Tuesday, May 26, 2009

Chiropractic for menstrual pains? No evidence. Period.

I'll hopefully convince you by the end of this blogpost, that there are bogus chiropractors in the UK.

Menstrual pain (or to give it its posh name, dysmenorrhoea) is estimated to affect between 45 - 95% of women at some point. (Bit of a rubbish estimation, if you ask me, but it gives an idea of its occurrence).

Here we have a condition which is widespread, can be debilitating, can be chronic, and the main respite from which is through painkillers. A perfect combination for a theatrical placebo. (And a cynic would add it was a regular monthly income).

It takes a leap and jump in the logic to imagineer how chiropractic could assist in the alleviation of dysmenorrhoeaic pain, but it goes something like this, courtesy of Pringle Chiropractic, Belfast:
[Pringle Chiropractic] are aware that many women who suffer from menstrual cramps also experience frequent back pain. Is there a connection? Both may be related to subluxation in the lower spine that affects the nerves that serve the female anatomy.
More hand waving than the Queen on a walkabout. Subluxations are interesting little chaps - it seems they are impossible to x-ray, and the definition of what they are has changed over time - they used to be a considered a disruption in innate intelligence but that has been dropped for obvious reasons and replaced with something along the woolly lines of
a loss of function in the spine and nervous system due to a reduction in its normal motion or alignment.
- from Pringle Chiropractic, Belfast again. And what, amongst other things do Pringle recommend for menstrual pain?
Good, old fashioned chiropractic adjustments.
Glasgow Chiropractic also are keen to espouse the amazing ability of chiropractic to deal with menstrual pain, by starting off by talking about chiropractic for menopausal symptoms, using this paper from Obstetrics and Gynaecology. Which is interesting because dysmenorrhoea and menopause are completely different beasties. I guess Glasgow Chiro just lumped them together in a sort of hand-wavy "women's problems"-type way. In fact, according to Latthe et al., the predisposition factors for dysmenorrhoea are as follows:
Age < 30 years, low body mass index, smoking, earlier menarche (< 12 years), longer cycles, heavy menstrual flow, nulliparity, premenstrual syndrome, sterilisation, clinically suspected pelvic inflammatory disease, sexual abuse, and psychological symptoms.

Glasgow Chiro claim:
Chiropractic provides the mechanisms through which dysmenorrheic women can be relieved of their pain in a drug-free environment and even go on to live a life free of period pain.
which is pretty much a statement of cure.

It's a fairly widespread chiropractic claim to be able to assist in menstrual pain - a quick squizz on Google shows that alongside Pringle Chiropractic, Belfast and Glasgow Chiropractic, Tooting Chiropractic, Townhill Total Health, Bank Chambers Clinic in Chipping Sodbury and Newcastle Chiropractic to name a few, also insist that chiropractic can assist in some way with menstrual pain.

So, given that there is a widespread belief within chiropractic circles that it can cure or relieve dysmenorrhoea, what decent evidence exists to back this up?

It should come as no surprise to anyone who knows anything about chiropractic that the answer is "not a jot".

A Cochrane Review in 2006 titled Spinal manipulation for primary and secondary dysmenorrhoea concluded that:
Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea. There is no greater risk of adverse effects with spinal manipulation than there is with sham manipulation.

The Clinical Evidence section of the BMJ places Chiropractic in the "Unlikely to be beneficial" category for dysmenorrhoea.

BUPA's page on chiropractic categorically states
Currently, there is no evidence that spinal manipulation helps to relieve period pain.

The NHS page quotes the Cochrane review above and follows its conclusion.

What about the General Chiropractic Council? Does it recommend chiropractic for menstrual pain?


It used to. In this letter (.doc) written in 2004 to the GCC on behalf of Actions for Victims of Chiropractic, Frances Denoon happens to quote from the GCC's document "What Can I Expect When I See A Chiropractor?" which states:
benefit may also be seen for some types of asthma, digestive disorders, migraine, infant colic and menstrual pains.
The current version of this document can be found on the GCC website here (.pdf), dated Sept 2007, and the same passage now reads:
You may also see an improvement in some types of asthma headaches (including migraine) and infant colic.
It seems clear that following the publishing of the Cochrane Review, in 2006 showing that chiropractic had no demonstrable effect on menstrual pain, the GCC (in an attempt to show it was evidence-based) removed menstrual pain from its list of treatable disorders.

