#48: Chiropractic, Goop, and the war on reason
[The following is an excerpt from 'The Skeptic's Guide to Sports Science', Chapter 9: Complementary and Alternative Medicine in Sport - www.nbtiller.com/book)]
Chiropractic differs from many of the alternative therapies already discussed because it has no roots in traditional Eastern medicine, and is a relatively new invention. The UK National Health Service provide the broadest definition of chiropractic: a treatment where a practitioner called a chiropractor uses their hands to help relieve problems with the bones, muscles and joints. The treatment was conceived in the late 1800s when D.D Palmer (an anti-vaccination proponent with a staunch belief in the magical properties of magnetic healing) allegedly restored hearing to a deaf man by adjusting his spine. Needless to say, the plausibility of such a miraculous feat is decidedly weak. Palmer, concluded that nearly all physical ailments should be attributed to subluxations of the spine, and chiropractic was born. More contemporary chiropractic has distanced itself from subluxations of the spine as the sole determinant of illness, principally because it’s an absolute claim that can be tested (via x-ray, for example). Chiropractic now self-identifies as a system of specific manipulations designed to free-up joints in the body that aren’t moving properly; it’s purported to influence neural pathways and general health.
Used extensively by individual athletes and sports teams, particularly in the United States, a 2002 survey [see ref. 130] on chiropractic use among the teams of the National Football League (NFL) had 22 responses, and highlighted the sport’s perceptions of this alternative treatment. Certified trainers generally considered chiropractors to have an important role in the NFL, principally for treating lower-back pain and other musculoskeletal injuries. A majority of trainers (77%) had referred at least one player to a chiropractor, and 31% of teams had one on staff. But such widespread use (at least within professional football) says nothing of the treatment’s effectiveness.
While exploring databases for studies on chiropractic, it was apparent that the literature was saturated with case-studies, review articles, commentaries, and opinion pieces, but largely devoid of randomized, placebo-controlled trials (i.e., high-quality studies). This relative deficiency renders it problematic making any firm conclusions on the effectiveness of chiropractic beyond we need better research if we are to recommend chiropractic. Moreover, it’s troublesome even interpreting some of these data given that such a majority are published in journals aligned with chiropractic; the Journal of Manipulative and Physiological Therapeutics, for example, is the official journal of the American Chiropractic Association. The Journal of the Canadian Chiropractic Association have a homepage on which they espouse the "scientific quality and vigor of the journal [sic]"; I suspect they mean scientific rigor, and the mistake doesn’t inspire me on their rigor or vigor.
From a journal not directly aligned with a chiropractic organization came a 2010 study on chiropractic claims in the English-speaking world  with the aim of assessing the frequency with which affirmative claims were made about the effectiveness of chiropractic in treating asthma, headache/migraine, infant colic, colic, ear infection/earache/otitis media, neck pain, and whiplash. The authors reviewed 200 websites published by chiropractors, and the claims of nine chiropractic associations in Australia, Canada, New Zealand, the United States, and the United Kingdom. Their investigation revealed that 190 (95%) chiropractic websites made unsubstantiated claims regarding at least one of the aforementioned conditions. Moreover, 90% of websites and all nine associations made unsupported claims about headache/migraine, specifically. Such an overt disparity between claims and empiricism is a damning indictment and, as the study concludes, represents an ethical and public-health issue.
Although chiropractic-related adverse events are rare, there is documented evidence of gross negligence which warrants consideration, if only to serve as a warning on the dangers of pseudoscience-based practice. Published case-reports and case-series highlight more than 200 patients who were suspected to have been seriously harmed during spinal manipulation, with the most common adverse event reported as vertebral artery dissections , whereby an artery located in the neck, and which supplies blood to the brain, sustains a flap-like tear to its inner-lining. While 200 injuries are more-than-sufficient, be mindful that this number represents just the published cases, and there likely exist countless others which remain unreported.
Perhaps of greater concern is the practice of neonate chiropractic; the spinal manipulation of babies. There are several reports detailing injuries inflicted on babies and small children, including a 2013 case in which a baby’s neck was broken by a chiropractor. The injury was first reported to the Chiropractic Board of Australia who dismissed the case without reporting it to the public, allowing the chiropractor to continue practicing on the condition he undertook education with an expert in the field of pediatric chiropractic. By way of defense, chiropractors have distanced themselves from these horrific scenarios, and are quick to label those responsible as manual therapists rather than trained chiropractors, while opponents argue they’re one-and-the-same. Such pleading is reminiscent of the no true Scotsman fallacy, wherein one attempts to protect a generalization from counterexamples by changing the definition in an ad hoc fashion to exclude the counterexample.
Geoff: No Scotsman would put ice in his whiskey!
David: But my uncle is Scottish, and he puts ice in his whiskey…
Geoff: Ah, but no ‘true’ Scotsman would put ice in his whiskey.
