Adventures in Chiropractic: Part 4, the report

Parts 1, 2 and 3 can be found here, here and here.

Background

When I started this little investigation I had to decide how to go about it. What would be the premise for me visiting a chiropractor? Something must have made me decide to visit. Would I make up conditions, would I exaggerate minor problems or would I be truthful? I decided to go with truthful, not least because I'm a terrible liar and have a bad memory so would probably forget a key point and get found out. The only thing I did do was give a false surname as I didn't want them to associate me with my sister, mostly because I didn't want anything to reflect badly on her if things went wrong.

Fortunately I've been having some issues that could arguably warrant investigating. I get pins and needles in my left hand when I wake up some mornings. It's completely dead and like I'm wearing a very large glove over it, but after a few minutes of consciousness (usually accompanied by rolling off the arm) it's back to normal. Also in the mornings I ache a lot, mostly after I've been doing physical activity the day before (I took on an allotment earlier in the year that required a lot of work and I have dug over every inch of it over the last few months). I have some pain in my left hip occasionally, again mostly when I'm asleep. The pain seems to enter my semi-conscious dreams but will go away within a few minutes of consciousness. Finally, I get some pain in my right knee, intermittently. Probably the most problematic of this litany of aches and pains (god I hate getting older!) is the morning stiffness. My bedroom is on the second floor so I have a lot of stairs to descend each morning, and I feel a bit like Frankenstein's Monster on occasion, staggering down with my knees struggling to bend. Stomp stomp stomp. 

So that was the list I took to the chiropractor. As to why now, well, it had recently been my birthday so I said it was a "treat" to myself to get things checked out. I tell you this now because the report is to inform me how he proposed to treat these problems.

I had also decided that while I would be truthful about my science background, and the fact I am trying to complete my PhD, I would not present as sceptical about the treatment. I would listen and wouldn't appear incredulous or ask any awkward questions. Prior to this appointment I decided to change tack slightly and use what was most likely my last interaction with a chiropractor to get some clarification on the things he had said in his talk.

The Summary
As I entered the room he asked how I found the talk the previous night and asked what I learned from it. I said it had raised some questions but I would get to them at the end of our appointment, mostly because I didn't trust myself to maintain my credulity. He said he was going to go through the summary of my problems, then go through the treatment process, discussing how long it will take to get me better and how much it will cost. 

He briefly summarised my problems, and mentioned my cluster headaches as something that I hadn't come to him about but he wanted to discuss later (he never did). He said that my problems had been getting progressively worse over the last year, a characterisation to which I objected. I've been more physically active this last year than I have been for a few years, and it takes time for the body to adjust to that, whereas he was making it sound like there had been a progressive deterioration in my condition that could lead to serious consequences for me if I don't get treatment. He was surprised that this was how I had interpreted him and gave yet another example from dentistry. He asked me if I woke up with toothache one morning would I think that was from a short-term problem or a long-term problem that I hadn't noticed? I said it depended on what was causing the tooth ache, an answer he didn't seem to be expecting. He went on to explain that the point he was trying to make the previous night was that people think that problems that have only been affecting them short-term must therefore have short-term solutions and it's not like that at all.

I countered him by saying that sometimes things do have a short-term cause and used an example of a car accident. You can't say that every time I get in a car I am causing mini-problems which cause damage, I get in a car with no negative consequences and then one day I'm in an accident which causes, say, whiplash or a broken leg. I said the way he made it sound was that everything we do harms our body which I don't feel is entirely accurate. He said he "understands [my] point of view and in some ways [he] agrees and in other ways [he] would disagree because everything we do to our body has a consequence". "But some of those consequences can be positive," I replied, which he admitted was true. After all, I reminded him, when we exercise we ache but we have also improved our health. The point he claimed to be trying to make was that if he took the patient at face value that a problem had only been present for a few months then he'll treat as such and if he fails to make the patient better he's "misinformed" that patient. It's about being "realistic" and "honest".

