Here's my latest article for Argument magazine. My original idea was to investigate a specific chiropractor, whom I know treats very young children (no more than a few months old), but because of time constraints I went with a straight-forward skeptically-minded write-up. The format and requirements for Argument meant that it ended up being quite different to the (very long) article I had originally planned, but that might not actually be a bad thing.
I'll post a link to the full PDF edition of the magazine as soon as it's up.
Chiropractors turn their backs on the evidence
The popularity of chiropractic treatment for children continues to rise, despite the lack of evidence that it works.
In mainstream medicine, new therapies and treatments are subjected to rigorous clinical trials and rounds of review before they are approved for use on patients. The same rules don’t seem to apply to chiropractors and other alternative therapy practitioners. The ubiquity and apparent medical legitimacy of chiropractic means that we’ve ended up in a situation where more and more children are being treated in ways that don’t work and might even be dangerous.
Pseudoscientific and mystical origins
The illustration was done by Jonas Alexander Larsen especially for this article.
Few people are aware that chiropractic’s origins have nothing to do with treating back pain. Just over a century ago, in 1895 to be precise, a Canadian by the name of Daniel D. Palmer smacked a deaf janitor on the back, and, so the story goes, gave the man his hearing back. Shortly afterwards, Palmer readjusted the spine of someone suffering from heart trouble and apparently provided immediate relief. Convinced that the two cases couldn’t be a coincidence, Palmer put two and two together and made chiropractic.
As the spine houses the nerves that run from the brain through the rest of the body, Palmer reasoned that misalignments in the vertebrae of the spine interfere with nerve connections and disrupt the flow of the body’s ‘guiding energy’.
He called this energy ‘innate intelligence’, something not unlike the Chinese concept of chi, and thought it was connected to God. The core of chiropractic is the application of short sharp force to push the displaced vertebrae back into alignment, which allows the body’s energy to flow again and optimises health. Palmer was so convinced by this idea that he claimed "99% of all diseases are caused by displaced vertebrae" – throwing germ theory right out of the window.
No better than conventional therapies
There are countless conventional medical treatments where we’re not sure exactly how they work – we just know that they do. Whether or not chiropractic realigns energy flow (it doesn't) isn’t the most important issue. The most important issue is whether or not it actually works. More than a hundred years after Palmer came up with chiropractic, we’re still no closer to finding any solid evidence to support many of the therapeutic claims made by chiropractic practitioners.
Whilst there are some practitioners who still believe in Palmer’s idea of innate intelligence – an idea that contradicts all of what we know in modern science and medicine – many chiropractors actively distance themselves from chiropractic’s vaguely mystical origins and instead concentrate on treating musculoskeletal problems like chronic neck or back pain. As a treatment for adults with back pain, chiropractic works just as well and no better than standard physiotherapy, exercise and non-steroidal anti-inflammatory drugs (NSAIDs) like Ibuprofen – the only difference is that chiropractic is a lot more expensive and chiropractors have a vested interest in keeping you in treatment for as long as possible.
Manipulating parental concern
But it’s not just adults with bad backs that chiropractors treat. Many of them have taken advantage of new parents’ heightened concern and uncertainty as a way of locking children into cycles of treatment. The Norwegian Chiropractors association’s Mother and Child page starts with (translated into English)
“To be born can be a huge strain on the body. The child is generally resistant to this, but even a normal birth can have a major impact on the child … This may lead to symptoms that are noticeable immediately after birth, or only after a long time. Flatulence, colic and crying are some of the most well known… Often this is due to blockages and malfunctions of the spine.”
So-called ‘Traumatic Birth Syndrome’ is apparently painless in 95-97% of sufferers. The only way to detect TBS is a chiropractic examination, but there’s actually no good evidence that chiropractors can even detect anything in babies’ spines, which are mostly made of soft cartilage and hidden under lots of fat, with just their fingers.
Many of the things chiropractors claim to treat in children, such as poor feeding, unsettled sleep patterns, crying, restlessness, being easily startled, preferring to feed on one side and reflux, are normal things that affect nearly all children at some time or other and mostly resolve themselves over time. Some chiropractors also claim to treat much more serious conditions, such as cerebral palsy, epilepsy, ADHD and Tourette’s syndrome, which is the kind of ‘panacea’ thinking that is much closer to chiropractic’s pseudoscientific, magic panacea origins, than its legitimate claim as a therapy for back pain.
Low levels of evidence
This tactic of manipulating the worries of new parents seems to be working; ‘preventative’ or ‘wellness’ care is one of the most common reasons why young children are taken to a chiropractor, despite the fact that it’s based on a scientifically implausible idea. A 2010 survey of nearly 1000 chiropractors from across Europe found that more than 95% of them had treated children in the past year (around 20,000 children per month), mostly for musculoskeletal pain.
After reviewing all the available data, first in 2005 and then again in 2008, two chiropractors from the Canadian Chiropractic Association concluded that “
Health claims made by practitioners regarding the application of chiropractic manipulation as a health care intervention for paediatric health conditions are, for the most part, supported by low levels of scientific evidence.” Another review in 2012, again by chiropractors, found that the number of studies had gone up significantly but, importantly, the quality of the studies hadn’t. Researchers had looked into things like colic and even bed-wetting and jet lag, but there was not a single study investigating whether chiropractic helps children with back pain, despite, as the 2010 survey showed, musculoskeletal pain being the principal problem chiropractors claim to treat.