That means the GCC, the UK regulator of chiropractics, is fully aware that dysmenorrhoea cannot be treated successfully with chiropractic. No doubt it will have made every effort to communicate this to its members and ensure that no-one was claiming otherwise. I'll be arranging for complaints to be made to the GCC regarding the above chiropractor's claims.

I now suggest to you that, given the evidence above, any chiropractor that suggests that chiropractic is a worthwhile therapy for menstrual pain is bogus. Period.

BPSDB

16 comments:

  1. Dr* T

    You obviously just do not understand subluxations. Let me enlighten you with this comprehensive guide to subluxations I have just found. :-)

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  2. I would suspect that the trials in the Cochrane review are way underpowered for detection of rare but serious adverse effects of the kind that people like Ernst warn about for "high velocity low amplitude" chiropractic.

    As usual, since chiropractic spinal manipulation may well carry a risk (albeit a rare one) of adverse effects, there seems no reason to use it for conditions where it is (i) demonstrably of no benefit; and (ii) not backed by any kind of plausible underlying rationale. But of course I'm repeating what you've said.

    Anyway, nice work.

    I suppose the large number of chiro- "practices" offering this, er, "treatment" should come as a surprise - not.

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  3. A clinical pilot study conducted at the National College of Chiropractic reported that women who received chiropractic care experienced a significant reduction in menstrual pain and suffering.

    In another case study, a woman kept a journal of the severity of her menstrual-related pain for four months prior to receiving chiropractic care and three months during. Her pain was significantly less severe and there were fewer episodes.

    As an alternative to drugs and surgery chiropractic care may be just an effective natural way to subside debilitating effects menstrual symptoms.

    Additionally, the US National Institute of Health issued a consensus statement in 1998 stating that acupuncture may help relieve certain types of pain, including menstrual cramps as a complementary medicine for care.

    Exercises such as yoga have also proven beneficial by some women to reduce symptoms of monthly menstruation.

    http://www.chiro.org/research/ABSTRACTS/Prospective_Case_Series.shtml


    It took me 5 minutes to find this information. It seems to me that either you are not very good at finding research or you just already have your opinion made up. I have been in practice as a chiropractic physican for 30 years and have helped 1000 of women with these types of problems.... I am sure you will not print this in your blog.... (that is to try to get you to do it) just would be interesting to know if you are being paid to have such an opinion ...... the interent is the great equalizer.... these tactics just will not work anymore.... just do a search on twitter for the REAL people that are seeing chiropractors for all kinds of problems.. See what they are saying..... not everything has reasearch on it yet.... of course you know that only 15% of everything used in medicine has research that supports the ue of it.

    I hope you have good life tearing down things that work for whatever you may be getting paid to do it.... pretty sad.... but again the Interent is making these things transparent....

    I would be happy to speak with you about this in person at some point - maybe you could help me understand where you are coming from?

    Dr Robert Sheely
    Chiropractic Physician since 1980
    Trenton, Ohio

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  4. Yeah - sod your high quality Cochrane meta-analysis I've got a case report and a pilot study!

    And I bet you're in the pay of teh Big Farmer!!!

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  5. Is that a barrel full of fish? Lucky I've got a gun handy!

    A clinical pilot study conducted at the National College of Chiropractic reported that women who received chiropractic care experienced a significant reduction in menstrual pain and suffering.Reference please, and does "pilot" mean "tiny and poorly controlled" as it generally does?

    In another case study, a woman ...A woman. One woman. Great. This reminds me of the old pharmacology joke: "An experiment was conducted on mice. The mice in Group A survived. The other mouse died."

    As an alternative to drugs...What's wrong with drugs, exactly? I happen to like drugs. A lot of great music was written on drugs.

    the US National Institute of Health issued a consensus statement in 1998 stating that acupuncture ...
    Exercises such as yoga...
    The cat (Felis catus), also known as the domestic cat or house cat to distinguish it from other felines and felids, is a small predatory carnivorous species of crepuscular mammal that is valued by humans for its companionship and its ability to hunt vermin, snakes, scorpions, and other unwanted household pests... what's that? Why am I suddenly talking about cats? Well, why are you talking about yoga and acupuncture in a discussion about chiropractic?

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  6. Hello Robert - thanks for dropping by.