He was happy that we'd caught my back problems early, but he was concerned with the numbness in my hands because "that's nerves, that's pressure, you can't deny that". He then conflated my numbness and my general aches and pains and said I shouldn't be feeling so stiff in the mornings. He's eight years younger than I am and he doesn't wake up feeling achy every morning. I reminded him that eight years ago I didn't either, which he said "didn't matter" and I shouldn't be feeling this. It's "not normal" and it's a sign that my body is "not quite doing what it should be doing".

He went on to talk about what he'd found in my spine. He had a couple of posters on the wall, one of a silhouette of a body with the spine highlighted which he'd put some marks on, and another showing a "healing curve" or something, with time along the x axis and some form of "health" marker along the y. We focused on the body poster first. The marks were where he'd found problems - there was tension in the lower part of my back, in my middle and up towards my neck (so, that's tension in all of my back then). He thought a lot of it came from posture and that was "potentially" causing the numbness in my hand because the nerves in the hand come from the neck. We looked at my "posture check" photos - the ones they took before my first appointment when I was wearing heals (which I rarely wear) and felt stiff and awkward by dint of having a camera pointed at me. He said that my head weighs around 6kg "which is about average" and I was shifted forward from the "ideal" line by about 3cm which means my head "effectively head weighs 14kg instead of 6kg" and so my upper spine is working "more than twice as hard as it needs to". He was really surprised I didn't get neck pain, to the point that I got the feeling he thought I was lying. He said he didn't know how long I'd been doing this for and told me that it could have been as long as "ten or fifteen years", and his "genuine worry" was that it could get worse as I get older, strongly implying that if I wasn't careful I'd end up like those unfortunate elderly people who walk around bent double.

This had all felt like a weird combination of scaremongering and rejection of my concerns about scaremongering. It also felt a lot like bet-hedging and setting me up for a long - and probably expensive - treatment programme. If all problems have long-term causes, they must therefore need long-term solutions, and if he can't make me better in the time-frame he suggests then the problem must have been there longer than I realised. Meanwhile, my body was on a steady decline, that would lead to inevitable decrepitude unless I sought treatment.

I was confused by his insistence that the longer a problem had been present the longer it would take to heal. A sudden broken bone can take months to heal while a tumour that's been growing for years can be removed in a single surgery. It felt more like a mantra than anything based on evidence, and reminded me of the "like cures like" saying from homeopathy. "Long-existing problems have long solutions", and by the way, all your problems have been long-existing even if you don't realise it.

I'd been increasingly puzzled by the analogies with dentistry as it didn't seem like an obvious one to me. But a little bit of googling shows that it seems to be a go-to analogy for chiropractors. For example,

When do you start seeing a dentist? When you have a toothache or serious problem in your mouth? Or do you have a checkup to see if your teeth are healthy and in good shape? Unfortunately most people know a lot more about managing the health of their teeth than they do their spine.

Website for a chiropractor in Spokane, Washington 

or,

Much like your dentist helps prevent disease of the mouth and decay of teeth and gums, the Chiropractor will help prevent the degeneration of your spine and the nerve interference, dysfunctional movement patterns, and symptoms that come along with it. Everyone knows they are supposed to go see their dentist once a year for x-rays and several times a year for cleanings and check-ups. Wouldn’t it make sense to have your spine screened and checked for possible problems?

Website for a chiropractor in Los Angeles, California

Similar statements have been spoken by my chiropractor, both in our appointments and in the talk he gave. But why dentistry? It seems an odd analogy. I may have an answer. A 2005 paper by Nelson and colleagues suggested that "the dental profession is a practical and successful parallel" to chiropractic:

Note how a lot of this is about conferring status onto chiropractors. Dentists are highly regarded because they are specialists in dental care. Given what I've learned about chiropractic so far, I cannot see any fair comparison.

The posture check raised serious concerns for me. As I stated in my first post, I wasn't asked to remove my footwear despite this having an impact on posture. And the results were very strange. How did he calculate my head weight? I didn't think to ask at the time but googling suggests that it is very hard to calculate the weight of an attached head and certainly cannot be done from simply looking. The average weight he gave was also heavier than the values I was able to find, though none of them gave a source for their values. I did, however, find one paper, Hansraj (2014), that gave the average weight of head and neck as 6kg, so if I'm being generous I'll say he misspoke by saying it was the weight of my head, forgot to mention it included the neck weight and said "weight" when he really meant "force". I should add that the paper also gives no source for the head and neck weight. As for the claim I put 14kg of force on my neck from holding it slightly forward, I can find nothing to tell me how they were calculated. This isn't to say it is necessarily wrong, just I have no way of independently verifying the value.

