HEADACHE HORIZONS Done by Hand Chiropractics, the headache patient, and the lost art of touch. By Peter McAllister, MD The Birth of a Chiropractor Daniel David “DD” Palmer was a tall charismatic Blood supply to the head, pituitary gland, C1 scalp, bones of the face, brain, inner and grocer, who became a phrenologist, spiritualist, middle ear, sympathetic nervous system. Eyes, optic nerves, auditory nerves, sinuses, magnetic healer, and medicinal potions entre- C2 mastoid bones, tongue, forehead. Cheeks, outer ear, face bones, teeth, C3 trifacial nerve. preneur. Born inToronto, Canada, DD discov- Nose, lips, mouth, eustachian tube. C4 Vocal cords, neck glands, pharynx. ered as a young man that his “cures” found a C5 more receptive audience in the midwestern US, and so he emi- C6 Neck muscles, shoulders, tonsils. REGION NECK Thyroid gland, bursae in the shoulders, elbows. grated southwesterly, selling tonics and magnets out the back C7 1 Arms from the elbows down, including hands, of a horse-drawn wagon before settling in Davenport, IA. T1 wrists, and fingers, esophagus, and trachea. Heart, including its valves and covering, In 1895, with several spectators gathered and to great T2 coronary arteries Lungs, bronchial tubes, pleura, chest, breast. T3 fanfare, DD thrust his clutched hands so forcefully into his Gallbladder, common duct. T4 Liver, solar plexus, circulation (general). patient’s thoracic spine that all present heard the alarming and T5 audible crack. The patient, a janitor who serviced DD’s office, T6 Stomach. T7 Pancreas, duodenum. was middle-aged, stooped, and habitually complained to DD MID-BACK T8 Spleen. T9 Adrenal and suprarenal glands. about his hearing loss—telling him that one day his hearing Kidneys. T10 was sharp as a barn owl and the next he was deaf as a box Kidneys, uterus. T11 turtle. Weeks before the dramatic crack, DD had observed that T12 Small intestines, lymph circulation. the janitor’s spine seemed bent, as DD would later write, to “an L1 Large intestines, inguinal rings. Appendix, abdomen, upper leg. ungodly angle.” Palmer wondered if there could be a connec- L2 Sex organs, uterus, bladder, knees. tion between the janitor’s deafness and his bowed backbone? L3 Prostate gland, muscles of the lower back, DD had been considering the spine and its relationship to L4 sciatic nerve. LOW-BACK Lower legs, ankles, feet. health and posited that there existed a spiritual (ie, God-given) L5 life force or innate intelligence within the human body flow- SACRUM Hip bones, buttocks. Rectum, anus. COCCYX ing from brain to spinal nerves to liver, kidneys, stomach, and PELVIS other organs (including the hearing apparatus of the ear), Figure. Chiropractic chart of viscera supplied by vertebral nerves. supplying nourishing energy (Figure).2 Although without evi- dence, DD further postulated spinal subluxations (ie, vertebral well completely devoid of innervation. Although DD Palmer misalignments) hindered flow of vital spirit, and that reducing believed that “95% of human disease” comes from spinal- subluxation with vigorous manipulation (a high-velocity, low- subluxation problems, we know now that human maladies are amplitude thrust) could restore this flow. caused by myriad scientifically provable causes among them The next day, when the janitor commented his hearing had infectious, autoimmune, degenerative, genetic, nutritional, “somewhat improved,” DD knew he was onto something big. and other etiologies.3 There is ample anatomic evidence that Cobbling together notions from magnetism, vitalism, bone- no neural path connects the spinal cord or nerve roots to setting, and other fringes of pseudoscience, and borrowing the the ear. Although spinal subluxations exist, they do not inter- Latin words chiros and practis—meaning done by hand—DD rupt innate intelligence, nor are they reduced by chiropractic found commercial success better than any healing magnets or manipulation. Quite simply, DD’s crack of the janitor’s back elixirs he had sold out of his wagon. Chiropractic was born. could not have restored even a modicum of hearing. A scientifically rigorous review of contemporary research A Lack of Evidence concerning chiropractic is both brief and disappointing. There Modern science tells us that there is no nourishing vital are few well-designed studies, in part because the discipline force flowing from spinal nerves to organs, without which they was quite antiscience until the 1970s, and the only positive would not survive—for example, a transplanted liver functions objective result is that it may be helpful for acute musculo- 24 PRACTICAL NEUROLOGY JANUARY 2019 HEADACHE HORIZONS 4 skeletal low back pain. Chiropractic appears to be roughly TABLE. CHIROPRACTOR VS NEUROLOGIST TRAINING equivalent to physical therapy, or a sheet of back stretching exercises, and possibly slightly superior to nonsteroidal anti- Chiropractor Neurologist inflammatory drugs (NSAIDs). That’s it. Chiropractic does Years of college 3 4 not treat asthma, ear infections, bed wetting, anxiety, irritable Average college