Are chiropractors charlatans or misunderstood?

Tegan Taylor: Are you a knuckle cracker, Norman?

Norman Swan: I'm not, no, it kind of turns my blood a little bit, the knuckle cracking thing. Doesn't it damage your joints as well?

Tegan Taylor: Oh, you're asking me? You're the doctor.

Norman Swan: Yeah. I haven't seen a randomised controlled trial or a systematic meta-analysis, you know, so if you haven't got that, what do you do?

Tegan Taylor: I don't like cracking my knuckles either. But I know that there's some people who love it, they find it really kind of satisfying to hear that crack. And then there's people who love to hear that crack in other parts of their bodies, like their neck and their back, and I just can't with it.

Norman Swan: Some people like it. Some people don't. Me, I don't like it.

Tegan Taylor: There's a whole profession around it.

Norman Swan: Yeah, which is what this What's That Rash? is all about.

Tegan Taylor: That's right. Today we're talking about chiropractic.

Norman Swan: I'm Norman Swan, physician and journalist, speaking to you from Gadigal land.

Tegan Taylor: And I am not a doctor, Tegan Taylor, coming to you from Jagera and Turrbal land.

So today's question comes from Sophie. She's asking quite a spicy question, Norman. Her wording is: Chiropractors, what do they do? And are they charlatans?

Norman Swan: Oh god, can't we have an easy one, like how to solve a runny nose? Yeah, well, look, it's important, chiropractors are an important part of the health system, the primary healthcare system, people go to them a lot for musculoskeletal problems, so these are important questions to answer.

Tegan Taylor: Well, I feel like the first question…and you did say you wanted an easy question, so here's one; can we have a definition please?

Norman Swan: Chiropractic goes back to the 19th century, to a father-and-son team who came up with this idea that a lot of disease could be put down to misalignment of the spine, they called it vertebral subluxation, where the joints that hold the spine together just are a little bit out, and that that determines health and disease in individuals. Mixed up in that is a whole idea called vitalism, which is that there is this ineffable essence in the body (I'm oversimplifying here), and that essence is important in terms of health and disease. And that manipulating the spine and correcting the subluxation helps this vital notion. Now, that is not a majority view in chiropractic. There's a subsection of chiropractors who believe that, but essentially that's what this father and son team thought. And it goes back even further. They were quoting a doctor in the 18th century who pushed that, a Jim Atkinson.

Tegan Taylor: I think you need to explain to me and our friends who might be listening, how they came to understand that this was Jim Atkinson's vibe.

Norman Swan: I hesitate to tell the story because there are a lot of good people doing chiropractic, but there are kind of nutty elements to it at the beginning of chiropractic. And, in essence, they had a seance and spoke to the dead spirit of this Jim Atkinson, this doctor in New York.

Tegan Taylor: Okay, I think we can all agree that that isn't what we would usually consider to be a good evidence base when we're talking on What's That Rash?. But I have to say, the origins of your own profession, Dr Norman Swan, are also a little shady.

Norman Swan: Well, that's what I was actually going on to say, that many years ago when I was studying the history of medicine for a series on Channel Four in the UK, there was a statement I found which was it only became safer to go and see a doctor than stay at home and hope for the best in 1913.

Tegan Taylor: I mean, okay, I can see why, I mean, bloodletting for starters. I know that you'd love to wield a leech if anyone ever let you. But also, I was looking through ye olde kind of medical things, kind of expecting this to come up; chloroform as an asthma treatment, cocaine for hay fever. Let he who has not done something weird in the medical sphere cast the first stone, so to speak.

Norman Swan: That's right. Like all of these things, they had some benefits, but a lot of medicine was just either charlatanism or it was hoping for the best. And the best doctors were the ones who did the least and just helped people through, rather than necessarily jumping into highly interventional stuff like bleeding you, making you anaemic and killing you from that.

Tegan Taylor: Okay, so I think we can agree that looking to the history is interesting, but not necessarily informative when we're coming to answering Sophie's question, at least. What are the modern-day claims of chiropractic?

Norman Swan: Well, when you talk to people who teach chiropractic in universities (as we did for this series), there is quite a few universities now that do chiropractic courses, you've actually got to train for quite a long time.

Tegan Taylor: It's five or six years isn't it.

Norman Swan: Up to five years and then there's an undergraduate and then there's a Masters you've got to do. The core business of chiropractic is low back pain. And that's the least controversial part of chiropractic. So if you're going to ask me are chiropractic practitioners charlatans? The answer is no, most of them are wanting to do the right thing for people who are in pain and disabled. And the core treatment that they use is spinal manipulation.

Now, chiropractors and physios will duke it out often over spinal manipulation, one saying the way we do it is the better way. But there's a lot of similarity. They will do some mobilisation with you, they might do massage, they might do heat treatment. And then comes the manipulation itself.