    I wanted to respond to some of the bits in your somewhat paranoid comment:

    It seems to me that either you are not very good at finding research or you just already have your opinion made up.I (like most people) knew very little about chiropractic and menstrual pains, being neither a chiropractic nor a women. I did what any sensible skeptic would do and looked at the trustworthy sources - Cochrane, NHS site, BUPA site. All quite clear in their opinion. So, in actual fact, I'm very good at finding research, although you may be in denial.

    chiropractic care may be just an effective natural way to subside debilitating effects menstrual symptomsEven though all the respectable evidence says it doesn't? Sounds like you are in denial.

    blether about a pilot study and case studyI only look at decent research - like the Cochrane review, you know the one you are in denial about?

    I am sure you will not print this in your blog.... (that is to try to get you to do it) Unless it's racist or offensive etc it stays up - have a look at any of the other blogposts. Unlike the one-sided world of CAM and other placebos, dissent is encouraged - just be reasonbaly polite.

    just would be interesting to know if you are being paid to have such an opinion ...... Aaaahhhhha haha ha ha ha ha ha. This one loses you the argument immediately. "Oh noes, someone has evidence to say that my placebo therapy doesn't work!" - you have 2 choices - look at the evidence, or be paranoid. You have chosen the latter. Sounds like you are in denial about the evidence (have I said that?)

    not everything has reasearch on it yet....No, but chiropractic for menstrual pain has - and it doesn't do anything. I'd like to refer you to the Cochrane paper. Honestly, it exists.

    of course you know that only 15% of everything used in medicine has research that supports the ue of it.So your response is to add to that mound of useless therapy, rather than deal with it, keeping the good and ditching the bad? Why on earth would you want to do that?

    T

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  7. Worth pointing out that the claim that only X% of medical interventions have any evidence for them is very misleading.

    That claim is based on a very narrow definition of evidence.

    So, for instance, anyone over 80 receiving any medication is receiving interventions with 'no evidence' because they are usually excluded from clinical trials. Similarly children. Or people with multiple comorbidities.

    None of this means that there isn't actually good clinical evidence that these interventions work, just that they haven't necessarily been trialled in multiple RCTs in every possible population.

    If alt med were held up to that standard we'd need to be bringing in infinitesimal percentages.

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  8. pj said:
    If alt med were held up to that standard we'd need to be bringing in infinitesimal percentages.and statistical anomalies.

    I'm curious to know by what verifiable physical mechanism chiropractic can affect menstrual pains.
    I know that chiroquacks, like homeoquacks, have a pathological aversion to all things verifiable, but unless something is verifiable how do you know it works. How about they provide some incontrovertible, properly controlled studies of their own. Other providers of real medicine have to and do (so they can be torn apart and examined by all). But chiroquacks, like all quacks, expect other people to provide the research then they reject it because they don't like the results and demand some more... meanwhile making claims in spite of good research denying said claims.
    Bogus claims by chiroquacks (and all quacks) seems to more the rule than the exception.

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  9. Prospective case series on the effects of lumbosacral manipulation on dysmenorrhea.

    http://www.ncbi.nlm.nih.gov/pubmed/18394502

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  10. Thanks for the drive-by, anonymous (if that is your real name).

    Did you have any comment to make about the study? Or did you want it to appear a evidence, hoping that no-one would notice it was a study of all of 13 women, with no placebo, and relied and remembering how much pain you had a long time ago?

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  11. I realize this was posted well over a year ago, but I would like to add a few websites for updates.

    Do with them what you wish, I for one can attest to the point that chiropractics has greatly helped me with my pre-menstrual symptoms, as I am a woman, who does have a period. I had HORRIBLE bouts of PMS every month for 1.5-2 weeks preceeding my period, and then I found chiropractics, and it was purely by coincidence that it helped ease my PMS.

    http://www.dynamicchiropractic.com/mpacms/tyh/article.php?id=523 - There is a Medical Journal reference at the bottom.

    http://www.chiroweb.com/find/archives/women/dysmennorrhea/pms.html - This study shows the correlation between PMS and spinal problems.


