Chiropractor Anthony Pellagrino touts a dubious study of chiropractic for stroke

When it comes to chiropractic, my viewpoint is along the lines of a frequent saying for which I’m known: Chiropractors are poorly trained physical therapists with delusions of grandeur. What do I mean? First, although chiropractors are trained in spinal manipulation, their training is generally based on a long discredited notion based on the existence of subluxations. Unlike physical therapists, they are not trained in the full range of physical modalities and exercises to help with spine problems, and, worse, what they are trained in is not science-based. Second, all too many chiropractors go beyond spinal manipulation and claim to be able to treat all manner of conditions and disease unrelated to the spine, such as allergies, autism, asthma, and many more. As a result, I can’t really recommend chiropractic for anything. When patients ask me about it, I’ll say that it might be OK for uncomplicated back pain, but not for anything else, and for heaven’s sake don’t ever allow a chiropractor to manipulate your cervical spine. No, I really mean it. Even when there’s a small risk of stroke, it’s too high a risk when there’s no demonstrable benefit to neck manipulation, contrary to what chiropractors like Anthony Pellagrino claim.

Speaking of stroke, I came across this Tweet the other day from him:

Of course, I’ll get to the study soon enough. First, however, meet Anthony Pellagrino, a chiropractor, whose Twitter page amused me, as his Twitter bio describes him as “Chiropractor. Advocate. Scientist.” Um, no. If you’re a chiropractor, you’re not a scientist, because you’re practicing a specialty rooted in prescientific vitalism. In any case, “Dr.” Pellagrino runs a website called ChiroEdge, which claims to provide, “fresh, relevant, research-backed content for your practice.” (Well, not my practice. I’m not a chiropractor, fortunately.) But practice, if you can call it that:

“Research-based.” You keep using that term. I do not think it means what you think it means. And make no mistake “Dr.” Pellagrino is all in on the pseudoscience of chiropractic. He’s not one of the “reasonable” chiropractors who rejects the vitalistic, superstitious elements of chiropractic and focuses on physical manipulation to relieve spine and musculoskeletal complaints. Just check out his practice website, Absolute Chiropractic in Monmouth, NJ:

Neurologically-based chiropractic corrective care focuses on the proper function of the central nervous system in order to not only address the root cause of health concerns, but to allow you to live your best life possible. The role of the central nervous system, comprised of the brain and spinal cord, is to control and coordinate the function of every system in the body. Because messages to and from the brain travel through the spinal cord and spinal nerves, misalignments in the bones of the spine can interfere with this communication: resulting not only in pain and irritation, but also dysfunction of cells, organs, and tissues of the body.

This phenomenon is known in scientific literature as “subluxation,” and has been shown to decrease our body’s ability to adapt to the various physical, chemical, and emotional stresses in our lives. Through the use of gentle, specific chiropractic adjustments, we remove these misalignments, restoring proper communication between the body and the brain, allowing the body to function at its absolute potential.

This is, of course, nothing more than a more sciencey-sounding restatement of the vitalistic root of chiropractic in which the “vital force” flows from the nervous system and spinal cord, a flow whose disruption by subluxations causes disease and can be restored by chiropractic manipulation. Perusing “Dr.” Pellagrino’s Facebook page, I see all sorts of bizarre claims, for example, the claim that chiropractic can treat neurodevelopmental disorders:

And this unsupported claim that chiropractic can help dysmenorrhea:

And this horrifying post suggesting chiropractic for ADHD:

And, of course:

Which brings us back to the study. First of all, note that “Dr.” Pellagrino doesn’t actually link to the study itself, even though it’s in the open access journal Scientific Reports. The study claims that even a single chiropractic treatment can improve symptoms after a stroke, which is a pretty bold (and totally unsupported) claim. The study is entitled The effects of a single session of chiropractic care on strength, cortical drive, and spinal excitability in stroke patients, and it comes from the New Zealand College of Chiropractic; Auckland University of Technology; Aalborg University, Denmark; Riphah International University, Pakistan; National University of Science and Technology, Pakistan; University of North Texas Health Science center; and Koç University, Turkey. (Truly an international collaboration of quacks!) Heidi Haavik is the corresponding author.