The safe form of spinal manipulation, or the safest form, is where you actually have reasonable velocity, in other words, a bit of force to it, and low amplitude. In other words, you're not moving the spine in a terribly big way. So it's high velocity, low amplitude is kind of what people talk about in spinal manipulation. And the reality here is that when they've done randomised trials, the results are different from acute versus chronic low back pain.

Tegan Taylor: So it's something that's happened recently, maybe from an injury, and it's quite severe versus something that's trailing on for a long time.

Norman Swan: Yeah, and the randomised trials suggests…regardless of who does it, whether it's a chiropractor or it's a physiotherapist, they can frequently give significant pain relief in the short term. But when you follow people out to six weeks, 12 weeks and a year, there's no difference. So it might help you in the short term, but it doesn't make any difference in the longer term. And that's the core business of chiropractors. Where it gets highly controversial is cervical spine manipulation.

Tegan Taylor: So that's the neck bit of your spine.

Norman Swan: Yeah, two main reasons why people would do that. One is that you've got a stiff neck, maybe with pain going down into your arm. So it's like the equivalent of low back pain, where you've got low back pain that goes down into your leg. Other reasons for doing cervical manipulation would be for different kinds of headache. The reality is that cervical pain is a bit like back pain, it does get better by itself, and you don't want to be too restrictive about how you do it. And there is a risk in terms of cervical manipulation, regardless of who's doing it, because, you know, I'm talking about really quite a significant thrust, even though it's over low amplitude, over a low distance. Now, the studies that have been done suggests that the complication rate is very low in experienced hands, but when they do occur, it can be quite serious. So a survey of British neurologists found that quite a significant percentage of them had seen cervical complications, and so this can be a stroke.

Tegan Taylor: I thought this stroke thing had been debunked.

Norman Swan: No, it can happen, because you've got this artery coming up through the spine into the back of the head called the vertebral artery, and you can get a dissection in this vertebral artery.

Tegan Taylor: That's doctorese for it splits, right?

Norman Swan: Yeah, that's right. You get the blood tracking into the lining and it can obstruct the vertebral artery.

Tegan Taylor: Can I just put something out there though; if you've got neck pain, and you want to treat it, you've got a low risk of complication with something that's a hands-on but drug-free approach, or you've got potentially using painkiller drugs, which we know also come with their own complications, like, how do you weigh that?

Norman Swan: Well, I'll tell you how I weigh it for myself is…I mean, I get neck pain from time to time, would I let somebody…

Tegan Taylor: It's me, isn't it, I'm the pain in your neck.

Norman Swan: You said it, not me. Would I have cervical manipulation? Not on your nelly. I mean, I've basically got pain in the neck, would I risk stroke or harm, even though the risk is incredibly low? No, I wouldn't. Particularly when I know that some other manual techniques can help. For example, there is some evidence that massage can help neck pain, there's some evidence that putting…a lot of neck pain is actually spasm in the neck muscle, and if you actually tense that muscle and then relax it, you can actually help to relieve the pain. One of my tricks at the ABC is when I see somebody with neck pain, they've heard that I can help, and I set them up and I just get them to tense up that muscle and relax it, tense that muscle, no manipulation at all, and in fact that reduces pain.

Norman Swan: So now I know why you're so dim on chiropractors for neck pain, because you're gonna…

Norman Swan: I'm a competitor.

Tegan Taylor: What does the ABC's occupational health and safety have to say about this?

Norman Swan: That's exactly right, I've just condemned myself to get the SEC. But the point being is that there are milder ways of doing this.

Tegan Taylor: Lots of chiropractors also do massage as well, they're not just one-trick snappy ponies.

Norman Swan: That's right, and they're holistic. So good chiropractors will talk to the person, they'll look at their gait, they'll try and help them with their gait and their strengthening, very much like physiotherapists would, they do try other techniques. So it's not just the thrust, and that's what a good chiropractic course will teach them. It's just when it gets to the nutty stuff like this vitalist idea and that all disease comes from the spinal column. And there's very little evidence for that. And they believe, for example, they can treat asthma. And there's really not a shred of evidence that…unfortunately, because it'd be nice if you could…but that manipulating the spine can actually fix asthma.

Tegan Taylor: Most of what we talked about just now has been about adults. But I've seen quite a lot of places advertising chiropractic for babies and children, like quite a lot, and in my area as well. And I just wondered if there was any evidence at all whether it was safe or effective for babies. They're talking about newborns.