    Lastly, there was a question that someone asked, what is wrong with drugs? Well, for starters, narcotics pose a HUGE risk for dependancy, and personally, I don't want to be chemically addicted to a mind altering drug. Also, side effects. This website, http://www.choosenatural.com/alternative/medicine/8L/pms/pms.htm - scroll to the bottom - lists medicines prescribed for PMS, and the potential side effects that they can cause. I would rather take a much safer, more hollistic approach, even if, at the end of the day it is "all in a person's head." - Which as I stated, I live with this. Correction, I LIVED with this - for 13 years, until I found chiropractics.

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  12. Hi Aly,

    Thanks for stopping by and thanks for describing your experience, which does indeed seem to be a coincidence.

    In good quack fashion, articles promoting quack therapies will give the reference (knowing that few will check it) and then completely misrepresent the data.

    Both references you give are for the same research team, with the former including the latter in it's report.

    You can find the *actual* paper here. I'll guide to the last line of the abstract:

    "...the group receiving the placebo first [followed by chiropractic adjustment], although improving over the baseline, showed no further improvement when they had actual treatment"

    So, there was some positive results seen with placebo, and given the small numbers involved (16) a false positive (as admitted by the authors) was quite probable.

    This is standard quack treatment of data - cherry pick, misrepresent and misguide.

    (The argument about pharmaceuticals is a red herring - their efficacy will not affect whether or not chiropractic is quackery!)

    T

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  13. Why are you all fighting? Chiro has helped me, "a woman" woohoo....with my menstrual cycle. I stopped as I moved and the pain is back. I have started again and am waiting to see what happens.

    Considering most clinical studies for the pharma industry are bogus as well (I used to work in the industry) why not just let Chiro ppl do their thing and have their claims. If you like to experience, go ahead, if not, don't.

    Just stop this madness of replying in such mean and rude manner.

    I have no respect for Dr. T
    Kathy

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  14. I agree with Kathy - when a patient (mind you, "patients" are presumably why you are writing this blog and why you wanted to go to medical school in the first place. That is why, right?) - anyway, when a patient attests that a treatment makes them feel better, and as long as that treatment is not harmful to the person, their family members, advertising sponsors nor the ozone layer, then what is your problem as a doctor? If your patient wants to feel better and has discovered a method for which you cannot personally claim familiarity, not to mention for a chief complaint of which you will also not ever be able to claim anything but anecdotal knowledge yourself, then what is your problem? What is your goal as a physician? The Veterans Administration sanctions and uses both chiropractic and acupuncture to treat PTSD and chronic low back pain experienced by veterans. Do you have more resources at your fingertips via the internet someone else with your same level of experience, if not more since we are talking combined resources/brains of an entire medical community which sanctions such treatments? If it is your personal vendetta to see that women, our subjects for the discussion of menstrual-related pain, are relegated to drug therapy only, and that all employers must allow women to stay home on the days where they are completely disabled due to opiates, and the medical community perhaps could sponsor overnight childcare while the mothers are unable to operate heavy machinery, then I suppose you have a case. I, myself, have suffered debilitating periods for 25 years and see the head of ob/gyn, director of The Center for Pelvic Pain and endometrial laproscopic surgeon, author of several books and instructor at a medical university AND I take drugs when I cannot walk due to cramps AND I am a student at a chiropractic college after a 14 year career as a massage therapist helping women with menstrual issues AND I have my soon to be patients in mind when I do a history. If there is a method to a healer's madness, it is to put forth and/or support safe alternatives to the limitations of scope of practice of the primary care practitioner. If you cannot, as a PCP, keep your patient at the forefront of your treatment plan and actually include their experiences as legitimate, then perhaps you should re-think your intentions as a healer, if, in fact, that is what you are.

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  15. It says pretty clearly at the top that I'm not a medical doctor, or healer or charlatan, or whatever.

    I'm sick of people trying to take my money because I'm in pain and they say they can alleviate that, when in fact, they can't they just want to trade on my desire to be pain-free for a quick buck and as a resultant, I consider them either nasty, opportunistic, immoral bastards (I don;t care whethere they are big pharma cos, nutritional cos, individials) or they are dangerous deluded misguided irresponsible bastards, who could do with learning some actual science rather than practicing bullshit on people.

    T

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  16. "If it is your personal vendetta to see that women, our subjects for the discussion of menstrual-related pain, are relegated to drug therapy only..."

    What a silly thing to say. I didn't say this or anything like it. You have rendered the rest of your point of view irrelevant by slurring me like that.

    T

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