resolution of the conflicting radiologic interpretations, and with the other unanswered questions, we can only speculate about what really happened.
The COAST study
The new study is titled “Chiropractic Observation and Analysis Study (COAST): providing an understanding of current chiropractic practice.” It was published in The Medical Journal of Australia in November, 2013. The eight authors included medical professors, chiropractors, ethicists, and statisticians. The full text is available online.
It was a cross-sectional study using the established BEACH (Bettering the Evaluation and Care of Health) methods. 180 chiropractors in Victoria, Australia were randomly chosen from the register and 52 eventually completed the study (a satisfactory response rate). Female chiropractors were under-represented, but otherwise the respondents were similar to the general population of chiropractors. They were asked to record details of 100 patient encounters by hand on paper forms, and they were given a $200 honorarium as an incentive. A total of 4,464 patient encounters were recorded. The forms documented several things:
- Demographic characteristics of chiropractors
- Demographics and health profiles of patients
- Reasons patients gave for seeking chiropractic care
- Problems and diagnoses identified
- Care provided
Selected results (numbers rounded):
- Characteristics of chiropractors (see Box 1)
- The mean number of patient care hours a chiropractor worked in a week was 27, spread over a mean of 6 clinic sessions
- The mean number of patients seen per week was 84
- Patient characteristics (see Box 2):
- 58% of patients were women
- 44 patients were under the age of one year (1% of total encounters), 3% were age 1-4 and a total of 9% of patients were under the age of 15
- Information on age spread, language, ethnicity, and occupation was reported
- Source of payment: patient 81%, health insurance 46%, plus a very small percentage paid by workers compensation and other sources
- Problems managed (see Box 3)
- Most common: back problems – 46%
- Neck problems – 11%
- Muscle problems – 7%
- Other musculoskeletal diagnoses (all less than 4%, listed in descending order of frequency) included back syndrome with radiating pain, “other,” sprains and strains, shoulder problem, nerve-related problem, bursitis/tendinitis/synovitis, kyphosis/scoliosis, foot or toe complaint, ankle problem, osteoarthritis (not spine), hip symptom, leg or thigh symptom, injury (0.55%)
- Non-musculoskeletal diagnoses – health maintenance or preventive care 4%, headache 3% (some of these could have been of musculoskeletal origin), nerve-related problem 1%, general complaints 1%, and depression 0.48%
- Advice provided: therapeutic exercises in 52% of encounters, general exercise 21%, posture 21%, ice packs 11%, heat therapy 8%, supplements 5%
- Other information: median duration of encounter 15 minutes (range 11-20), follow-up recommended in 85% of encounters, patient referred by another patient 52%, referred by a GP 4%, referred to a GP 3%
- Techniques used (Box 4)
Explanation: Activator = a hand-held spring-loaded device that delivers and impulse to the spine, drop piece = chiropractic table where a section of the patient’s body can be quickly lowered, blocks = wedge-shaped blocks placed under the pelvis, chiro system = includes applied kinesiology, sacro-occipital technique, and neuroemotional technique, flexion distraction = a treatment table that flexes in the middle for traction and mobilization of the lumbar spine
Infants and children only represent 1% and 9% of chiropractic patients, but even that is too many, since there is no evidence that children benefit from chiropractic treatment and there is a risk of injury.
Chiropractors are often thought of as “back specialists” but less than half of visits are for back problems.
About 10% of visits are for non-musculoskeletal problems. There is no evidence that chiropractic is effective for non-musculoskeletal problems.
“Health maintenance” was listed for 4.24% of encounters. It wasn’t clear how many of these visits were for maintenance adjustments. There is no evidence that maintenance adjustments provide any benefit to patients. There is controversy among chiropractors about whether “chiropractic wellness care” should be an integral part of their practice.
The category of “spinal problems” included an unspecified number of chiropractor-recorded diagnoses of “chiropractic subluxations” without a definition of what that meant. Most chiropractors no longer believe there is a bone out of place and use the word to mean dysfunction rather than displacement. It would be better if the term “subluxation” was no longer be used at all, since “no supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention” and “the subluxation construct has no valid clinical applicability.” In other studies, 98% of chiropractors believed that “most” or “many” diseases were caused by spinal misalignments and over 75% of chiropractors believed that subluxation contributed to 50% or more of visceral disorders like asthma or colic. The present study really doesn’t tell us anything about Australian chiropractors’ beliefs; it only tells us what diagnoses they wrote down.
There is cause for concern in the treatments listed. Activator methods are not supported by evidence. Half of American chiropractors in a 1991 survey said they used them, but the percentage in this study appears to be much lower, around 20%. The use of “chiro system” appears to be around 12%, but that is worrisome since the methods that includes are all bogus: applied kinesiology, sacro-occipital technique, and Neuro Emotional Technique (NET). The study showed that 5% of chiropractors recommended supplements, but it did not specify which supplements were recommended, so we have no way of knowing if any of the recommendations were evidence-based.
This new study doesn’t tell us what percentage of chiropractors try to follow science-based principles, but it offers some hints that will have to do until a study is done to address that question directly. It tells us that a substantial number of chiropractors use quack methods, and the ones who do obviously can’t be science-based. It tells us that children are being treated with chiropractic in the absence of any evidence that it is effective. It suggests that these Australian chiropractors are not trying to act as family doctors or primary care gatekeepers, as some American chiropractors do. It doesn’t indicate that Australian chiropractors are trying to treat diabetes, as some American chiropractors have been doing. The study leaves many questions unanswered and raises some new ones; and it doesn’t provide any evidence to support the claims that chiropractic is being “reformed.” Preston Long thinks it hasn’t been and can’t be reformed from the inside; and if it could, it would no longer be “chiropractic.”
This article was originally published in the Science- Based Medicine Blog.