Time-frames
We finally got to talking through my treatment options. There were two: the short-term and the long-term. Short-term was to try and get rid of the pain and feel a bit better, long-term was to try and to do the same but to also "try and solve the problem". I was then asked which one I'd like to do, having been given no information on what either would entail. I asked if we could talk through both but I really felt like I was supposed to exclaim "option two of course!".

I was then asked how long I thought it would take to feel better. This felt like a very odd question as I hadn't been given a proper cause of my problems, or even clear evidence that the problems, apart from the hand numbness, I had were anything to worry about. I said I don't know, it depends on what's caused my problems, but he tried to push again, "based on you... how long would you expect things to take to get to the point where you're feeling better?" Based on me, as opposed to who? It was a very strange way of asking this question and I felt like I wasn't giving him the answers he wanted. I again said I don't know because he's not told me what's causing the problems. I went back to his dental analogy and said if it turned out I needed a root canal that's going to take a while to get sorted compared to if I just needed a quick filling.

He finally decided to explain to me what he thought was going on: "basically, what's happening in your body is too much pressure is building up on the nerves." This is apparently why I get the aches and because the brain isn't able to send its signals to the muscles it's "not getting the optimum performance out of them". He reassured me that he could see no evidence of a slipped disc or "anything of that calibre" but then said that without doing scans he couldn't say definitively. This felt very much like he was trying to scare me into getting scans. I'm sure he felt like he was just trying to cover himself should it turn out there was something else going on, but it felt like yet another subtle suggestion that I couldn't trust my body and it was most likely hiding all sorts of problems from me.

He summarised by saying that it's a build up due to poor posture and poor core, meaning that my "muscles aren't holding [me] in the right position". My spine was apparently out of position, which leads to too much pressure on the nerves and therefore my muscles aren't doing their job properly. He then asked again how long I thought it would take for me to get better. I found this line of questioning incredibly strange. It's not something I've ever experienced from a healthcare professional. I've been given treatment plans, told that if something doesn't get better in a particular time frame to return, but I've never been asked how long I thought my chest infection or pulled muscle would take to get better. If anything I've been the one asking for time-frames so I know what to expect and how long to wait before I should be seeing any improvement.

I didn't understand why he was so insistent on my giving an answer but I gave in and came up with an answer of a couple of months of doing some core exercises. "Without having any treatment, you mean?" he queried. "Well, possibly," I replied, thinking that being given core exercises to do was a form of treatment. He got a bit flustered at this point and eventually said that "you're right, in the fact that core exercises are going to be useful, definitely, down the line" but went on to say that it was not a muscle problem, so just strengthening the muscles isn't going to be enough. Instead we have to "solve the actual underlying cause, which is the fact that the joints are stuck" which prevents the muscles from doing their job properly.

"But how does that work?" I tentatively asked. "Because the brain controls the muscles through the nerve," was the reply. Things then got so confusing I can't paraphrase and will instead have to quote verbatim to convey the full extent his explanation,

"So if those nerves weren't there we wouldn't be able to control our muscles, so it's almost like the chicken or the egg scenario, if you just focus on where the symptom or the muscle's coming from we don't fix the underlying cause, the problem's going to keep coming back."

Paralysis Diversion

I was deeply confused by this but my confusion gave me an opportunity to ask about something that had puzzled me from the previous evening's talk. He'd said that the brain controls the organs through the nerves but I'd read an article that stated,

The vagus nerves along with autonomic ganglia and nerve plexuses provide overlapping sympathetic and parasympathetic nerve supply from many directions and sources (in concert with chemical, hormonal, and circulatory factors) to assure continued function of the body’s organs, independent of spinal nerves. This is why severance of the spinal cord in the neck area, shutting off brain impulses to spinal nerves, can cause paralysis of muscles from the neck down while the body’s organs continue to function. (A serious transverse spinal cord lesion above C5 in the upper neck can cause respiratory paralysis and often death.) Transplanted organs, relying upon hormones supplied by blood flow, can function without reconnection of severed nerves. [my emphasis]