Despite the research generally ill-performed, and the negative press, not all chiropractic claims are wholly unfounded. Indeed, the use of chiropractic for the treatment of lower-back pain has some mildly interesting data. For some patients with lower-back pain, spinal manipulation by a trained practitioner seems to be effective, but not more-so than most other forms of treatment. Even in this narrow domain, the data are of limited validity due to methodological deficiencies. Indeed, a review  in The Spine Journal (the official journal of the North American Spine Society) highlighted: "No studies combine high-quality cost data with adequate sample sizes and controls for confounding factors." From the American Chiropractic Association’s own journal, a 2006 review  on the treatment of lower-extremity conditions (i.e., foot, ankle, knee, and hip) suggested that: "future chiropractic research should use higher-level research designs, such as randomized controlled trials." The lack of RCTs, as aforementioned, represents a real deficiency in the data, and it appears that even for lower-back pain – which is the chiropractic mainstay – the evidence is decidedly weak. The principal concern is that double-blind studies (where both patient and practitioner are unaware of the treatment) are impossible, and single-blind studies are unlikely because patients generally know if their spine is being manipulated. Moreover, musculoskeletal pain is not an objective outcome. Finally, and mercifully, a critical review (a review of reviews) from 2011  collated data from no-less than 45 systematic reviews on numerous and varied conditions including: lower-back pain, asthma, pediatric conditions, and gastrointestinal problems. After assessing all outcomes, it was concluded: "collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition."
When it comes to clear and objective evidence, few practical and hands-on treatments can be considered to have such a negative record. And yet, chiropractic enjoys widespread mainstream success, with its own associations, clinics, degrees and doctorates, and many-a-practitioner on the payrolls of sports teams and private physiotherapy practices. It’s sadly common for the commercial noise surrounding a practice to exceed the evidence in support of its use, but the mismatch between claims to efficacy and supporting evidence is as great here as I’ve ever seen. In fact, it’s often the least-evidenced products that receive the greatest public lauding. This is something I’ve termed the evidence-paradox, and while its causes require more consideration, several potential attributions were postulated in Chapter 1. Many chiropractors are campaigning to be considered as primary caregivers alongside real physicians. This is a growing moral and ethical concern given the reluctance of some chiropractors to publicly acknowledge the deficiencies in the data, or take responsibility for the associated risks.
CAM is the result of therapies conceived without the grounding principles of evidence-based practice; at the very least, it’s not underpinned by evidence that’s deemed by modern medicine to be of sufficient standard, hence its alternative classification. Nevertheless, CAM thrives under such prohibition, and we see frivolous health advice administered in numerous facets of the industry. For example, consider Goop, a modern lifestyle brand founded in 2008 by actress Gwyneth Paltrow. The online magazine maintains an outwardly wholesome appearance, and the website catalogues articles on flattering styles of swimsuit, hair and makeup, food and fashion. Beneath the façade, however, numerous alternative practices are condoned, and while some are scientifically questionable, others may have demonstrably harmful effects. There are archives of articles on alternative medicine, supernatural phenomena, healing, and detox. Regarding detox therapies for the liver, for example, one article quoted an American naturopath:
“I have found that the majority of diseases that manifest physically originate in the etheric energy body,” … [the clinician] uses her own system of medicine. It draws on Ayurveda, homeopathy, yoga, anthroposophy, traditional Chinese medicine, and naturopathy to create personalized protocols to help people optimize their well-being."
Among the various concoctions available for purchase through the site is the Implant-O-Rama System; At Home Coffee Enema, priced at $135. This and similar products have been discussed in published medical reports documenting harmful repercussions of use (see Detoxing in Chapter 6). Despite being contrary to the advice of doctors and scientists – whose jobs depend on advising the public on best-practice in this respect – the product has sold very successfully to a global market. The Mayo Clinic (a prestigious, non-profit academic medical center based in the United States) advise that a colon-cleanse should only be considered when necessary to predicate a colonoscopy, and even then it should be performed under guidance from a physician, and by safer means. The Goop website famously published an article espousing the benefits of vaginal jade eggs, which was fast criticized by professional gynecologists. Finally, at the time of writing, the site contains a piece on How to connect with people who have died.
Many individuals (celebrities included) use their influence and reach to further their brand, help the needy, or promote a political message, but it’s axiomatic that much harm can be wrought when such individuals offer advice on which they’re not appropriately credentialed. It’d be particularly erroneous to prefer health advice from facets of the media over that from a physician or other health professional; the stakes are simply too high. We all have specialisms in which our opinions are valid; we should stick to our specialisms.
130. Stump, J. L., & Redwood, D. (2002). The use and role of sport chiropractors in the national football league: A short report. Journal of Manipulative and Physiological Therapeutics, 25(3), E2.
131. Ernst, E., & Gilbey, A. (2010). Chiropractic claims in the english-speaking world. The New Zealand Medical Journal, 123(1312), 36–44.
132. Ernst, E. (2007). Adverse effects of spinal manipulation: A systematic review. Journal of the Royal Society of Medicine, 100(7), 330–338.
133. Todd, A. J., Carroll, M. T., Robinson, A., & Mitchell, E. K. (2015). Adverse events due to chiropractic and other manual therapies for infants and children: A review of the literature. Journal of Manipulative and Physiological Therapeutics, 38(9), 699–712.
134. Baldwin, M. L., Cote, P., Frank, J. W., & Johnson, W. G. (2001). Cost-effectiveness studies of medical and chiropractic care for occupational low back pain. a critical review of the literature. The Spine Journal : Official Journal of the North American Spine Society, 1(2), 138–147.
135. Hoskins, W., McHardy, A., Pollard, H., Windsham, R., & Onley, R. (2006). Chiropractic treatment of lower extremity conditions: A literature review. Journal of Manipulative and Physiological Therapeutics, 29(8), 658–671.
136. Posadzki, P., & Ernst, E. (2011). Spinal manipulation: An update of a systematic review of systematic reviews. The New Zealand Medical Journal, 124(1340), 55–71.