The introduction cracks me up. After a recitation of the burden of stroke and the lengthy and intensive nature of known effective rehabilitative treatments for stroke patients, Haavik and colleagues speculate wildly:

One possible intervention that may improve post-stroke motor recovery, but has to date not been adequately tested, is chiropractic care. Chiropractic care involves an holistic approach to health with a particular focus on the relationship between the spine and nervous system11. Traditionally, the main focus of chiropractic care has been the location, analysis and correction of vertebral subluxations. Vertebral subluxations are recognized as a biomechanical lesion of the spine by the World Health Organization (ICD-10-CM code M99.1). They have been defined as a self- perpetuating, central segmental motor control problem that involves a joint, such as a vertebral motion segment, that is not moving appropriately, resulting in ongoing maladaptive neural plastic changes that interfere with the central nervous system’s ability to self-regulate, self-organize, adapt, repair and heal. Chiropractors identify vertebral subluxations using a combination of pathophysiologic indicators of spinal dysfunction and then correct them using a variety of manual techniques, the most common being specific high-velocity, low amplitude adjustments that are delivered by hand to the subluxated spinal segment

The World Health Organization embracing quackery? Again? In any event, this is nonsense. The motor difficulties associated with stroke are not due to problems in the spine but because relevant parts of the brain have been killed or seriously injured by the stroke. Hence, there is no reason to suspect that subluxations have anything to do with it or that spinal manipulation would be particularly helpful in post-stroke therapy. None of that stops Haavik from paddling bravely up the river of chiropractic pseudoscience by conducting a randomized clinical trial of chiropractic care for stroke patients. Subjects were recruited from the Department of Physiotherapy and Rehabilitation at Railway General Hospital. Study volunteers were required to be at least 12 weeks out from a stroke and to have ongoing plantar (foot) flexor muscle weakness, but have the ability to contract their plantar flexor muscles on command. These are pretty broad inclusion criteria; most notably they do not appear to control for overall severity of stroke. As for the exclusion criteria, subjects were ineligible to participate if they exhibited no evidence of spinal dysfunction (presence of vertebral subluxation indicators identified by a chiropractor). (This one cracked me up. No subluxation? How does the chiropractor know?) Potential subjects were also excluded if they had absolute contraindications to spinal adjustments (including spinal fracture, atlanto-axial instability, spinal infection, spinal tumor, or cauda equina syndrome), or had experienced a previous significant adverse reaction to chiropractic care (defined as an untoward occurrence that results in death or is life threatening, requires hospital admission, or results in significant or permanent disability).

Here’s the flow chart:

A single session of routine chiropractic care was the experimental intervention, described thusly:

The chiropractic adjustments performed in this study were either high-velocity, low-amplitude thrusts to the spine or pelvic joints or instrument assisted adjustments15. These are standard adjustment techniques used by chiropractors.

More interesting was this, the control intervention:

The control intervention involved the chiropractor performing a similar examination to the chiropractic care intervention followed by the participant being moved into adjustment setup positions similar to the chiropractic care intervention. The chiropractor did not contact on a segment deemed to be subluxated during the control set-up and no adjustive thrusts were applied during any control intervention. This control intervention was primarily intended to act as a physiological control for possible changes occurring due to the cutaneous, muscular or vestibular input that would occur with the type of passive and active movements involved in preparing a participant/patient for a chiropractic adjustment.

Basically, I hope you can see the problem. Participants could well be aware of what group they were in if they had even a passing familiarity with chiropractic. This might not have been a big deal, but this was a crossover study; so participants saw both interventions. Also, there was no questionnaire to assess whether patients guessed which group was which, and, of course, the chiropractors couldn’t be blinded with respect to group. Yes, the statistician was blinded to experimental group, and the patients were not told which group they were in, but this is in essence a poorly blinded experiment. Worse, it enrolled only 12 subjects.

So what were the outcomes? Obviously, there was a reported benefit, but look at the confidence intervals! They’re huge:

Following the chiropractic care intervention there was a significant increase in strength (F (1,11) = 14.49, p = 0.002; avg 64.2 ± 77.7%) and V-wave/Mmax ratio (F(1,11) = 9.67, p = 0.009; avg 54.0 ± 65.2%) compared to the control intervention. There was a significant strength decrease of 26.4 ± 15.5% (p = 0.001) after the control intervention.

So basically, this was, as is the case for most studies of this type, a very unimpressive bit of data. The study was small. The blinding was questionable. The outcomes demonstrated wide variability. I also can’t help but wonder why investigators in several countries spread all over the world were only able to recruit 12 subjects, failing to meet their accrual goal of 15 subjects.

So what we have is yet another example of dubious science in the form of a small clinical trial conducted by practitioners of pseudomedicine that doesn’t really result in any evidence supporting the efficacy of that pseudomedicine. Yet a “chiropractor” named Anthony Pellagrino, who describes himself as a scientist, seizes on these incredibly preliminary and questionable results as strong evidence for the efficacy of chiropractic in stroke, same as it ever was. It matters not to him that chiropractic causes, not treats, stroke. Meanwhile, what the heck is Scientific Reports doing publishing such nonsense?