As an example of how the scientific evidence continues to be ignored, the Norwegian Chiropractors' Association continues to advertise chiropractic spinal manipulation as an effective treatment for infant colic, despite a comprehensive review of the published literature in 2009 (by scourge of alt-med practitioners, Edzard Ernst) concluding that ‘the totality of this evidence fails to demonstrate the effectiveness of this treatment’.
Without lots of properly conducted clinical trials, it’s very difficult to tell whether people report feeling better because of placebo effects, misdiagnosis of the original illness, the effect of other on-going treatments, or things just getting better with time.
Serious and under-reported risk
So it may not work, but is it dangerous? No medical intervention is entirely without risk, but there's a reasonable expectation that the benefits of a treatment outweigh its potential risks. The problem with chiropractic, especially with children, is that there isn’t any evidence that it works to balance out the increased risk that the child is subjected to. A systematic review of 13 studies published up to June 2004 uncovered 14 significant spinal manipulation-related injuries in children up to 18 years of age, 9 of which were serious and 2 of which were fatal (one child died from a brain haemorrhage and another from dislocation of a bone at the base of the skull following neck manipulation). Ten of the 14 injuries were attributed to treatment at the hands of chiropractors.
The numbers of serious injuries is low because the risk is low, but the number of children who suffer side-effects and injuries is likely to be much larger. Adverse events related to chiropractic are chronically under-reported, largely because chiropractors in most countries are not regulated and monitored in the way same as conventional medical practitioners. Here, the precautionary principle in medicine should apply: in the absence of scientific consensus on the risk of manipulating children’s spines, the burden of proof falls on chiropractors to show that it is not harmful, and they can make a start by thoroughly and systematically documenting and reporting patient outcomes.
There isn’t just the direct harm of the chiropractic treatment, but also the indirect harm caused by avoiding necessary conventional treatment: Many fundamentalist chiropractors are against childhood vaccinations, for example. Paying for extended periods of treatment that you don’t need and doesn’t work can also be considered a financial harm - not to mention parents running the risk of incurring the child’s wrath when they find out good chunk of their inheritance was spent on getting them expensive back-rubs.
Either deceiving themselves or their patients
Chiropractors who perform spinal manipulations on children either believe in Palmer’s nonsensical, unscientific principles of chiropractic, or, if they have tried to modernise their medical philosophy, continue treating patients despite the fact that what they’re doing hasn’t been shown to work or has been shown not to work. They’re either deceiving themselves or they’re deceiving their patients; in either case they’re undermining their case for legitimacy as a genuine medical therapy and putting patients at risk unnecessarily.
‒ Chiropractic has been practised in Norway since the early 1920s.
‒ Although it is still considered an alternative therapy in most countries, chiropractors have been considered licensed health care professionals in Norway since 1988 and the practice became integrated into public health services in January 2006.
‒ There are currently just over 600 registered chiropractors in Norway.
‒ They perform an estimated 1,5 million examinations and treatments a year on the 7–8% of the Norwegian population that visit them.
‒ Chiropractic in adults works just as well and no better than exercise and painkillers when it comes to treating back pain – it’s just a lot more expensive.
‒ Back pain is the most common reason why children are treated by a chiropractor, even though there has yet to be a single study published showing that it works.
‒ For any non-back-pain-related problems, there is no reliable evidence that chiropractic works any better than a placebo.
Sources and further reading
Alcantara, J., Ohm, J., & Kunz, D. (2010). The chiropractic care of children. Journal of complementary and alternative medicin. 16, 6, 621–26.
Cohen, M. H., & Kemper, K. J. (2005). Complementary therapies in pediatrics: a legal perspective. Pediatrics, 115, 3, 774–80.
Cunningham, D. (2012) Science Tales. Brighton: Myriad Editions.
Ernst, E. (2009). Chiropractic spinal manipulation for infant colic: a systematic review of randomised clinical trials.Complementary Medicine. 63, 9, 1351-53.
Gleberzon, B. J., Arts, J., Mei, A., & McManus, E. L. (2012). The use of spinal manipulative therapy for pediatric health conditions: a systematic review of the literature. The Journal of the Canadian Chiropractic Association. 56, 2, 128–41.
Gotlib, A., & Rupert, R. (2005). Assessing the evidence for the use of chiropractic manipulation in paediatric health conditions: A systematic review. Paediatrics & Child Health. 10, 3, 157–61.
Gotlib, A., & Rupert, R. (2008). Chiropractic manipulation in pediatric health conditions--an updated systematic review. Chiropractic & Osteopathy. 16, 11.
Homola, S. (2010). Should Chiropractors Treat Children? Skeptical Inquirer, Volume 3,4. Retrieved from http://www.csicop.org/si/show/should_chiropractors_treat_children/.
Lee, A. C. C., Li, D. H., & Kemper, K. J. (2000). Chiropractic Care for Children. Archives of Pediatrics and Adolescent Medicine. 154, 401–407.
Norsk Kiropraktikforening (n.d.). Om barn og utvikling. Retrieved from http://www.kiropraktikk.no/?PageID=115
Singh, S. Ernst E. (2009). Trick or Treatment. London: Corgi.
Spigelblatt, L., et al. (2002). Chiropractic care for children: Controversies and issues. Paediatrics & Child Health. 7, 2, 85–104.
Vohra, S., Johnston, B. C., Cramer, K., & Humphreys, K. (2007). Adverse events associated with pediatric spinal manipulation: a systematic review. Pediatrics. 119, 1.