Sam Homola, Science Based Medicine 

So how did his description of the body explain how people with paralysis were able to live for years after their injury? I have to quote verbatim again as there's no way I can do justice to the chiropractor by paraphrasing,

"That's dependent on where, because a nerve is made up of so many different branches, so different nerves control different things. So, for example, the best analogy would be Christopher Reeves, you know, he cut, he fractured his neck, and basically damaged the whole of his spinal cord. So what happened with him was that he's basically, almost, if you imagine, cut through that nerve straight through there [referring to part of his spine model], so that everything below that level just doesn't work because the brain can't get the information through. But these nerves are made up of multiple different sections, so we can say for example that one quarter controls pain and temperature, or one controls movement, one controls stuff that we don't even know about, so that's what we call the autonomic nervous system, which is the stuff we have no control over, but the brain does that in the background. So if you imagine a cross-section of the nerve, you'd see it in multiple different areas, so it depends on when they damaged the nerve and where they damaged the nerve."

I admitted that I wasn't following and he asked me what I wanted him to explain better (er, all of it?!), so I reiterated my question and went into more detail, saying that if the spinal nerve had been damaged sufficiently to cause paralysis, how are the stomach and liver and all the other organs functioning because by his explanation the previous evening they shouldn't be.

"It's certain parts of the nerves depending on what's damaged... so for the quadriplegic people they've just cut off the motor supply, so that's what controls your muscles, everything else still flows through it but their motor supply doesn't work any more."

He tried to get off the subject by saying that he was just trying to make the point that if there's pressure affecting part of your spine it can be having impacts on other parts of your body "that you don't even realise". He then alluded to the claims he made in the talk about how patients find relief from issues they don't seek out treatment for, but that get better following chiropractic treatment all the same. 

"Just because a nerve is trapped, doesn't mean it's just affecting your muscles, it could be affecting other things in the body as well... It's not trying to say to you that if you don't do this you're going to get problems with your organs, it's just to make you think that things could be related."

He reiterated his claims from the previous evening that patients with IBS and reflux have had these problems go away even though they haven't specifically treated for them. He gave headaches as another example of something they could treat without specifically treating. "Most people think that headaches are something that you should have, but 80% of headaches stem from problems in your neck". This statistic appears to be incorrect. A paper by Page (2011) summarised previous research into headaches stating,

Approximately 47% of the global population suffers from a headache, and 15-20 percent of those headaches are cervicogenic [neck-related].

Page (2011)

Time-frame Redux

We went back to the time-frame. He said that he agreed with my guess that it would take a couple of months to see improvement. To get to a point where things are "stable" would be a "few months" whereas to get my spine to be "completely correct... or the best we can possibly get it to" would take longer. This is where that healing curve poster comes in. It looked a bit like this one from here:

He explained that the first aim is to get me from the bottom left hand corner which is where I'm starting off, to the point where the lines diverge at "feeling better". If we're looking for my body to "be the best it can be", which "isn't just out of pain, this is, the body's moving effectively, you're getting the right signals to everywhere, your core's strong", that can take a lot longer, possibly over a year. So that's the long-term. The short term is "just getting you feeling better". I was then asked which one I was looking at pursuing.

Before I answered I wanted to know, given it's winter and I won't be doing so much gardening, how I was going to assess how I'm getting better or whether it was just due to a lack of physical activity. "Because you're going to use pain as the only gauge, or are you going to use other things to gauge it by?" he asked. I wasn't sure how to answer this. He told me not to base improvement just on my pain, "because if you base it purely on pain, if every time someone got rid of pain and I said to them 'I don't need to see them any more' and then a week later they said they're in pain again, that means we haven't solved the problem, all we did was momentarily reduce the pain signals". Instead he would do all the "tests" we did in my initial appointment again - check the posture, see if I still ache in the morning (isn't aching a type of pain?), see how I move and so on.

