Chiropractic For Autism

May 14, 2010 at 4:50 pm (Chiropractic) (, , , , , , , , , , , , , , , , )

This PDF from Discover Chiropractic is headed “Chiropractic and Autism: Studies Give Hope”.

The evidence on Pubmed

Having read the headline, I searched for autism and chiropractic on Pubmed. Here’s what Pubmed says:

No items found.

You get the same result if you search for autism and spinal manipulation.

Discover Chiropractic’s Evidence

I thought I’d take a look at what the papers cited by Discover Chiropractic actually said. The second paper is this one: link to abstract [saved as PDF here]. The first paper cited (published in Clinical Chiropractic) costs $31.50 to purchase and the abstract has scant detail:

This article describes the diagnostic criteria, etiology, prevalence and optimal management strategies available for children with autism, based on a review of the literature.

It is not clear from the abstract whether the review of the literature was systematic. I would guess that this paper is more likely to be a comment piece on autism in children rather than a systematic review of the literature on chiropractic and autism.

Onto paper number two. The Journal of Vertebral Subluxation Research (JVSR) paper referred to a small study, with just 14 participants.

JVSR Methods

Of these 14, seven subjects were allocated to a chiropractic group receiving “full spine adjustment” and the remaining seven were allocated to a chiropractic group receiving “Atlas Orthogonal upper cervical adjustment”. So the two groups were both “chiropractic treatment” of one sort or another, and there was no placebo arm in this study.

It is unclear why the authors compare two forms of chiropractic treatment rather than comparing one or more forms of chiropractic with a sham procedure.

To evaluate the clinical effects, the authors used ATEC (Autism Treatment Evaluation Checklist). This is a one-page form consisting of 4 subtests: “The ATEC is designed to assist parents, physicians and researchers to evaluate various treatments for autism.”

Digression: the checklist was apparently developed by Bernard Rimland, who was “the founder of the Autism Research Institute, which now promotes chelation and unproven nutritional therapies for autism, and supports Dr Andrew Wakefield”. Rimland was apparently a “high-profile supporter of the discredited idea that the mercury preservative thimerosal in vaccines caused autism”. [I quote from a piece by Dr Aust that refers to Rimland having authored papers in the Journal of Orthomolecular Medicine. We will return to CAM journals later.]

I cannot tell from the abstract what the authors’ hypothesis was. This page on “how to write a research paper” seems to be quite clear on this point:

Summarize the study, including the following elements in any abstract. Try to keep the first two items to no more than one sentence each.

  • Purpose of the study – hypothesis, overall question, objective
  • Model organism or system and brief description of the experiment
  • Results, including specific data – if the results are quantitative in nature, report quantitative data; results of any statistical analysis shoud be reported
  • Important conclusions or questions that follow from the experiment(s) [My emphasis.]

See also page two of Trish Greenhalgh’s How To Read A Paper, which states that:

Unless it has already been covered in the introduction, the hypothesis which the authors have decided to test should be clearly stated in the methods section of the paper. [My emphasis]

We are told that the authors compared two forms of chiropractic and evaluated children using ATEC, but we are not told what the authors expected to find.

JVSR Results

We see percentages for improvement on ATEC scores in the two groups, and are told that there are five of seven children in the full spine adjustment group who improve and six of seven in the upper-cervical group who improve.

We are not told whether such improvements are typical in children with autism over the period of time that covered the trial. There is no information on how likely it is that these results would be seen purely by chance. As we are looking at developmental delay, we might expect to see improvement with or without treatment.

JVSR Conclusions

The authors conclude that “In this study, the clinical outcome of chiropractic care showed higher efficacy with upper cervical adjustment when compared to full spine adjustment in autistic children. Further studies are recommended.”

All they have shown is that when you compare chiropractic treatments in two groups, one group seems to improve more than another. We don’t know from this study whether chiropractic is effective, as we do not know how a control group might have fared.

Further studies are recommended by the authors. I have one or two ideas as to the nature of further studies.

Perhaps there should be some consideration of comparison of chiropractic spinal manipulation therapy and sham SMT. A larger number of subjects might participate in future trials – certainly more than fourteen, one would hope.

Hopefully, the authors will include a hypothesis when writing their abstract.

Comment from the authors on the reliability and validity of ATEC would also be welcome. As would discussion of the random assignment of subjects – i.e. how subjects were allocated.

A note on Alt Med Journals

I am far from the first commenter to pick up on problems with alternative journals. AP Gaylard highlighted some suggestions made by R Barker Bausell in his book “Snake Oil Science – The Truth About Complementary and Alternative Medicine“. One of these recommendations was to:

Give more credence to trials published in well known medical journal and give no credence at all to those published in CAM journals.

Dr Aust has also been quite outspoken on the trouble with CAM journals: here, and in a follow-up post. The follow-up post contains a summary of what Dr Aust perceives as being the modus operandi of the alternative journals.

I am wary of papers published in alternative journals and on one occasion found that a paper cited by the author of an article in an alternative journal was actually misrepresented by the author.

