Recently social media and then the mainstream media exploded with outrage following the publication of a photo showing a Melbourne chiropractor “treating” a newborn baby by suspending the child in midair, holding its foot high as it thrashed around in protest.
No possible benefit could be achieved by this manipulation and serious complications could have resulted. Obvious questions followed. Are chiropractors trained to care for neonates and children? What is the evidence that chiropractic can treat childhood diseases and what is the position of the Chiropractic Board of Australia on the care of children by chiropractors? There is a sorry tale of regulatory impotence highlighted by this case.
The chiropractic profession is in turmoil, indeed at an important cross road as individual chiropractors align themselves with those that champion an evidence based approach to the care they give and those “vitalistic” chiropractors who adhere to antiscientific and certainly non-evidence based concepts of the founder of the profession, one Daniel David Palmer. I understand and sympathise with the concerns that trouble the evidence based carers in this situation especially since website data would suggest that the majority of Australian chiropractors belong to the latter camp! Their rhetoric often features opposition to vaccination. So what did Palmer believe and teach?
At the end of the 19th century Palmer, at various times a school teacher, grocer and fishmonger, announced to the world that he had discovered a revolutionary treatment capable of curing all diseases. Borrowing from similar concepts current from about 1820, Palmer declared that health was associated with the integrity of an “innate intelligence” or life force that “runs the body through the mind as long as it is habitable”. The flow of this life force could be distorted by minor displacements of the bones of the spine (vertebrae) Neither the life force nor the misalignments were visible but physical manipulation of the spine could unblock the flow of innate intelligence and restore health. He related his enthusiasm for spinal manipulation to two experiences, the instant return of hearing for a deaf man and the curing of another with chronic heart failure by spinal manipulation. He confidently insisted that he could cure syphilis and gonorrhoea, at that time incurable and that “chiropractic” would “eradicate perversities, monstrosities, wars and rumours of wars, and all manner of addictions”. So you would think that here is a tale for historical reflection that modern chiropractors would appreciate was generated before scientific knowledge was available to dismiss these concepts as nonsense. Well if you so thought you would be wrong. Thousands of “vitalistic” chiropractors in 2019 adhere to what they call “subluxation theory”, the minor invisible distortions of the spinal column that disrupt innate intelligence and cause a huge array of diseases in organs and tissues remote from the spine.
As is true for physiotherapy, there is a soft evidence base that chiropractic can help with musculoskeletal problems of the back and neck. However if you Google “Vitalistic” chiropractic you will see chiropractors advertising that they can treat/cure more than 60 disorders that have nothing to do with muscle and arthritic problems related to one’s spine. Increasingly the focus is on childhood ailments so many chiropractors talk of treating Asthma, Autism, Attention Deficit Syndromes, bedwetting, colic, troubles with breast feeding and even boosting children’s immune system. Many chiropractors advertise that they can turn a “breech” baby (Turner technique) a problem Obstetricians insist should only be attempted in hospitals with appropriately skilled staff. Some chiropractors advise mothers to bring newborns for manipulation after that traumatic journey through the birth canal and that at least six checks in the first year of life to assure proper spinal development is appropriate. A few years ago there was an uproar when it was discovered that a chiropractor was visiting a neonatal unit in a major hospital where he would manipulate the spines of the babies!
In asking why there is this focus on building a paediatric practice two comments are relevant. Chiropractors are not taught paediatrics during their course work at university. Despite this the Chiropractic Association of Australia has proposed to Australian chiropractors that they should work together to promote the idea that they should pursue a dominant position as Primary Care givers displacing the role of GPs in that space! Surely it’s not being too cynical to suggest that this broadening of the scope of practice for chiropractors is all about establishing a more lucrative form of practice. They justify the initiative with their confident that “subluxations” can cause so many diseases.
