Chiropractors, Naturopaths, Concussions and Senate Bill 2390

The is a bill before the Oregon Legislature,  House Bill 2390,  similar to Senate Bill 1535 from last year, that

Allows chiropractic physicians and naturopathic physicians to provide release for athlete who sustained concussion or is suspected of sustaining concussion.

What follows is a slightly rewritten analysis from last year. Before reviewing the reasons as to why it is a bad idea for the athletes of the state, most of whom will be children, to be cared for by ND's and DC's, I would like to add a letter I received from Britt Hermes, a former ND and the author of the Naturopathic Diaries, concerning allowing ND's to evaluate children for concussion:

I am a former naturopathic doctor who practiced in Washington and Arizona. I graduated from Bastyr University in 2011 and then completed a naturopathic residency in pediatrics that was accredited by Bastyr. I left naturopathic medicine after discovering that its professional organizations, regulatory boards, and practitioners have been deceiving the public about the benefits and safety of naturopathic care, in addition to the medical rigor of naturopathic education.
In school at Bastyr, I completed the required coursework in neuroscience that spanned one year. This coursework was taught at the undergraduate level, and I know this because I have since taken additional neuroscience coursework as a Master’s student in medical research. 
The differences between the naturopathic coursework at Bastyr and in my Master’s program are extreme. At Bastyr, I was taught by a naturopathic doctor who describes herself as a "board certified homeopath" and healing touch practitioner. Her name is Alicia Gonzalez, and she taught students to provide homeopathic remedies and "healing touch" to patients with head injuries. Homeopathy is a debunked practice of folk medicine that involves administering minuscule doses of substances, including poisonous plants, snake venom, and heavy metals, to treat patients. Healing touch is no better, which is based on a magical energy projected from the hands. If these sound absurd, they are indeed because both are considered to be medical fraud.  
But Gonzalez continues to promote homeopathy and other disproven treatments for traumatic brain injury, such as in this article in the flagship journal of the naturopathic profession. This is not an isolated incident of one naturopathic instructor promoting nonsensical treatments for serious health conditions. I was also taught disproven alternative cancer treatments and herbal remedies to be used in lieu of the vaccines that protect us from ravaging infectious diseases.
When I decided to re-educate myself in science and evidence-based medicine, I realized that all of my courses I took at Bastyr, which were always described as being the “same basic and clinical science courses as conventional medical school,” were severely lacking in depth and breadth of medical rigor. It is this reason, that none of my science courses from Bastyr transferred to my Master's program upon my professors evaluating my course syllabi.
The naturopathic profession continues to claim that naturopathy is a science-based, safe, and effective practice. Make no mistake—charging patients for treatments using homeopathic pills and "healing touch" and other folk remedies is fraudulent and unethical by the standards of any medical profession.
I am deeply concerned that NDs are being considered for the responsibility of assessing concussions in children. There is absolutely no way that naturopathic doctors are trained in even the basic medical procedures for evaluating brain trauma in coursework or in hands-on clinical training.
In my time at Bastyr and in my naturopathic residency, I saw but one case of a child with a concussion. In that moment, I experienced the gravity of my limited training and referred the child to a medical doctor at Seattle Children's Hospital.
If naturopathic doctors would be allowed to release children with concussions, Oregon lawmakers would be making a mistake that would endanger the lives of its future generation.

What is A Concussion

A concussion is a form for trauma, an injury to the brain. The brain floats in cerebral spinal fluid, which acts as a cushion. If the skull hits something, or is hit, hard enough by a fist or a football helmet or a wall, the cushion fails and the brain smashes into the skull. Trauma results.

The patient can then have headache, confusion, ringing in the ears, seizures, double vision and other neurologic symptoms. The number and severity of the symptoms depends on what part of the brain is injured and the severity of the injury.

Treatment is resting the body and the brain and avoiding re-injury. There may be long term sequelae to concussions, especially repeated concussions, such as depression, dementia and Parkinson's.  The brain is not forgiving when injured, physically, emotionally or spiritually.

It is a huge problem, with 300,000 sports related concussions a year in the US and this only counts concussions that led to a loss of consciousness, perhaps 10% of all concussions. Children are both more prone to concussion and, perhaps, long term sequela.

So concussion is a serious and widespread medical problem.  It may not be an optimal approach to have those with little or no education, training or experience in medicine care for children with concussion.  Except, probably, in Oregon.

Education

Chiropractors and naturopaths like to pretend that their 'medical' education is equivalent to medical school. Nothing could be further from the truth.

Chiropractic

During the public hearing it was offered that the education of a chiropractor is equal to that of an MD. While there are superficial similarities, the whole of chiropractic education is through the lens of chiropractic theory: that there are misalignments of the spine, subluxations, that block that body's ability to heal, and that chiropractors can identify and adjust these subluxations to restore health.

The whole underlying concept of chiropractic is a pseudo-science, with no basis in anatomy, physiology, or reality. As one review notes

Chiropractic and allopathic medicine differ the greatest in clinical practice, which in medical school far exceeds that in chiropractic school. The therapies that chiropractic and medical students learn are distinct from one another.

Medical education is grounded in reality; Chiropractic education is grounded in the fantasy of innate intelligence, subluxations and spinal adjustments.

Naturopathy

Naturopathy education also appears to be superficially similar in the number of hours devoted to the basic sciences. When compared to the education of a Family Practice Physician, it is clear that ND's have a fraction of the training required to become and MD/DO.

21,700 for FP education and training, 6400 for an ND.

Doesn't look so good, does it?