The article was published in Alt Med Review (Alternative Medicine Review) and the title was “Hot Flashes – A Review of the Literature on Alternative and Complementary Treatment Approaches”. The paper that was misrepresented was looking at evening primrose oil versus placebo for treatment of hot flashes, and was authored by R Chenoy et al.

More

There is an erratum for the paper published in JVSR:

The original publication of this paper was from a draft that contained errors in described data. This was corrected and the revised version published. Please refer to the Letters to the Editor related to this paper for more detail.

Discover Chiropractic is also the name of a website run by sceptic blogger Zeno. This website should not be confused with the Discover Chiropractic who issue newsletters claiming that chiropractic may give hope to children with autism and their families.

About these ads

14 Comments

  1. apgaylard said,

    Nice post. Amongst the may problems you spotted in the JVSR paper, there is no mention of blinding either. This is a concern as the parents both scored the symptoms and participated in the treatment. To quote from the full paper: “There was one dropout casefrom the first group, in which the parent refused to continue to handle the difficulties of stabilizing her child during x-ray procedures. ” And, “The clinical improvement of the autistic children was evident from the parent’s observations, through decrease of ATEC scores.”

    Thus there is a strong chance that helping their child through what at least one parent found to be an uncomfortable treatment protocol may tend to unconsciously pre-dispose the parents to seeing improvement against the subjective rating scheme used.

    Given that the very small prior probability of spinal manipulation treating autism in any meaningful way, I do wonder whether the x-rays could be ethically justified.

  2. draust said,

    I agree with AP – how could giving these kids x-rays be ethical?

    I would have said that x-raying autistic kids for no good reason was almost up there with giving them lumbar punctures and colonoscopies.

    Good to see you back, Adrian, BTW. Any chance your blog will be re-activated?

    And many thanks (to jdc) for the links.

    Talking of the, er, standards of “peer-review ” at AltMed journals, this makes enlightening reading.

  3. jdc325 said,

    Thanks for commenting Adrian, some excellent points there.

    …there is a strong chance that helping their child through what at least one parent found to be an uncomfortable treatment protocol may tend to unconsciously pre-dispose the parents to seeing improvement against the subjective rating scheme used

    Yes, there is some good discussion of misplaced consistency from Stuart Sutherland in Irrationality and from Robert Cialdini in Influence. From Irrationality, with house-hunters the example:

    Apart from the time and effort expended in the search, they will have spent a great deal of money. If they are not to feel foolish, they must justify to themselves the commitment they have made… [they tend to exaggerate the good points and minimise the bad points].

  4. jdc325 said,

    @draust

    Thanks for the comment. I read the Majikthyse post when it was first posted, and should have remembered it. Will add a link to it in my post.

  5. Andrew Gilbey said,

    Good post, JDC.

    I recollect recently reading a chiropractor’s claim to treat children with autism, although I never did work out whether they were claiming to treat autism or just other problems suffered by children who are autistic.

    Extraordinary claims require extraordinary evidence. By definition, I don’t think that evidence will be found in the JSVR. In fact, what you are more likely to find in the JSVR are more extraordinary claims.

    So what other extraordinary chiropractic claims are there? How about chiropractic can help with multiple sclerosis and Parkinson’s disease? Sounds extraordinary to me! But here’s what [JSVR] research has to say about that: A causal link between trauma-induced upper cervical injury and disease onset for both MS and PD appears to exist. Correcting the injury to the upper cervical spine through the use of IUCCA protocol may arrest and reverse the progression of both MS and PD.

    See: http://www.erinelster.com/files/jvsr%20ms%20and%20pd%2081.pdf

    JSVR have also published articles on cancer and infertility.

    In the same way that slapping a television on the side will not improve the quality of the picture if your aerial is disconnected, why, why, why, would chiropractors think their subluxation based practices could possible affect disorders such as these?

  6. Andrew Gilbey said,

    And here’s another extraordinary claim: Chiropractic helps ADHD (Not kids with back pain and who happen to have ADHD, but ADHD proper!)

    You can check out the abstract (no pun intended) here: https://www.jvsr.com/abstracts/index.asp?id=381

    If you do have a read, you’ll see it involved 50 sessions of manipulation over about 35 weeks. Poor kid!

    Interestingly, there is a possible way in which 50 sessions of chiropractic could help a kid with ADHD, but it has little to do with spinal manipulation, and a lot to do with the idea of punishment, as understood in Skinner’s theory of operant conditioning! For example, let’s say my boss sent me for fifty sessions of chiropractic because I spent too much time trolling interesting blogs, then I suspect I’d stop trolling and doing a bit of work. (Later headline: Chiropractic increases worker productivity!)

  7. jdc325 said,

    Thanks for the links (and for the interesting comments) Andrew. PDF on PD and MS remarkable. They found that 100% of patients involved had subluxations and ~90% improved after chiropractic. Impressive figures… almost too impressive.

