Adventures in Chiropractic: Part 1, the consultation

It's been a decade since a libel action was brought by the British Chiropractic Association (BCA, the main association that regulates chiropractors in the UK) against science writer Simon Singh for a piece he wrote in the Guardian during Chiropractic Awareness Week where he said that the BCA "happily promotes bogus treatments". The case was eventually dropped by the BCA and it led to much-needed revisions of UK libel law, but not before chiropractic underwent a level of public scrutiny it had not faced before. It was an excellent example of the Streisand Effect.

I hadn't thought much about chiropractic in the intervening years until my sister developed painful and persistent sciatica from which she sought relief from anyone who offered hope. As her GP had been dismissive she sought help from outside the NHS and this is how she found herself visiting a local chiropractor. I was concerned for her, knowing that chiropractic manipulation has led to death and stroke but was also aware how much pain she was in and how desperate she was for it to go away.

Ten years is a long time, particularly in medicine, and it may be that chiropractic has changed for the better. So I thought that rather than rely on potentially out-dated information I would see for myself. I booked an appointment to see a chiropractor at the same clinic as my sister and so first thing on Monday morning I found myself sitting in waiting room for my consultation.

Patient Forms

Before the consultation began I had to fill out some forms. Some of the questions were basic stuff - name, address, age, doctor, etc. Others were more bizarre: they wanted to know if I was married and "if applicable", my partner's name. (As an aside, I get really fed up of companies thinking that marital status is anyone's business but mine and my hypothetical partner's.) There was a pain diagram that looked almost identical to this where I had to mark where on my body I had pain and of what type. I was asked for my "personal health goals" which included answering the questions:

• How long has it been since you have felt your best - years/months/days [delete as applicable]
• How long have you been thinking about pursuing your health - years/months/days [delete as applicable] 

Talk about leading questions!

Posture Analysis

Once the forms were complete there was another step before I could see the chiropractor; I had to have my posture analysed. This sounds highly technical but actually involved the receptionist taking photos of me with an iPad in the waiting room. It wasn't even against a plain or scaled background, I stood in front of the chairs and she took a photo of me looking at the camera and one side-on. I was wearing my ankle boots which have small (~1 ½ inch) heels and wasn't asked to remove them. I hate having my photo taken and go all stiff and unnatural so I have no idea how well it represents my true posture.

Medical History

The consultation lasted half an hour, about 20 minutes of which was spent chatting about my health. It seemed weirdly unfocused, with lots of pushing to try to get me to put time frames on when a particular ache or pain began but with little questioning of how the pain manifested or what, if any, treatment I received for it. I spoke about when I pulled a muscle in my lower back about 8 years ago which was so severe I couldn't sit down comfortably for a few weeks (to the extent that I quit my temp job), but there was no pressing on whether I got a formal diagnosis, or what treatment I had, or how long it took to recover. It wasn't that I was withholding, I would have happily volunteered the information if asked, but he seemed to have no interest in anything beyond what parts of my body hurt and how long they had hurt for.

Spinal Analysis

Finally we came to what turned out to be a rather cursory exam. The first part involved me standing on two electronic scales, one for each foot, and then looking forward so I "don't cheat" in order to determine whether or not I distributed my weight evenly. I put about 6kg more weight on my right side than my left and was asked if that "made sense" to me. I said yes, I regularly stand with my weight more on one side and at that time was favouring my right, but I did silently wonder how many people would have their weight perfectly evenly distributed. Fortunately, some research has been done on this and the answers are not that surprising. It turns out it's quite common to not have your weight evenly distributed between both legs, and for fairly simple reasons,

A broad supporting base, one of the prerequisites for a stable equilibrium, can easily be arranged by standing with the legs apart (observing the restriction mentioned above), but if a conscious effort is made to distribute the load-pressure as evenly as possible on the right and on the left foot, this is rather difficult. This fact can be proved by anyone attempting to stand with the right foot on one scale and the left foot on another, equally balanced.

Consequently there is every reason to assume that the load-pressure upon the feet is unequally divided between them when the individual takes up an upright position.

The position of the arms in relation to the body, and the turning and bending of the body to the right  or to the left, cause the centre of gravity to be thrown on to the right or the left leg, with the result that one leg receives more load-pressure than the other.

Marsk (1958) p4

A study of 40 healthy men found that it was common for weight to be unevenly distributed. The results showed the classic bell-curve of a normal distribution,

Frequency distribution of the average difference in weight supported between the feet during standing posture. Four measurements for each of 40 normal men. (Murray & Peterson, 1973; p743).

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The study found that the mean difference between legs was 5.4kg and the median was 4.8kg. Now, this study is just on men and is several decades old but the fact still remains that it is highly unlikely that anyone standing on the scales will have their weight perfectly evenly distributed across the two. That this is being used as evidence of problems that need correcting is disingenuous at best.