To further boost a scientific facade chiropractors can buy an “Activator”, an instrument that costs about $800 and is listed by the Therapeutic goods administration (TGA), giving it undeserved credibility. This device delivers a mild tap to the spine and back when the chiropractor pulls its trigger! U Tube has many examples of this useless instrument doing everything from making sure both legs are of equal length to correcting a subluxation. There are also three bogus instruments many chiropractors have in their office which purport to show that adjustment by the Activator has worked as the machines display a “response” to treatment.
Which brings us to consumer protection (or the lack thereof) and the regulation of the activities of health professionals. The Australian Health Practitioners Regulation Agency (AHPRA) was established to promote innovation and flexibility among registered health professionals and to protect consumers from shonky registrants. All chiropractors must be registered with AHPRA and this profession is overseen by the Chiropractic Board of Australia (CBA). The Boards are supposed to oversee adherence to the “National Law” which demands that all practitioners practice evidence based care and do not engage in false advertising. There is no real oversight of the quality of the Board’s work by AHPRA and when complaints are made about registrants AHPRA appoints lay officers of the Agency to investigate. It is not unusual for individual complaints to take three years to complete. Complaints are not necessarily brought to the Boards attention.
Over the last few years colleagues and I representing “Friends of Science in Medicine”(FSM), have had a number of face to face meetings with AHPRA and representatives from a number of its Boards particularly the CBA. We have submitted many hundreds of examples of “vitalistic” chiropractors breaking the National Law with their false advertising. The culture at AHPRA that inculcates their Boards, features a risk stratification approach wherein they only take seriously complaints related to serious harm done to individuals. There is no appreciation of the harm associated with delays in accurate diagnosis and the commencement of effective treatment nor the harm done as many spend a lot of money on fraudulent services. There is little appreciation of the truism that effective consumer protection is about preventing harm not chasing offenders.
As FSM provided hundreds of examples of Chiropractors, Osteopaths and Traditional Chinese Medicine Practitioners and fewer but serious cases involving nurses and medical doctors breaking the National Law, AHPRA was forced to set up a “class action” approach wherein a first step would be to write to offending registrants asking them to clean up their advertising to bring it in line with the National Law or face investigation and possible penalties. At our last meeting the compliance rate was about 45%.
There is however a mammoth “ elephant in the room” when it comes to AHPRA and its Boards protecting consumers from misleading or fraudulent care. Boards can insist on changes to advertising but we have been told over and over by AHPRA that the legislation under which they operate, gives Boards no power to regulate (modify or stop) a registrants scope of practice. In other words Boards can control what registrant say but not what they actually do! Would that pass the pub test?
FSM managed to get the situation with chiropractic invasion of paediatrics on the agenda of the COAG Health Council three years ago. Ministers actually asked AHPRA if they would recommend strengthening the act the so that they could modify scope of practice. AHPRA replied that this was not necessary. We now find some chiropractors advertising on websites “ we can’t tell you here all the things we can do for your children but call us———-“
So finally to return to our dangling baby. Public outrage and a shocked Victorian health minister saw the minister place a ban on chiropractors manipulating the spine of children under two. Monash university has been asked to review the evidence for the effectiveness of spinal adjustment for children.(They won’t find any). Importantly the CBA has placed a nation wide ban on the spinal manipulation of children under 2. This is an important precedent as it suggests the CBA does have the power to limit scope of practice after all. One notes however that a command from the CBA a few years ago that chiropractors were not to offer services to unborn children had little effect.
Please Jenny Mikakos, Minister for Health in Victoria, while you are alarmed by the mistreatment of an infant, it is important that you discuss with your COAG colleagues the need to review the effectiveness of AHPRA and its Boards and the need to give the appropriate legislation the strength to really protect consumers from non-evidence based care. Such a review is long overdue.
John Dwyer is an Emeritus Professor of Medicine at UNSW and the Foundation President of “Friends of Science in Medicine”, an organisation championing the need for clinical care to be underpinned by credible scientific evidence of clinical effectiveness.