Hokum Locum

A Menu of Dietary Delusions

Neither Nutrasweet nor sugar-rich diets produce any change in children’s behaviour. (New England Journal of Medicine 330:301-307, 1994)

The subjects were tested in a double-blind, placebo-controlled trial. The trial was reported in the local press and produced a predictably outraged response from local nutritional quacks who have carried on regardless. Their beliefs are based on faith and are therefore not amenable to reason. For another good New Zealand review see NZ Medical Journal 27/9/89 (Diet and Behaviour) and 23/8/89 (Children’s diets: what do parents add and avoid?).

Evening primrose oil has been touted widely as a “natural” remedy for a host of conditions such as pre-menstrual tension and menopausal symptoms. The active ingredient is gamma-linolenic acid and it was tested in a randomised, double-blind, placebo-controlled trial of 56 menopausal women experiencing episodes of sweating or flushing. It was found to be no better than a placebo.

It is worth noting the value of such studies. Randomisation means that patients have an equal chance of receiving either the “test” substance (gamma-linolenic acid) or a placebo. This ensures that both wings of the trial are identical in terms of age, sex, number of smokers, etc. Double-blind means that neither the subjects nor the investigators know who was taking the “test” substance or placebo until the study has finished. It is no wonder that quacks decry such studies which remove bias, prevent cheating and usually show that quack remedies are useless. (BMJ 308: 501-503, 1994)

Smart Drinks

These are amino acids and other precursors of neurotransmitters which are being promoted among teenagers at music and cultural festivals. Smart drinks are claimed to “fire up the brain” and give the young executive an “edge”. Could there be anything more loathsome than a hyperactive yuppie? I remember reading about the smart drinks phenomenon in the US and I am not surprised that they have arrived in New Zealand. There is no evidence that smart drinks have any effect on either memory or intelligence. (NZ Doctor 31/3/94)

Sick of Work?

All that is necessary in New Zealand to get a sickness benefit ($22 per week more than the dole for those under 25 years of age) is to persuade a doctor to sign a prescribed form from the DSW.

Over the years I have seen many flagrant abuses of the SB. The best one was a young person who had been on a SB for over two years because of a perforated ear-drum. When I refused to sign the certificate she simply went to a more compliant doctor.

The court news regularly detail the activities of professional criminals and drug addicts who are described as “sickness beneficiaries”. My attempts to find out which doctors were signing these certificates were thwarted by DSW who cited “medical confidentiality”. The great irony is that at the time they were expecting doctors to inform on beneficiaries who were fiddling the system but were not prepared to put their own administration under scrutiny.

A reporter in Germany was able to obtain 41 days sick leave from five different doctors even though he told them he was perfectly well but just wanted a few days away from the office. One visit lasted four minutes, involved no examination and was worth 12 days off! (Dominion 29/3/92, Worker highlights easy access to sick leave)

This sort of abuse arises from poor ethical standards, which also extend in Germany into drug licensing (see Skeptic 27).

Laying On of Hands

The introduction of ACC around 1972 saw a great increase in both the use of physiotherapy and private physiotherapy practices. In Skeptic 29 I commented briefly on the widespread use by physiotherapists of unproven treatment modalities such as ultrasound. Ultrasound treatments have been introduced on a basis of applied experience rather than from controlled scientific study. Dr Linda Maxwell writing in the NZ Science Monthly, March 1994, has studied cellular processes at injury sites and found that ultrasound may enhance inflammation and actually cause more injury.

Physiotherapy is also traditionally used to build up muscle strength in patients with rheumatoid arthritis. A controlled trial by physiologists (New Scientist 16 Oct 1993 p17) found that this approach tended to worsen the flexion deformities seen in this condition. Work continues in the area of electrically stimulating the extensor muscles in an effort to counteract the tendency to flexion deformity.

Most injuries recover with time and I doubt whether the laying on of hands or the use of electrical gadgets by physiotherapists accelerates this process. Many of my patients become upset if they do not receive a referral for physiotherapy and few doctors will refuse in such circumstances.