This test appears to be designed to make patients think there are problems with their bodies that need fixing rather than this uneven weight distribution being a just a normal and natural thing. The chiropractor certainly tried to make out that this was a sign of trouble ahead. He said that while 6kg might not sound that much, it means I'm putting almost a stone more weight on one side of my body, making that side work harder, and "you can guess which joints will show problems in 30 years' time". I wish I had the foresight to ask to take the test again to see if the results were repeatable, but like most patients it didn't cross my mind at the time to question its validity. I've certainly been unable to find any evidence to indicate that the results mean anything for long-term physical health

Miscellaneous Tests

Following our dalliance with the scales I took a series of tests to check for various and rather vague things. I bent over to try and touch my toes, then bend side to side and was asked if I feel any difference between the two sides (I didn't). I then had to lie on the bed face-down and he felt along my spine, finding "tension" all the way down. Then I had to lie face-up on the bed and hold my leg straight and lift it as high as I could. The chiropractor asked if it hurt and was the pain in my back or my leg. It was in my leg, because I have tight muscles and am not very flexible. He said I had some "tension" in my right leg, never really explaining what he meant by the term or if it meant anything significant.

I sat up for the next set of tests which were to check for range of motion in my neck. I had to turn my head to the left and the right, bend my head to the left and right, and look up and down. These are pretty standard tests that I've done for physiotherapists in the past. He said I had slightly more range when looking to the left than the right which meant I had lost "a little bit of movement", though unless I was able to turn my neck further in the past he has no way of knowing that.

I have no idea if you should have a exactly equal range of motion for both sides but it seems highly unlikely that you would. One study I found shows that normal range of motion varies between people and reduces with age, with no ill-effects, so unless I was outside that normal range of motion for my age group (I wasn't) I think trying to imply that there is a problem because I have a very slight difference in my ability to turn my head left compared to turning it right seems, well, disingenuous at best (a phrase I seem to be using more than usual in this piece).

I then had to extend one arm out from my side with my head facing in the opposite direction, first my right arm and then my left, to see if I got any tingling after 10-15 seconds. Apparently this would tell him if I had a "blood flow" problem or a "nerve" problem. He then felt my neck and located a couple of tight areas (weirdly missing the spot where I actually had some tightness) before going on to reflex tests. I was good in everything except for my left elbow (I didn't watch so I can't say if there was actually a problem there or not). This was explained as a problem with my nerve and that there was probably a "blockage" somewhere in my neck.

Finally he took my blood pressure and used a finger monitor to take various but unspecified readings which were "perfect". He also got me to do a grip test and gave me an anecdote about another left-handed patient who apparently had more grip in her right hand than her left and chiropractic fixed this without trying. When I came to do the test I realised that I unintentionally wasn’t gripping so strongly with my right hand so as not to be like that patient. The perils of anecdotes!

Conclusions So Far

I'm writing this post after the adventure has concluded so it's hard to not have the later experiences impact on my views, but I was already feeling quite concerned. I knew enough about chiropractic to know that neck manipulations were dangerous and the way the chiropractor seemed determined to trace everything to my neck worried me.

The consult had the gloss of a proper medical consultation – I was asked for a pain-related medical history and given standard movement tests that I’ve done in the past – but thinking about it later, and especially while writing this post, it is clear that it is nothing more than a gloss, a sheen, that tries to hide the lack of substance beneath. The medical history didn’t ask anything about other aspects of my health – I’m currently on antidepressants which didn’t raise any questions other than how long I’d been on them, and I had a bad cough throughout the appointment yet it was never even acknowledged, let alone asked about. Equally, there was no questioning of family history of back or joint related issues, despite sciatica and arthritis running in the family.

I didn’t go in with a specific complaint, rather I said I was seeing him as a sort of birthday treat to myself as I’m getting stiffer in the mornings and taking longer to recover from exercise. He was happy that I had come in early rather than leave things until they were serious, but I got a real sense that he felt that without chiropractic my body would be on a downward spiral from which it would not recover.

Every problem I had was due to either “tension” or my “nerves”. My aches and pains were all traced to nerves in my back and neck, with no acknowledgement of the importance of, say, muscles. I found this focus on the nerves strange, and a bit disconcerting as the body is more than just a receptacle for our nervous system.

I left the consultation and mentally compared it to the consult my sister had with an A&E doctor when her pain had her in tears one day. The doctor gave her a very thorough exam. They went through a massive number of movement tests, quickly and professionally, and explained their findings and why they were confident that she hadn't slipped a disc (phew!) and it was sciatica caused by inflammation around her sciatic nerve. They gave a clear treatment plan and guidance on what to do if things improved and if they didn't. We came away reassured and clear in how to proceed. In contrast, the consult with the chiropractor involved very basic tests, with results that were made to seem concerning rather than reassuring, and I was left ill at ease with the state of my body. 

Update
Posts two, three and four are now up.

References

Marsk, A. (1958) Studies on weight-distribution upon the lower extremities in individuals working in a standing position: assessing the results of the measurements of load-pressure differences against the background of handedness and some clinical observations, Acta Orthopaedica Scandinavica, 29: sup 31, 1-64.

Murray, P. & Peterson, R. M. (1973) Weight distribution and weight-shifting activity during normal standing posture. Physical Therapy, 53: 741-748.

 

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-->Swinkels, R. A. H. M., & Swinkels-Meewisse, I. E. J. C. M. (2014) Normal values for cervical range of motion. Spine, 39: 362–367. -->