Norman Swan: Chiropractors sometimes will offer services to treat infant colic with spinal adjustment. I'm not suggesting that it's particularly risky, what they're doing with the baby, but are you spending your money wisely? And good luck to them if it's mild and not terribly manipulative, but if you're going to manipulate baby's spines, there's no evidence for it. And you're taking a risk.

Tegan Taylor: There is one more thing, and we will come back to Sophie's question in just a second, but there is one more thing I want to ask you about when it comes to chiropractors because there's a real controversy around whether or not they should be allowed to call themselves Doctor.

Norman Swan: Yeah, the AMA doesn't like that at all. But what the AMA, the Australian Medical Association, and other medical organisations around the world forget is that medical doctors acquired the title Doctor…they just decided that they were going to call themselves Doctor in…I think it was in the 19th century. And of course surgeons after spending five or six years at medical school getting the title Doctor, then spend another six years getting rid of the title Doctor so they become Mr or Ms. It varies according to state. So in New South Wales it tends not to happen, but it does a bit more in other states, particularly Victoria. And that's very common in Britain, for example, that surgeons will call themselves Mr or Ms rather than Doctor. And of course when you're a junior doctor and you're doing a ward round with the boss, the surgeon, they've got this aura about them because they're now called Mr or Ms.

Tegan Taylor: I don't want someone coming at me with a knife if they're not a doctor.

Norman Swan: It's just as much of a sham, doctors calling themselves doctors, we haven't got PhDs. So I don't get too upset about all that. The reality is the only real doctors are the ones who've earned it and those are the ones who've got a PhD.

Tegan Taylor: Okay, then Mr Swan…

Norman Swan: Oh, don't let me operate on you.

Tegan Taylor: I wouldn't. Chiropractors; are they charlatans?

Norman Swan: The answer overwhelmingly is no. They've been well trained, they've done these university courses. And like any profession, there's a minority who really go to the extreme of the original theories here. But the vast majority of chiropractors want to do the right thing and do do the right thing and make an important contribution to primary health care in this country.

Tegan Taylor: Well, if you are now angry at Norman and would like to send him an email directly, if you're a chiropractor or the Australian Medical Association, you can email us.

Norman Swan: You know what we should do for merch? We should have voodoo dolls that we send out.

Tegan Taylor: That is a missed opportunity.

Norman Swan: Yeah, well, maybe not, we can do it with needles, and it could either be therapeutically for acupuncture or to really get up my nostril.

Tegan Taylor: We actually have had some feedback, not on chiropractors yet, obviously, but we did ask people last week to send us in their skincare routines, and, boy, did they. There are a lot of people who just love Sorbolene.

Norman Swan: And that's a good thing because Sorbolene is as cheap as chips, and it's what dermatologists recommend for dry skin and the treatment of eczema to prevent eczema getting worse. So slap it on, it's good, and most people don't use enough.

Tegan Taylor: We also had an email from Doug which I didn't get on first glance, but suddenly I realised what he's talking about: 'I started following the good doctor's skincare routine, and now I'm looking a lot like Pinocchio. What should I lather on next?' Do you remember what you admitted to using on your face or made it sound like you used on your face?

Norman Swan: Look, Doug, I know what you mean. You know, Pinocchio, when he told a lie, his nose extended. And what I said (which was a lie, actually) was that for my skincare I get a compounding pharmacist to mash up some Viagra and then I rub that on my skin.

Tegan Taylor: So I couldn't possibly understand what you mean, Doug, I'm not that kind of girl.

Norman Swan: No, but what should you lather on next? I think soap, get rid of the Viagra.

Tegan Taylor: And then we did actually have a piece of feedback from someone who was actually a guest of ours on the Health Report…

Norman Swan: A real doctor?

Tegan Taylor: A real doctor.

Norman Swan: A Mr, a surgeon!

Tegan Taylor: Exactly. And what he was asking us is why didn't we talk about nicotinamide for skincare, which piqued my interest because I know that it's also called niacinamide. And so if you've heard that, it's a form of B3. It is in a lot of skincare products, but he had a really interesting use for it.

Norman Swan: So this is an Australian randomised trial in the New England Journal of Medicine, 2015, using nicotinamide supplements in people with seriously sun damaged skin who've had skin cancers. And what they showed was that a nicotinamide supplement reduces the risk of recurrence of these skin cancer lesions. Unfortunately it's not in widespread use because it's low cost and there's no drug company pushing it.

Tegan Taylor: Yeah, it's a shame. But you know what else is low cost? Sending in a question to What's That Rash?.

Norman Swan: Yeah, the only cost is to us and when we answer it,

Tegan Taylor: Send your questions to thatrash@abc.net.au, or, as always, send us a DM on Instagram, we're @ABChealth.

Norman Swan: Recommend us to your friends, and subscribe wherever you get your podcasts.

Tegan Taylor: And we'll see you next week.