Treatment Options

The first section was going to be the most intensive part of the treatment, I was informed. He provided yet another analogy, this time of the gym - you go a couple of times a week to get fit, you wouldn't go once a month and expect to see change. So we'd start off with two adjustments a week to begin with, lasting for "a couple of months, I normally say 90 days, about three months or so" (notice how we've just added on an additional month of treatment in less than 5 seconds). Half way through we'd do an assessment or a "check-in" to see how I'm progressing, and then at this point exercises would be added because "if you try and add exercises when your body's not at the right position, you're almost trying to build a house on foundations that are not quite strong enough". He said this is where he diverges from physiotherapy because they just give exercises at the start which he feels isn't the solution as it's just "improving the strength around the problem" because the problem is not the muscles, it's the nerves. Once I get to the point of the healing curve where the lines diverge I have to make a choice whether to leave things and wait for the problems to come back - "you can do that, you can wait for things to come back and then come back in. Obviously the only problem with that is that you're not really solving it, you're just waiting for pain to come back" - or we can go for the long-term solution and try and fix the problems at which point appointments should become less frequent.

He asked if I would be able to do two treatments a week. I asked how long the sessions last and was told to give 15 minutes for them. "The actual adjustments don't take that long" but they like patients to come and lie down to relax for a bit before they are adjusted and then they can stay for a bit afterwards if they wish.

I asked him to explain what an adjustment actually was.

He reached for his spine model and laid it on his bed to demonstrate. 

"You know when people talk about chiropractic they talk about popping and clicking? The point of what I do is to remove those blockages, those 'subluxations' we call them. When I adjust you I put my hands either side and that will then correct the spine in the right position. The whole point of it though, is to try and take the pressure off those nerves and those areas. So you'll hear these popping and clicking motions but it's just gas, it's just air being released and I'll do that in multiple different places and that will help take the pressure off. So that's what an adjustment is.." .

Did anyone follow that? Because I didn't.

I asked if he was trying to release the gas.

" No, [I'm] trying to put the spine to sit in the right position. So if you imagine if your spine is out in multiple places, by pushing it on the spine it'll force the spine to get back into the right position. That then momentarily takes the pressure off the nerve which means then the brain can send the information more effectively. Unfortunately what happens then, though, is that you go back to normal routines, the spine comes out of position again. And this is why at the beginning we need to see you so often, because your body doesn't hold it in the right position... It's like a routine habit that your body gets into.”

He said he sees a chiropractor every three weeks because that's as long as his body can "hold" itself in position.

I said it seems like a very badly evolved body but he said it's not, "the body's fine, it's what we do to it, that's the issue". This isn't true. Research has shown that back problems have been a problem for much of our evolutionary history, with fossils from over 4 million years ago showing signs of significant back pain. It's not "our lifestyles", it's the fact we have evolved from quadripedal tree-living apes.

When humans stood upright, they took a spine that had evolved to be stiff for climbing and moving in trees and rotated it 90 degrees, so it was vertical—a task Latimer compared to stacking 26 cups and saucers on top of each other (vertebrae and discs) and then, balancing a head on top. But so as not to obstruct the birth canal and to get the torso balanced above our feet, the spine has to curve inwards (lordosis), creating the hollow of our backs. That's why our spines are shaped like an "S." All that curving, with the weight of the head and stuff we carry stacked on top, creates pressure that causes back problems—especially if you play football, do gymnastics, or swim the butterfly stroke. In the United States alone, 700,000 people suffer vertebral fractures per year and back problems are the sixth leading human malady in the world. "If you take care of it, your spine will get you through to about 40 or 50," said [anatomist and paleoanthropologist, Bruce] Latimer. "After that, you’re on your own."

Gibbons, 2013

Toxins

Before we ended our time together, I wanted to ask about the terrible description of toxins he gave in the talk. I said I'd been peripherally involved in some ecotoxicology studies looking at heavy metal contamination so when I heard him talk about Big Macs being described as toxins, "it's been a while since I've had a Big Mac but last thing I knew they weren't actually toxic".

He said that it's related to the 'Three Ts" and toxins can mean anything from diet related to smoking to alcohol, "they're all things that can affect how our body functions, that's what we mean by toxins". He admitted that the reason they call them "toxins" is for the alliteration "otherwise it would be two 'T's and something else which just doesn't flow". He then went on to say that we can sometimes call it "physical stress, emotional stress and chemical stress, if you want to be more scientific, but "Three Ts" is easy to remember".