GPA 3.37 3.78 bowel, autism, attention deficit hyperactivity disorder (ADHD), Entrance examination No Yes or any other nonmusculoskeletal condition, despite many practitioners’ website proclamations. Years of training 4 4 There is no evidence that chiropractic has any role in the Postgraduate training No ≥ 4 years 5 treatment of headache. Chiropractic may, in fact, be harm- Subspeciality certified 3% 75% ful when applied to the cervical region in an attempt to treat headache. Vertebral artery dissection leading to stroke (in schools, chiropractic students are taught marketing, finance, some cases fatal) has been reported, as have dural tears and and business operations from the beginning of training. There cervical nerve root and cord trauma.6 Under-reporting of cer- is a specific emphasis on what it takes to get patients in the vical trauma by chiropractors appears to be a major problem.7 door—and keep them coming. Many chiropractors market The use of total spine x-ray imaging, common in chiropractic themselves as primary care doctors, capable of providing offices, is also not without long-term health risk. 8 health care to the entire family from infancy through end of life; there have even been cases of intrauterine chiropractic Why Do Patients Go? manipulation!11 Although marketing a chiropractic practice Using email listserves of neurologists and headache special- as a primary care provider may be a good way to build up a ists, I asked 78 colleagues, “Do you send headache patients for patient base, not everyone agrees with that model; some chi- chiropractic care? If not, why not?” Of the 42 who responded, ropractors, for example, are antivaccination proponents. 35 (83%) said they did not and would not refer their patients with headache to a chiropractor, citing lack of evidence of Anchoring Bias efficacy and concerns about harm, particularly in the neck and Many musculoskeletal conditions resolve over time, without suboccipital regions. Only 7 (17%) routinely sent their head- intervention. If patients have less pain after a few visits, they ache patients to chiropractors, and all came with caveats, such may assume chiropractic manipulation was responsible, when as “I only refer to Dr. X; she’s gentle and doesn’t do manipula- it may have been nature taking its course. To be fair, the same tion” or “I only refer for low back pain, not headache.” could be said for visits to physicians or physical therapists. Although neurologists and headache specialists may not be enamored of chiropractic, it seems our patients are. There are Hands-On Care more than 77,000 chiropractors in the US treating more than Perhaps the chiropractor’s most valuable tool is neither 35 million annually (~12% of the population),9 vs approxi- their ill-proven gadgets—thermal analysis and wobble chairs mately 17,000 neurologists, 500 board certified in headache come to mind—nor their unnecessary whole spine x-rays, but medicine by the United Council on Neurologic Subspecialties rather their hands, for to lay hands on a patient is to establish (UCNS). There are 10,000 chiropractic students in 18 accred- a human connection, vital to the doctor-patient relationship. ited schools and 2,500 new chiropractors and1,500 chiroprac- Chiropractors lay hands on patients, instantly establishing a tic assistants annually. Differences in training and qualifications primal connection that has the unspoken power to engender abound (Table). The US Bureau of Labor predicts chiropractic goodwill and contribute to a heightened sense of well-being, will grow by 16% by 2026, because, as the Bureau’s website or even the perception of being “healed.” Traditional allopathic states, “The field is attractive to patients because chiroprac- medicine seems to have all but forgotten this ancient healing tors use nonsurgical treatment methods and do not prescribe art of touch, busy as we are ordering high-tech tests and click- drugs.”10 Many people go to chiropractors seeking chronic ing and box ticking on our computers, attending to an “iPa- pain relief that includes migraine and other headaches. Simply tient” in a machine, but leaving the real patient out in the cold. put—chiropractors see our patients. It is reasonable to ask why patients go to chiropractic, The Importance of Human Touch despite an overwhelming lack of evidence to support its use in Several months ago, I was rounding with a new medical all but a select group of patients with low back pain. student and observed that after seeing 10 patients, she had declined to shake hands with any. I gently asked if there was Chiropractic Marketing some reason, cultural, hygienic, or otherwise, for her lack of Chiropractors aggressively market themselves as a safe participation in this ageless form of greeting. To my surprise, alternative to traditional medicine. Unlike allopathic medical she informed me that at her medical school they were taught JANUARY 2019 PRACTICAL NEUROLOGY 25 HEADACHE HORIZONS not to “violate the patient’s personal space.” A handshake, percussed the region, mined deeply the muscle spasm.