It more than the quantity of hours in education and training that makes a physician, it is also the quality of the content. ND curriculum is even more focused on pseudo-science than chiropractic: homeopathy, hydrotherapy, acupuncture, energy therapies, and more make up a significant portion of the naturopathic education.. Time spent studying pseudo-science and pseudo-medicine is time not spent studying and understanding reality-based medicine.  Those educated in the care and feeding of unicorns are not qualified to care for horses.

The naturopaths testifying at the hearing suggest that since they have been given primary care designation they should be allowed to diagnose and manage concussion as well. I would suggest that two wrongs do not make a right.

Training

No MD or DO is even remotely ready for independent patient care upon graduation from medical school. After graduation MD's and DO's have a residency to learn their speciality. Internal Medicine, Family Practice and Neurology residencies are three years; neurosurgery takes 7 years.  It is the residency, practicing under the guidance of senior physicians, is where doctors really learn their profession.

Neither naturopaths nor chiropractors have a residency; they usually go straight from school and into practice.  The few that do complete a residency do so in the field of naturopathy or chiropractic, further reinforcing their pseudo-medical trainging.

There is no subspecialty naturopathic training in neurology; chiropractors can be certified as a chiropractic neurologist in 40 days of internet classes, or 300 classroom hours. Compare that to the over 8000 hours (assuming a mythical 8 hour work day) it takes to be a real neurologist, much of which is spend in direct patient care.

It is why Dr. Steven Novella, a Yale neurologist, says

Chiropractic neurology appears to me to be the very definition of pseudoscience – it has all the trappings of a legitimate profession, with a complex set of beliefs and practices, but there is no underlying scientific basis for any of it.

and that

Chiropractic neurology does not appear to be based on any body of research, or any accumulated scientific knowledge.

Evaluating their education, training and practice, I would suggest that chiropractic and naturopathy are to real neurology and medicine what Guitar Hero is to Jimmy Page.

Literature

A search of the medical literature on PubMed for “naturopathic medicine concussion” yields zero publications.  There are no trials to suggest that the pseudo-medical practice of naturopathy can be applied to brain injury. Or any other real disease for that matter.

For “chiropractic concussion” there are 19 hits on Pubmed, out of the 7,511 medical publications on concussion. None of the article concern the competency or efficacy of chiropractors in the diagnosis and treatment of concussion.

There are no clinical trials demonstrating efficacy of chiropractic or naturopathic treatment for concussion. And there is no reason based on known anatomy and physiology to suspect that either  pseudo-medicine would have benefit in the the diagnosis or treatment of concussion.

Dangers

The Palmer School of Chiropractic recommends manipulation of the cervical spine for concussion.

There is an association with cervical spine manipulation in the young and vertebral basilar artery stroke

Results for those aged 45 years showed VBA cases to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA (95% CI from bootstrapping, 1.32 to 43.87). Additionally, in the younger age group, cases were 5 times as likely to have had ≥3 visits with a cervical diagnosis in the month before the case’s VBA date.

The association between cervical spine manipulation and stroke is consistent enough that the American Heart Association and the American Heart Association have released a scientific statement suggesting

Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients.

Complications fortunately are rare, as Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the Literature, showed

Thirty-one articles met the selection criteria. A total of 12 articles reporting 15 serious adverse events were found. Three deaths occurred under the care of various providers (1 physical therapist, 1 unknown practitioner, and 1 craniosacral therapist) and 12 serious injuries were reported (7 chiropractors/doctors of chiropractic, 1 medical practitioner, 1 osteopath, 2 physical therapists, and 1 unknown practitioner).

but for an intervention that has no benefit, the risk should be zero.  Young people have died after chiropractic manipulationperhaps including the recent death of “Queen of Snapchat,” Katie May.

And children are injured by manipulation when the correct diagnosis is missed.

Other (serious adverse events) leading to permanent neurological consequences have been reported. However all of these were attributable to a misdiagnosis leading to the inappropriate application of SMT (spinal manipulation therapy) with unfortunate consequences.

Yes. A child crippled by a useless intervention for the wrong reason is an unfortunate consequence. Given the lack of medical training by DC's and ND's,  further unfortunate consequences would seem inevitable.

If stroke were due to a medication, the medication would receive a black box warning at a minimum or be pulled from the market. The major Chiropractic organizations deny that chiropractic can cause strokes and continue to snap the neck, which can result in the same forces and injury as a hanging. But that is typical of pseudo-medicines: they never recognize that their intervention could be dangerous and alter or abandon practice accordingly.

The data suggesting a link between chiropractic manipulation and stroke is complicated and incomplete. However in medicine, but not chiropractic or naturopathy, the precautionary principle is applied:

if an action… has a suspected risk of causing harm to the public, in the absence of scientific consensus that the action or policy is not harmful, the burden of proof that it is not harmful falls on those taking an action.

and the action avoided.

The majority of chiropractors are of the opinion that spine manipulation is a treatment for concussion, even though the brain is distant from spine.

Most respondents agreed or strongly agreed that manual therapies may be appropriate in certain circumstances in adults (80%) and minors (80%).

But when all you have is a hammer, everything is a nail.

While there is no naturopathic specific treatment for concussion, naturopaths do have their own naturopathic manipulation.

It should give anyone concerned with the health of children a frisson of terror at the thought of concussed children being evaluated and managed by naturopaths and chiropractors.

Conclusion

Naturopaths and Chiropractors lack the education, the training, and the understanding of medicine and neurology to diagnose and treat concussion. Their therapies are at best useless and can result in strokes in one of our most vulverable populations, children.

House Bill 2390 should die in committee.