I found it surprising he was so ready to admit he didn't really mean actual toxins, but I do have a serious problem with him contributing to the misunderstanding of the term.

How Much?!

We ended with the awkward conversation of the cost. I was the one who raised it - he asked again if I could do two sessions a week and I said it would depend on the cost. He really didn't want to talk about this. "Take money off the table for the time being, if we had to do it would it be doable?". I said I didn't know and he was quite insistent that we needed to be able to book a full 3 months because "if we're going to do it, [he wants] it to get done properly". He reiterated that we needed to "stick to the plan" because if we don't it won't work and I'll blame him for this.

There were a few payment options. We were focusing just on that initial 3 months of treatment, at two sessions a week, so that's 24 sessions in total. To pay individually for each session it would be a total of £864 (which works out at £36/session). "However, you never have to pay that because we've got more affordable plans". It can be done in one or two instalments. One instalment would be £696, or £29/session, or £384 which is £32/session. He said he didn't mind which one I went for, his focus was on giving me the treatment I need. At a minimum of £116/hr I'm not really surprised he didn't care!

And that was that.

Conclusions

That was quite a ride. A few things really struck me. The first was the chiropractor's insistence that everything we do harms our body, and that chiropractic is the only way to rectify this harm. The second was that the body lies to us and has problems which we have no idea about. and that the chiropractor was the only one who was able to treat these, even if he didn't identify them. The third that he replied heavily on analogies and examples from other disciplines. I've never had that happen in any treatment I've received before from any medical practitioner (and I've seen quite a few, in a number of different countries). The fourth was how poorly he explained the basic underpinnings of chiropractic. I have no idea what he was trying to say when it came to why paraplegics don't go into immediate organ failure, or what an adjustment actually is, and I'm not really sure he knows either. And finally, I was really surprised at how generic the consult and treatment plan was. Everything can be diagnosed with the same few simple tests. Everything is treated with 2 sessions a week for 12 weeks. Everything requires a few minutes of manipulation. I chatted with my sister and she had an identical assessment despite having very different problems to me. She was presented with an identical treatment plan. This is not individualised care, it's the complete opposite.

There was a huge amount of management of expectations - the emphasis on long build ups for problems leading to long treatment plans, for example, and the focus on explaining how the body hides problems from us - which seemed to be a great way of excusing any lack of obvious improvement in patients. If you don't see an improvement it just means the problem is more deeply rooted than you first thought, it's not that the treatment is ineffective.

The thing that surprised me most was how short the actual adjustment appointments were. It sounded like the actual adjustments only took a few minutes, and the rest of the allotted time was just spent lying there "relaxing" (rather than, as I know I'd be doing, mentally calculating how much per minute you're paying for this). Given one of the big advantages suggested for the success of alternative medicine is the longer appointment durations it seems very strange to have the bulk of the appointments involve lengths that the NHS would envy. The chiropractor tried to explain it as not wanting to keep patients any longer than necessary but it still seemed odd to me.

Postscript

I visited the doctor about my numb arm. The chiropractor's comments about my reflexes being poor bothered me (it seemed the only test he gave that might have some validity) and the numbness is a bit concerning given how intense it can be. The doctor did a series of hand and arm tests and diagnosed carpel tunnel syndrome. She explained how the nerves were being trapped in my wrist and recommended I take ibuprofen and get a wrist support (something I haven't done yet, bad Sarah). She said it should go away in time but if not to come back and we could discuss more involved treatment options.

Oh, and since I finished getting the allotment ready for winter I haven't been exerting myself so much and all my aches, pains and stiffness have reduced significantly. Funny that.

References

Hansraj, K. K. (2014) Assessment of stresses in the cervical spine caused by posture and position of the head. Surgical Technology Internation, 25(25): 277-279.

Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T. (2005) Chiropractic as spine care: a model for the profession. Chiropractic & Osteopathy, 13(1): 9.

Page P. (2011) Cervicogenic headaches: an evidence-led approach to clinical management. International Journal of Sports Physical Therapy, 6(3): 254–266.