It is no surprise that costs of the ACC scheme have continued to rise each year. The burden of proving that their treatments are worthwhile rests with the physiotherapy profession. ACC should not pay for any treatments unless they can be shown to be both cost effective and scientifically valid.

Alexander Technique

The “Alexander Technique” (AT) is an extreme example of the laying on of hands. To quote a recent magazine article, “…by extending the neck and opening the back, it literally makes you taller and releases the body’s natural energy flow”.

Note the typical vague language of quackery: what does “open the back” mean and just what is this “natural energy flow” that quacks keep going on about? The usual anecdotal reports are quoted by satisfied patients: “My singing has improved tremendously…I felt lighter, taller…I’ve learnt to relax by opening and lengthening the back muscles!”

The founder, Frederick Alexander, was born in Tasmania in 1869 and longed to be an actor but suffered a mysterious loss of voice. The rest is worth quoting: “Sitting alone for nine years in a room containing only mirrors and a chair, he studied his position in every detail. It took two years for Alexander to discover only the fact that when he talked he was moving his face and chin forward and contracting the vertebrae in his neck. The muscles of his neck were becoming very tight and causing obstruction in his voicebox.”

I would have described his position as ridiculous and if he found the problem after two years what did he do for the other seven years? How does one “contract the vertebrae in the neck”?

Feeling a need to inform us further about AT the author followed up with three more anecdotal reports from satisfied customers who all described how they feel “happier, more positive, less stressed”.

Quackery has many recurrent themes. The founder of AT suffered a profound illness which was clearly psychological (nine years in a room with mirrors!) and led to him feeling that he had discovered the meaning of life.

The laying on of hands is the basis for the clinical effects (essentially placebo) of most forms of physical therapy such as chiropractic, osteopathy and AT.

Massage and postural “adjustments” are pleasant procedures for patients and it is not surprising that they go away feeling empowered and improved. Unfortunately, many become dependent on therapy and I have met many people who feel it essential to consult such therapists on a regular basis for years. This of course is encouraged by such quacks because it is great for business and they are able to take advantage of people who are incapable of taking responsibility for their own lives and health.

Ischaemic Heart Disease

Ischaemic heart disease (IHD) is a serious public health issue in New Zealand and is the leading cause of death for New Zealand adults. My own father died suddenly of a heart attack while on a golf course. He was 71 years old and had no known risk factors yet autopsy showed severe coronary artery disease.

The costs of treating IHD are considerable and surgical treatment is popular. Political pressure has seen the creation in New Zealand of an absurd number of cardiac surgical units compared to similar western countries. An American study (quoted in Lancet Vol 343 p412) of 1,252 patients showed no difference in employment status after one year between comparable patients who underwent either surgical treatment (angioplasty or bypass) or medical treatment (lifestyle modification, drug treatment).

Angioplasty involves passing a fine balloon catheter into an area of blockage and inflating it, while bypass surgery involves using lengths of vein to bypass the blocked area in the coronary artery. In a subset of 72 patients the median number of days from the start of treatment to return to work was 14 days for medical treatment, 18 days for angioplasty and 54 days for bypass surgery.

Clearly surgery is not always the best option and a lot more of our health resources could be better spent on prevention of this condition by risk factor reduction.

Death or Compensation

A court in the UK awarded a Falklands War veteran $220,000 for post-traumatic stress disorder acquired as a result of serving during that campaign.

This drew a sharp response from the defence editor of the Daily Telegraph (Dominion 10/3/94) who asks how this can be taken seriously at a time when thousands of veterans are converging on Normandy to commemorate the D-Day landings. The Falklands War veteran received his award for the stress of an action over two days! Many WWII vets saw active service for five years and returned to lead happy and successful lives.

Wars are horrible experiences from which soldiers can recover without the need or right to compensation. Post-traumatic stress disorder is simply a New Age euphemism for shell shock, and an insult to all servicemen who have done their duty and returned to civilian life. This absurd monetary award is an example of Welch’s law (after Parkinson): “Whenever compensation is available conditions will emerge to take up the compensation available”.

Deliver Us From Gynaecologists?

In Skeptic 29 I referred to abuses of gynaecology. In Florida, where 25% of deliveries are by caesarean section, the state legislature has forced doctors to change their practices, wanting the rate to be less than 20% by 1997. There is a higher rate of Caesarean delivery among patients with better health insurance and higher incomes, and the rate is lowest in teaching hospitals. (BMJ Vol 308 p432)

Failing the Sex Test

This is the headline of an article which appeared in the Dominion 17/3/94, and concerns an Indian clan which murders unwanted female children. Because of the illegal dowry system, girl children are too expensive so are murdered by being either strangled or smothered soon after birth. The tribe cannot afford amniocentesis which is also abused in order to predetermine sex so that female foetuses can be aborted.

It is important that such cultural practices are highlighted and discussed. It has been interesting to see how various other equally vicious cultural practices have fared following migration to western countries. Some doctors have been de-registered for performing female circumcision and I have even seen a reference in print defending this procedure!

The Indian authorities have taken little action over these murders since the status of women in India remains low. If there are problems over the dowry after marriage, it is a traditional practice to set fire to one’s wife and make the murder look like a kitchen accident.

How far should we go in either acknowledging or accepting traditional cultural practices? Nurses in New Zealand are judged on their “cultural safety” regarding Maori traditions and customs, which fortunately do not honour such abuses as infanticide.

Monkeying with Your Private Parts.

Rejuvenation! The wish of many a tired old man, and not so old: to regain the physical and sexual vigour of youth.

During the early decades of this century it was widely though not universally believed that such a rejuvenation, a turning back of the clock, could be achieved. It was thought that the secret of youth lay in the primary sex organs, so transplantation of the testis from young to old was the method adopted. In the 1920s a dozen or more surgeons around the world were ministering to this fervent desire by grafting the testes of young animals into those patients who could afford the fee.

We now know that this operation was quite useless, yet the surgeons and their hundreds of patients were on the whole convinced that the latter were indeed made to feel younger and fitter. Since that time we have discovered what formidable barriers the body raises against the introduction into it of “non-self” tissues. Material even from close relatives is rejected, and only in very recent times have methods been found for breaching the body’s defences to allow the intrusion of carefully matched foreign organs. This type of operation still makes newspaper headlines. Grafting between different species, using the techniques of sixty or more years ago, is impossible; rejection, the complete killing of the graft, would have been very rapid.

We have here, then, a most powerful example of the placebo effect, so a closer look at these events would follow naturally on Bill Morris’s article on the subject in the previous issue (Skeptic 27).

To set the scene, the medical background to the activities of the gland grafters, we note that as the century began the science of endocrinology was just beginning. The powerfully acting secretions of the endocrine glands were slowly being discovered and studied. First, the effect of extracts of thyroid glands on cretinism and myxoedema, then in the early twenties the anti-diabetic action of the pancreas extract insulin.

Gland Extracts to Restore Virility

It seemed a natural extension that an extract of the testis gland should restore flagging virility, and some unsuccessful trials along these lines took place. (when a hormone was, many years later, isolated from testes, and named testosterone. it was found not to have the effect sought.)

Seeking a more successful way of using the sex gland, surgeons looked to grafting. It was known at that time that cornea and bone could be transplanted from one person to another; it was not then realised that these successful grafts were rare exceptions — rather they were taken to indicate that grafts between people of any organ were possible. This view was strengthened when the discovery of blood groups enabled doctors to avoid the disasters which attended many of the early attempts at blood transfusion. The fact that some skin grafts did not “take” was ascribed to less-than-perfect technique, and many apparent “takes” were only the growth of the recipient’s own skin, and not the graft at all.

So the grafters got to work, initially on animals, and then on human patients. The usual technique was to excise the testis from the donor animal, open the scrotum of the recipient, and to place either the whole donor testis, or a slice, close up against one of the recipient’s testes, and then to sew him up again. In most cases the implanted tissue appeared to persist over time, giving the impression that the graft had “taken”. From our present standpoint we view this effect as the result of the rapid invasion of the graft by host cells, so the apparent “extra” gland was merely inactive host tissue.

Some of the earliest transplants into humans (1919 on) were carried out on those well-known experimental subjects, the residents of US gaols. These were man-to-man transplants, the “death row” of the prison serving as a regular source of fresh donor material. Dr Leo Stanley, chief Medico at San Quentin Prison in California, was the leader in this work, and carried out many transplants into “volunteer” prisoners during the 1920s. He and his patients were generally pleased with the results, and he impressed his fellow physicians sufficiently that several of them underwent the operation themselves.

In spite of this, there is no doubt that the most famous of the testis grafters was Serge Voronoff, a Russian émigré doctor of great wealth and charisma, active in Paris from the 1880s until the Second World War. Already in his 50s, and with a successful and fashionable medical career behind him, he turned in 1919 to the work that made him famous, his rejuvenation treatment. Lacking access to human material, he chose as donor animal the chimpanzee.

Believing that human grafts were possible, he picked on man’s closest relative as being the most likely to provide a transplant acceptable to the recipient’s tissues. Despite the expense (the chimpanzees alone cost a small fortune, as they each had to be caught in Africa and brought safely to France), he had many patients.

Voronoff’s fame during the 1920s arose not only from the “success” of his grafts, but also from his copious output of books on the subject, which he continued to publish long after the operation had passed out of favour. He had had from the outset critics who doubted the efficacy of the testis grafts, but it is uncertain whether, judged by the knowledge of the time, they had more reason for their skepticism than Voronoff had for his optimism.

The two British doctors’ journals took differing views: the Lancet was consistently critical of Voronoff’s medical claims and reviewed his books unfavourably, while the British Medical Journal was generally more approving.

Perhaps surprisingly, Voronoff’s undoing came not from a medical but a veterinary quarter. Emboldened by his success with human patients, he returned to his earlier interest in animals, and put his talents at the service of French agriculture. In 1924 he secured the use of a flock of sheep at an agricultural station deep in the French colony of Algeria. Some of the young rams of this flock received a testis graft, others were left unoperated. On reaching maturity, the operated rams were found to be heavier, and yielded more wool, than the unoperated controls. Not only this, but the progeny of the grafted rams also gave more wool.

Success?

Conclusive proof! Surely this evidence would silence those who had doubted. The animal results could be assessed objectively, unlike the confidential and subjective observations on the human patients. So groups of veterinarians and agriculturalists were invited to inspect the “super sheep.” All but one of the international visiting parties were quite convinced; only the British put their fingers on the fatal flaw in Voronoff’s case.

Translated into present-day statisticians’ jargon, he had failed to randomise his young rams at the start of the trial. It is as if we judged the winner of a race by noting who first crosses the finish line, without ensuring that all competitors started from the same place at the same time.

Knowing now that these grafts must have been rejected, we can only conclude that Voronoff had, perhaps unconsciously, selected the better quality rams for the transplant group, and that this superiority had carried on into the animals’ maturity, and to their offspring.

Voronoff’s claims for the superiority of the offspring of his grafted rams implied “inheritance of acquired characteristics;” thus, all unwittingly, he had strayed onto the battlefield between the Lamarckians and the Darwinians. So, by his sheep experiments, he widened the area of interest in his work beyond the medical, attracting the attention of veterinarians, agriculturalists and finally general biologists.

By 1930 medical opinion was already turning against him; the scrutiny of the non-medical scientists hastened this process. By their nature, his human operations were very private, confidential affairs, the results of which were quite inaccessible for objective assessment by others.

When the fad for this operation died down, and its uselessness was realised, the practitioners were widely ridiculed, and reviled as quacks and charlatans. This was incorrect and sadly ungenerous; with few exceptions these surgeons were sincere men who wholeheartedly believed in what they were doing. Voronoff himself defended his work until his death in 1951.

A Change of Glands

That is not quite the end of the story of the gland-grafters. At the same time as testis transplants were going out of fashion, as described above, endocrinology was discovering more and more hormones produced by the body’s many glands, and these were available for “treating” a wide range of disorders.

The pituitary gland, in particular, was found to have a special role in controlling the activity of other glands (it was at one time called “the conductor of the hormonic orchestra”). Injection of cells of the pituitary, then, could be used by unscrupulous doctors to treat whatever glandular deficiency the patient could be persuaded he had.

The leading practitioner, Dr Niehans, a Swiss, was active until the 1950s, and counted Top People (from Hollywood to the Vatican) among his patients. None of his injections could have been of any use.

What lessons ought we to learn from this story, this false turning in medical science? Firstly, we see that misguided enthusiasts can be as dangerous as unscrupulous quacks. Furthermore, we should all subject our enthusiasms to rigorous self-scrutiny.

If Voronoff had kept better records of his operations, and taken a more objective view of the results, he might eventually have seen his error. Had he invited a histologist to examine his early sheep grafts he might have been convinced that they had indeed been rejected by the host. From the patient’s viewpoint, a person unhappy with his present state of health, having undergone a very expensive and uncomfortable operation, carried out by a charming, confident and persuasive surgeon, can almost be guaranteed to confirm whatever outcome of the operation the surgeon suggests to him.

A last thought: in a period which delivered to women the suffrage, protective labour laws and power-driven domestic appliances, the “rejuvenation” movement was almost entirely male-oriented. No-one seems to have considered whether anything could be done to help the post-menopausal woman who longed to be twenty again.

I am indebted for the information in this article to The Monkey Gland Affair by David Hamilton, London: Chatto & Windus, 1986.

D is for Dog, and for Doctor

A colouring book for young patients of chiropractors says “A is for alligator and adjustment. B is for bells and for back. C is for caterpillar and for chiropractor. D is for dog and for doctor.” The latter two may have more in common than is apparent at first glance.

It is as much of a surprise to the medical profession to find that their standards of back care are under attack as it would be to a high-rise executive to be attacked through his office window by fighter planes.

The orthopaedic surgeon, secure in his strength and apparently limited in his intellect, seems ill-equipped to withstand the challenges mounted against him from a variey of paramedical platforms. The face of the enemy may be unfamiliar, but the threat to the doctor’s authority is absolutely clear. The battleground is the low back. The opposing forces clash at the point of pain.

The public has little confidence in the medical profession’s ability to diagnose or manage back pain. Recently, on my way to conduct a seminar, I took a taxi from my hotel. The driver, seeing my carousel full of slides, observed I was going to give a lecture. When I responded to his questions that my topic was back pain, he observed I must be a chiropractor.

The medical profession is justifiably under attack because the conventional medical management for back pain is often wrong.

Prolonged bedrest beyond five days is of no proven value, and admitting a patient to hospital merely to sit on him is boring for the physician and makes it difficult for the patient to breathe. Getting high on drugs seems somehow more appropriate on the street than in the clinic. The prescription of modalities, such as traction, to treat a structural spinal abnormality leads to lengthy treatment producing temporary alteration but which ends precisely where it began, with a structural spinal abnormality.

Medicine’s fascination with excessive and even unnecessary investigations proceeds towards one of two unfortunate conclusions.

The patient is told, “The results of your tests were negative. Get lost.”

Or, the surgeon is seduced into operating on an x-ray. When the radiograph, rather than the patient, demands treatment, I recommend that the surgeon content himself with the film, a view box and a pair of scissors.
Faced with this apparent lack of medical success, there is little wonder that many patients seek out alternative treatment, searching for “a backache remedy that works”.
Therapeutic touch is one such alternative. It is a non-invasive therapy utilising “the body’s own electromagnetic field” which assists the client (no longer the patient) to return to “a more balanced state of body, mind and creative spirit”. I suspect the client/patient is not the only one who is being creative.

Polarised Haemoglobin

The Magnetic Four Season Band is typical of the commercially available remedies to relieve backaches. Naturally, since over 80% of backache subsides spontaneously within three months, the Four Season Band comes with a money-back guarantee.

The advertisement also explains the Band’s mode of action to relieve back pain, namely the polarisation of haemoglobin by small magnets. I have no idea what that means, but I feel better already just knowing my haemoglobin has been polarised.

The lack of proof or scientific validity seems no deterrent to the method, and the picture is confused, as it is with so many spurious treatments, by the coincidental subsidence of pain or some unrelated additional benefit.

In the case of the Magnetic Four Season Band, for example, you might use the magnets to attach yourself to the outside of a bus and be allowed to travel for half-fare.

Skull Manipulations

Perhaps striking closer to home is the practice of craniosacral therapy. Instruction in this art form throughout North America generates an annual revenue of more than three million dollars.

The therapy is based on a philosophy expounded in 1908 by an osteopathic student, who felt that since suture lines were visible on the human skull, God had intended there to be movement. The fact that no movement can be demonstrated and that the suture lines commonly fuse over the age of 50 was, and is, considered irrelevant.

Having spent considerable time and money, and having been required to memorise, for example, the over 20 articulations at the base of the skull (none of which move) as potential sources of pathology, it is little wonder that the initiated are reluctant to dismiss the technique as a waste of time.

Furthermore, patients find it comforting to lie in a darkened room, listening to soft music and having their heads massaged. But transient relaxation does not justify a belief in the repetitive expansion and contraction of the skull every five to ten seconds, nor does it establish cranioscaral’s link, as described in one of their texts, with Phillipine psychic surgery.

And I have great difficulty in accepting craniosacral’s “Laws of the Lines of Gravity”, which state:

Man deals with himself in such a manner that his brain becomes more perfect because he arranges his lines of gravity in a different manner from any other creature. Also, the gravity lines pass through his diaphragm, and no animal has this diaphragm-gravity relationship.

I advise patients who wish to have the bones of their skull rearranged to choose their therapist carefully.

Whiplash Worries

Clearly we are on the road to confusion, and it is the patient who may become the accident victim. And what motor vehicle injury is more classic than whiplash?

Every one of us who has ever worked in an Emergency Room has treated this problem, and yet whiplash is not a diagnosis. It describes only a particular mechanism, commonly seen in rear-end collisions, which may lead to a variety of neck injuries.

The pathology after an acceleration-deceleration injury may be as simple as a minor muscle haematoma or as devastating as a cervical fracture with cord damage.

Each is a distinct entity requiring specific treatment, and the diagnosis should reflect the individual conditions — not the common physical cause.

Whiplash to the chiropractor offers a different vista. Gone is the range of diagnoses, to be replaced by the ubiquitous vertebral subluxations. Anatomical reality is replaced with a line drawing where the neck bows like a willow in the wind.

In case of accident, medical attention is not recommended, but the admonition to see a chiropractor follows immediately after advice to remain at the scene of the accident until all information has been collected, and before being instructed to notify your insurance company.

Thorough examination by a chiropractor is presented as a wise precaution to determine the presence or absence of injuries.

As an example, headaches are a current complaint after a whiplash-type injury, and according to matrial supplied by the chiropractor:

Most headaches result from spinal subluxations, in other words, malfunctioning vertebrae. These subluxations cause irritation of the delicate nerves and arteries that supply the head and face area, causing pain. Subluxed neck vertebrae can also interfere with the blood circulation to the brain.

The chiropractor’s adjustment keeps the body free of nerve interference and allows normal blood flow. This allows the body to use its own inherent healing ability to maintain a state of health.

A Blow to the Head

For minor cervicel adjustments, a chiropractor may employ the activator gun. This instrument closely resembles a dental implement which used to be used to pound an artificial crown on a tooth. A spring-loaded plunger is propelled a centimetre or so beyond the end of the barrel.

Patients are told that contact with the skin and subcutaneous tissues creates a subtle pressure wave, sufficient to restore minor subluxations without the discomfort or potential risk of a full adjustment. In Ontario, each trigger pull is worth $10.

Market Forces

In health care, as in any retail business, effective marketing means listening to consumer demands. Giving the client/patient what he or she wants is the name of the game.

When the validity of treatment is not an issue, everything from electric pain management to dietary regulation can have a place in the control of back pain. When you treat a self-limiting condition, easy access, lucid explanations, emotional support and physical contact are powerful weapons.

It should come as little surprise that most sociological studies rank the chiropractor well above the doctor in the ability to control back pain.

And where is the doctor? Has the battle been lost by default? Medical training provides little knowledge or skill to justify the restoration of public confidence.

The modern medical attitude says, “Well, Bob, it looks like a paper cut, but just to be sure, let’s do lots of tests.”

Even the doctor confronted by a patient on whose back clings a large, green monster may be reluctant to make a definite diagnosis.

Although the doctor thinks he has found the trouble, he may refuse to make a commitment until all the investigations are complete, all the while muttering under his breath about the complexity of back pain and the possibility of arthritis or cancer.

D is certainly for Dog, and seems an appropriate mark for the doctor’s attempt at back care.

The fundamentals of patient back education are too often left to junior colleagues without the depth of knowledge necessary to answer questions or the depth of experience necessary to command respect.

A concerned patient requires a clear understanding of the problem, but the lesson in consumer satisfaction so clearly demonstrated by the chiropractor is lost on the physician.

Doctors Gullible Too

Equally quick to criticise the chiropractor for non-scientific methodology, the doctor is equally vulnerable to promotions based on scant medical research — an appeal through showmanship rather than science.

Consider the cold laser. Lasers are high energy light beams which travel in perfectly straight lines. They can be used to signal satellites or to burn holes in bricks. When the energy of the beam is reduced below the combustion point there is no known effect.

Laser surgery relies on the laser’s ability to vapourise tissue. Laser therapy relies on the laser’s unseen ability to increase the energy-containing capacity of the mitochondria within the cell. There is no way to measure this!

Lasers are said to normalise Brownian movement, the random particle movement typified by dust motes in a beam of light. Since random motion is an element of quantum mechanics, and cannot be measured in the living body, there is no way this theory can be tested.

Furthermore, I find it difficult, even in a large scale model, to differentiate between normal random movement and abnormal random movement.

Finally, the laser is heralded as being able to increase the nervous system’s light-carrying capacity, or bioluminascence. This capacity, unknown to the neurophysiologists and anatomists, is well recognised by those who sell medical lasers for $10,000 apiece. Still, lighting up the nervous system has a great deal of appeal.

Having purchased my own expensive equipment, in order to keep up with the clinic across the street, I intend to treat all my joggers so that they can run safely in the dark.

Mind-Body Interaction

The back is an emotional target, and is subject to storng mind-body interaction. Dreaming he is falling, Jerry forgets the well known “always wake up before you land” rule and is flattened like a pancake in his own bed. Here is mind-body interaction in the home.

Six months of inactivity with a bad back, too much beer and too much televisio, and we have the perfect male specimen poised to return to the job. Here is mind-body interaction in the workplace.

Lack of physical stamina limits performance. Strength requires exercise. The willingness to actively participate in the recovery process is a positive mind-body interaction.

Using exercise to control back pain is not a new idea. One manual published in the 1920s pictures the author, complete with bow tie, demonstrating his own routines.

But modern medicine’s love of technology threatens to make even this simple idea unmanageably complex. A bride in her wedding gown standing next to a computerised exercise machine smiles out from a glossy advertisement and exclaims, “Superb! I passed my dorsal stress test. Have you?” I haven’t the faintest idea what she is talking about. I think I prefer the man in the bow tie.

Active, Healthy Machines

Given the choice, of course, many of the doctor’s patients also prefer technology to exercise. One case in point is the passive exercise studio, where you can assure yourself of a healthy, attractive body, painlessly, without perspiration, without the discomfort of strained muscle and bruised joints, and never be out of breath.

The answer, of course, is the machines do all the work. An electric table folds in the middle, helping you with your sit-ups. After a busy day at the clinic, the machines are in great shape.

The same appeal possessed by passive exercise motivates many patients to visit the chiropractor. It is far easier to let something or someone else do the work and take the responsibility than to take charge of your own problems. But chiropractic is not unique in its emphasis on passive techniques. Nor is it alone in its apparent disregard for anatomical considerations.

Manual therapy, performed by a broad spectrum of experts, remains shrouded in folklore and mystery. Thoracic manipulation, as a means of moving the thoracic vertebrae independently, disregards the intervening skin, fat and muscle present in the average living patient.

This same disregard for proven functional anatomy appears in the descriptions of the neurolymphatic reflexes. For example, symptoms of conjunctivitis (an eye complaint) may be treated with pressure on the appropriate reflex location, the upper humerus at the deltoid insertion (arm-shoulder connection).

As surprising as this sounds at first, it is in fact one of the better recognised non-anatomical connections. The next time you meet someone whose eyes are red and bleary from a previous evening’s party, punch her or him sharply over the outer shoulder and watch the eyes fly open. You have just demonstrated a neurolymphatic reflex.

Fallacious anatomy can be used to justify massage or manipulation which brings only temporary pain relief, and yet the patient’s comfort may be enhanced through the erroneous belief that some structural malalignment has been correxted. But when applied in a more sinister fashion, anatomical misinformation can create unwarranted fear and justify the continuation of unnecessary treatment.

Anatomical Misinformation

Dozens of medical conditions are purported to arise because of minor vertebral malalignments. The anatomy seems reasonable, the terms sound familiar, and the medical problems are easily recognised, and yet something is amiss. To accept the diagnosis you must believe. But there are several conflicting belief systems at work in the realm of back pain.

Where better to indoctrinate the true believer than in childhood. Convincing new parents that their infant’s spine requires manipulation to ensure normal growth not only increases current practice, but fosters the child’s lifelong adherence to the principle. “Bring your children for an adjustment. Teach them the benefits of chiropractic.”

Without the knowledge that most back attacks subside spontaneously within 12 weeks, that back pain is a self-limiting condition, and that most back disorders can be controlled through simple measures of self- help, a chiropractic schedule of adjustments outlining intensive care for 13 weeks, reconstructive care for two to two and a half years, and maintenance care for a lifetime seems almost reasonable.

Dependency a Problem

Dependency can be a serious problem, but patients readily accept the idea that their back can somehow be straightened, pressed and cleaned in time for them to pick it up before the shop closes. Passive acquiescence and dependency are the antithesis of active participation and self control.

For those who allow back pain to dominate their lives, the statistics paint an ominous picture. Anyone remaining off work with a bad back for more than six months has only a 50% chance of returning to work on a regular, full-time basis.

Remain off the job for a year, and the chance falls to 25%.

Remain unemployed because of a bad back for two years, and there is virtually no statistical probability that you will ever return to your previous employment in a regular productive capacity.

It is the doctors, far more than the chiropractors, who have been guilty of creating dependency. It is little wonder that many patients will use more than the “apple a day” to keep the doctor away from their backs. The medical profession possesses the potential to eliminate back pain as a major socio-economic problem, but we have yet to demonstrate our understanding of the solution.

Too many meetings, too many publications, and too much time and effort are addressed to the perfect surgical solution while neglecting the simple fundamentals of intelligent and effective back care.

Patients need a simple answer to what can be a simple problem. Most need support, not surgery. They need a platform from which they can achieve their own success.

Joint Responsibility

This is not a popular message. There are too many vested interests and too many strongly held differences of opinion to gain consensus. But whether we like it or not, the battle has been joined and will continue. Both the doctor and the chiropractor have a responsibility to promote better back care.

No longer can the physician place unwarranted emphasis on investigative procedures and invasive therapies.

No longer can the chiropractor hide behind non-diagnoses like “concomitant intervertabral subluxation complexes,” nor report that “the form of treatment given is chiropractic care”.

No longer can the physical therapist be allowed to treat patients solely with modalities possessing no proven therapeutic value, providing temporary pain relief at the risk of long-term dependency.

Dr Hill presented this at a conference of the NZ Society of Physiotherapists.