  8. dave said,

    Hello all,

    I happen to be a chiropractor who agrees with some of the criticisms which are voiced on this post. It is frustrating and at times embarrassing to read some of the claims which are made by some in my profession. It is even more difficult for me to read some of the literature which is published in an attempt to “validate” certain therapies for conditions seemingly out side of our scope of practice. We need quality research, not sham science.

    That being said, I have experienced many cases where my patients have reported amazing results for conditions that I wasn’t trying to fix. When proper motion is restored to restricted vertebra and the nervous system is able to communicate more effectively with the body spectacular healing can take place.

    Chiropractic care is not a cure all by any means, but it helps a lot of people enjoy a better quality of life.

  9. Nathan Wall said,

    Hi there,

    Its one thing to sit at home and create websites and blogs and what have you about things you dont believe in or just can’t fully comprehend yet. Trust me I get it your bored. The medical/pharmaceutical industry (yes both being greedy hypocritical industries) have shown NOT one help when it comes to autism nor any other neuro development disorder. If you honestly believe that drugs are the way to go then by all means take them. If you have spent your time researching others and trying to find faults in other peoples work to progress and failed to research your own methods and see the lack of if any improvement in helping these patients then sadly yes keep popping your pills, but why you do it shut up and let the rest of us live. This why why why chiropractors make these claims is because there is success its why the medical community cannot make the claims and have to sit and ask why why why they cannot. When you type and open your mouth you show that your very uneducated in the subject. Take a look at Pub Med or JAMA and find the countless articles that claim to have a better outcome on the patient but list the side effects a page long. If you want to cure your high blood pressure with a pill that makes you dizzy and dry mouth with aching joints then take a pill for your aching joints that is a literal toxin to your liver the take another one to help your acid refulx then please be my guest because that’s what your research shows…hop on the medical marry go round and take your downward spin all the while they get rich and you die slowly, but again dont drag others with you because your to narrow minded to actually do something different.

    This is the Truth just accept it.

  10. jdc325 said,

    @Nathan

    You appear to be arguing with things I haven’t said.

    On-topic, I’ll just pick you up on one thing: “why chiropractors make these claims is because there is success”. This was the point of my post – chiropractors make claims that they cannot substantiate. If they are going to claim success then they need to provide reliable evidence that they have in fact been successful.

  11. Dr. Robert Brant D.C said,

    Much of the research that we chiropractors and other CAM practitioners have at our disposal are case studies. We are all very well aware how weak case studies are in the world of research but the simple fact of the matter is that good quality research costs money. The chiropractic profession as a whole does not have the resources for research that many individual medical schools have. Because of this, the quality and quantity of chiropractic research is limited. This is not to say that there have not been very good studies relating the effectiveness of chiropractic care. There have been studies showing that it helps with neck pain, back pain, headaches and even hypertension. This year there was a study published in the Journal of Occupational and Environmental Medicine that showed support for chiropractic care following lower back injuries. As more resources continue to become available, you will begin to see an increase in the quality and quantity of chiropractic research. Until such time that we have good quality research to back up the claims you see in case studies, I will tell you what I tell my patients. I know for a fact that chiropractic care can help decrease pain, increase range of motion and thus increase your quality of life. If you see improvement in any other symptoms then that is just a bonus.

  12. jdc325 said,

    One tiny unblinded study with no placebo arm is simply not sufficient evidence to base a claim on – particularly when it’s as implausible as chiropractic being efficacious for autism. If you can’t afford to do proper trials and gather reliable evidence, then don’t raise false hopes by making daft claims about chiropractic.

    “This is not to say that there have not been very good studies relating the effectiveness of chiropractic care.” True – for example this, this & this. Since you’ve mentioned back pain and headaches, I’ve made sure to include papers that looked at low back pain and headaches. I hope you enjoy reading them.

    “I know for a fact that chiropractic care can help decrease pain, increase range of motion and thus increase your quality of life.”
    Please do enlighten us – how do you know this for a fact?

  13. Maria Wise said,

    Nothing is a one-fit all approach. I have a child with Autism that has improved with a GFCF diet, also restricted colored dyes and preservatives. Does that mean its a cure for all children with a diagnosis of Autism? NO.

    It does not take a scientist to know the link between the brain and the rest of the body. Perhaps it does work for some. I have to agree with another commenter that you seem bored?

    If taking drugs like Depakote make a parent think they are doing right by their child with Autism, that’s there choice, but truthfully once a week or twice a week chiropractic visit isn’t that big of a deal, I would think its less risky thank taking a drug like Depakote (or other drugs used with children with Autism and other behaviors)

  14. Richard Fox, D.C. said,

    While I agree that empirical evidence done in double blind studies are the rule for evidence based approach treatments. The problem with researching Autism and the various spectrums/sub-spectrums of Autism, is that Autism is a condition unique to each patient. In other words, when you meet one patient with Autism, you’ve met one patient with Autism. It is a condition unique to the individual, and one’s sesnorimotor filters may be different from the others. It is not like a neoplasm, or disease, where you will see repeated signs and symptoms and repeated results.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 406 other followers

%d bloggers like this: