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The Cure

Legislative Alchemy

In Legislative Alchemy I: Naturopathy, II: Chiropractic and III: Acupuncture, we learned how state legislatures transform scientifically implausible and unproven diagnostic methods and treatments into legal health care practices. Examples typical of the sheer nonsense found in both proposed and actual legislation include:

Naturopathic health care [is] a system of health care practices for the prevention, diagnosis, evaluation and treatment of illnesses, injuries and conditions of the human body through the use of education, nutrition, natural medicines and therapies and other modalities which are designed to support, stimulate or supplement the human body’s own natural self-healing processes.

[Chiropractic is] the science of adjustment, manipulation and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that may interfere with the normal generation, transmission and expression of nerve impulse between the brain, organs and tissue cells of the body, which may be a cause of the disease, are adjusted, manipulated or treated.

[Acupuncture is] a form of health care that is based on a theory of energetic physiology that describes and explains the interrelationship of bodily organs or functions with an associated acupuncture point or combination of points that are stimulated in order to restore the normal function of the bodily organ or function.

This is gobbledygook, tarted up with a few scientific-sounding terms — “physiology,” “tissue cells,” “diagnosis.”

 

We know in fact that:

The legalization of nonsense as health care has a deleterious effect on the public. Each year, millions in the U.S. visit state-licensed naturopaths, chiropractors and acupuncturists, exposing themselves to diagnoses of conditions that do not exist and treatments for these non-existent conditions, as well as treatment of real diseases with implausible and ineffective therapies. They will spend millions of dollars on these visits, paying with either their money or yours.

Although it is reasonable to assume that correct diagnosis of a real disease or condition will be at times foregone and effective treatment delayed in these visits, we don’t really know the full extent because no one appears to be looking at this issue in a systematic way, although we do have anecdotal reports. As well, it is reasonable to assume that these unnecessary treatments for imagined conditions will be injurious in and of themselves in some cases. Again, all we have are anecdotal reports, as no one is collecting the data in any systematic way.

Which brings us to . . .

The Cure

One possible solution is that states stop further licensing of “CAM” providers. Although I have not researched the issue, I do know of one instance in which this occurred. In 1959, the Florida legislature abolished the licensing authority for naturopaths, although anyone who had a license at that time was allowed to continue practicing. Anyone else holding himself out as a naturopath in Florida can be prosecuted for the unlicensed practice of a health care profession. Attempts to re-established naturopathy licensing in Florida have failed.

As you can well imagine, it would be a long, contentious, expensive and laborious process to halt the licensing of chiropractors in all 50 states, acupuncturists in 43 states and naturopaths in the 16 states where they are currently licensed.

A second, simpler solution presents itself in the form of curtailing the use of implausible and unproven practices via legislation without directly repealing the “CAM” provider practice acts. The basic premise is that scientifically plausible health care practices can be used unless and until they are shown not to work. Implausible practices, however, must meet a higher standard. In other words, it is in essence “extraordinary claims require extraordinary evidence” fashioned into health care consumer protection law.

Before looking at how this might be achieved, let’s begin with proposed legislative findings. These are typically recited at the beginning of a bill and become part of the bill’s legislative history. In turn, should a court need to interpret particular language in the bill once it is enacted into law, the legislative history can be used in determining what the legislature meant, referred to as “legislative intent.”

We will call our proposed state legislation

The Science-Based Healthcare Practices Act

Legislative Findings:

Whereas, the Legislature finds that those healthcare practices not based on generally accepted scientific principles and those healthcare practices which have been proven ineffective:

cause unnecessary expenditure of time and money by the public for ineffective treatments; and

expose the public to the risk of delay of appropriate and timely diagnosis and treatment; and

violate nationally and internationally accepted ethical norms; and

pose an unnecessary risk to the public health by exposing the public to treatments that carry risk of harm without a sufficient benefit to justify that risk.

Whereas, the Legislature finds that healthcare practices not based on generally accepted scientific principles misrepresent the sciences of biology, physiology, anatomy, physics and chemistry to the public, which undermines the legitimate public interest in a scientifically literate citizenry.

Therefore, the Legislature finds that it is in the best interest of the public health, safety and welfare to protect the public from healthcare practices which are not based on generally accepted scientific principles or have proven ineffective.

“Extraordinary claims require extraordinary evidence”

The proposed statute would read, in part, as follows:

Sec. XXX.xxx, (Your State’s Name Here) Statutes

(1) Notwithstanding any other provision of (Your State) law, no healthcare practitioner licensed by this state shall engage in the diagnosis, treatment, operation, or prescription for any human disease, pain, injury, deformity, or other physical or mental condition if such diagnosis, treatment, operation, or prescription is implausible because its implied mechanisms or putative effects contradict well-established laws, principles, or empirical findings in chemistry, biology, anatomy or physiology, and it is either

(i) not supported, to a reasonable degree of scientific certainty, by good quality randomized, placebo-controlled trials, or

(ii) not supported, to a reasonable degree of scientific certainty, by a Cochrane Collaboration Systematic Review or a systematic review or meta-analysis of like quality.

The standard “is implausible because its implied mechanisms or putative effects contradict well-established laws, principles, or empirical findings in chemistry, biology, anatomy or physiology” was taken from “Illinois Department of Professional Regulation Medical Disciplinary Board (MDB). Board Policy Statement: Complementary and Alternative Therapies. November 1999,” quoted in an SBM post by Dr. Kimball Atwood. While the Illinois Department of Professional Regulation’s policy was, as a whole, disappointing, its definition of “implausible” is useful.

The level of evidence required in for implausible practices is based on R. Barker Bausell, Snake Oil Science: The Truth About Complementary and Alternative Medicine (New York: Oxford University Press 2007), Chapter 11 (“What High-Quality Trails Reveal About CAM”) and Chapter 12 (“What High Quality Systematic Reviews Reveal About CAM”).

Why, you may ask, if a practice is implausible, would we allow it at all? Why the provision regarding studies?

This is a perfectly reasonable criticism and if you wish to go ahead with the process of eliminating such practices altogether from state law, please do. I simply offer this as a solution which might be politically achievable, as the proposed legislation does not actually do away with any “CAM” provider type.

In opposition to this legislation, “CAM” providers would be put in the position of arguing that their diagnostic methods and practices are not implausible, which is fairly easily defeated per the legislation’s definition. Alternatively, they would have to argue that, even if implausible, their diagnostic methods and therapies should be permitted anyway. This is, of course, what is already happening — they are used despite implausibility and lack of evidence,a position “CAM” providers currently need not defend once they achieve licensed health care provider status.

I also agree that it is not a good idea to spend considerable resources testing biologically implausible claims and this post is not an argument that even more resources should be expended doing so. But, while the U.S. government is at it, we might as well put the results to some good use.

The proposed legislation’s “out” based on high-quality trials also helps avoid a claim of direct conflict between the “CAM” practice acts and the new law, a conflict that would invariably wind up in the courts. For example, the proposed law does not prevent a chiropractor from claiming he can detect “subluxations” in a patient and proceeding to “adjust” them for the purpose of, say, treating the patient’s asthma. But because detection and adjustment of subluxations in general and its effectiveness in treating asthma in particular are highly implausible, a chiropractor will need an high level of evidence to legally make this claim. That evidence does not currently exist — and let me just go out on a limb here and predict it never will.

Likewise, an acupuncturist is not prevented from recommending acupuncture to treat infertility but, again, because of the implausibility of the proposed underlying mechanism of acupuncture and its putative effect on infertility, he must meet a high level of evidence to make that recommendation and commence treatment. Again, the evidence isn’t there and, again, I’ll predict it won’t be in the future.

Ordinary claims require ordinary evidence

But, what about those diagnostic methods and therapies, like chelation, which, at least initially, seemed plausible, but, even though disproved, continue in use?

For them, we have this:

(2) Notwithstanding any other provision of (Your State) law, no health care practitioner licensed by this state, shall engage in the diagnosis, treatment, operation, or prescription for any human disease, pain, injury, deformity, or other physical or mental condition even if such diagnosis, treatment, operation, or prescription is plausible because its implied mechanisms or putative effects are in accordance with well-established laws, principles, or empirical findings in chemistry, biology, anatomy or physiology, if

(i) good quality randomized, placebo-controlled trials, or

(ii) a Cochrane Collaboration Systematic Review or a systematic review or meta-analysis of like quality,

demonstrate, within a reasonable degree of scientific certainty, that said diagnosis, treatment, operation or prescription is not effective for said human disease, pain, injury, deformity, or other physical or mental condition.

The Science-Based Healthcare Practices Act would not eliminate all implausible and unproven healthcare. For example, a diagnostic method like thermography for breast cancer detection might slip by the implausibility test and remain on the market, not because it’s a reliable diagnostic tool, but because no trial meeting our statutory standard says it isn’t reliable.

And just to be sure

I propose a few other provisions to avoid attempted end-runs around the legislation’s purpose.

To help forestall any fudging on the science, the following would be included:

“Each term in this section shall be interpreted according to its generally accepted meaning
in the scientific community.”

To make clear that “subluxations,” “qi,” vitalism and the like do not get a pass on science simply by virtue of their inclusion in the practice acts:

“It shall not be a defense to prosecution for a violation of this section that a diagnosis, treatment, operation, or prescription is within the scope of practice, as defined in Chapter X, (Your State) Statutes, of a healthcare practitioner accused of said violation.”

And, to help ensure that poor quality trials cannot be used to buoy scientifically implausible health care practices (with thanks again to R. Barker Bausell, Ph.D.),

“Good quality, randomized placebo controlled trial,” shall mean a trial meeting the following minimum criteria:

(i) involving the random assignment of participants to a credible placebo control group; and

(ii) employing at least fifty participants per group; and

(iii) losing no more than 25 per cent of its participants over the course of the study; and

(iv) published in a high-impact, peer-reviewed research journal.”

Enforcement

Now that we’ve created a prohibition against implausible practices without really good evidence that they actually work, as well as plausible ones that don’t work, how to enforce it?

That authority could be given to the various boards which currently oversee health care practitioners but this seems inconsistent with the purpose of the act. If the legislature is trying to erect a barrier of scientific evidence (both basic and clinical) between the practitioner who employs implausible diagnostic methods and therapies and the patient, then the very practitioners who ignore science would not seem best suited to the task.

The medicine and osteopathic boards might be suitable to enforce our proposed legislation as against M.D.s and D.O.s, but even medical boards have proven reluctant to discipline physicians whose practice includes implausible and unproven therapies. In fairness, perhaps they were hamstrung by lack of statutory firepower sufficient to specifically address implausible, unproven and disproven practices.

One solution is to give enforcement authority to the state agency overseeing the unlicensed practice of a health care profession. This agency would already have the investigational and prosecutorial bureaucracy in place to proceed. Here, our proposed statute adopts its enforcement procedures from Florida’s “Unlicensed practice of a health care profession” statute, which gives the Department of Health (DOH) the authority to investigate and prosecute.

Briefly, if the DOH has probable cause to believe the Science-Based Healthcare Practices Act has been violated, it can issue a cease and desist order and impose a civil penalty. If the violator is recalcitrant, DOH can go to court seeking an injunction and the consequences escalate from there. Of course, the alleged violator can dispute the charges and have his day in court.

Conclusion

The Science-Based Healthcare Practices Act is an imperfect solution to the problem of legislative alchemy. It is preferable to avoid licensing practitioners whose tenets violate basic science. Given the impracticability of repealing over 100 separate state practice acts, imposing an evidence requirement for implausible practices offers — if I may — an alternative solution. The Act would also have the beneficial effect of curtailing the use of diagnostic methods and therapies which, although not implausible, have proven ineffective.

Suggestions for improvement are welcome.

 

 

 

Posted in: Acupuncture, Chiropractic, Legal, Naturopathy, Politics and Regulation

Leave a Comment (135) ↓

135 thoughts on “The Cure

  1. Interesting, and perhaps necessary, model legislation. But I have some serious concerns about it.

    First of all, I think in your initial section you intended to say,

    and it is neither

    (i) supported, to a reasonable degree of scientific certainty, by good quality randomized, placebo-controlled trials, nor

    (ii) supported, to a reasonable degree of scientific certainty, by a Cochrane Collaboration Systematic Review or a systematic review or meta-analysis of like quality.

    As written, the legislation might outlaw any practice that was not supported by a Cochrane Review, at least if someone could prove that it violated “well established” principles. I don’t think you meant that.

    More importantly, though, I think the legislation is too vague to be effective. It might even be unconstitutionally vague, given its quasi-criminal nature. The disagreement, even in the “scientific community” (do you have a definition of that term? are chiropractors part of that group?), there would be much disagreement over whether a particular fact is a “well-established law[], principle[], or empirical finding[].”

    The phrase “within a reasonable degree of scientific certainty” is useful for, say, determining the admissibility of expert testimony, I don’t think it is useful for determining whether a particular practice would be legal. Likewise, what is an “implied mechanism” or “putative effect”? If a mechanism is stated outright, is that OK? And “putative” according to whom? The person providing the treatment? Similar treatment providers?The terms are useful to scientists discussing such things, but I don’t think that they’re useful in law.

    Lastly, and most importantly, this legislation casts too wide a net. I am concerned that this legislation would snare some very legitimate doctors treating rare diseases. For some diseases, there is insufficient science surrounding treatment because there aren’t enough patients to run “good quality randomized, placebo-controlled trials.” My son was treated for a rare neurological language disorder at a children’s hospital using a drug for which there was, as far as I remember from what the neurologist told us and from my own research, no known mechanism of effect and no controlled studies. Practitioners just use it, and it works sometimes. It worked partially for my son. (No, this isn’t just bias on my part hoping for success–the neurologist insisted on an independent speech-language pathologist to evaluate my son every month, and the pathologist had to be one who was not treating my son.) Under this legislation, I think doctors would be afraid to use this treatment because there is no articulable “plausible” mechanism for the drug to work. Perhaps it doesn’t “contradict” and “well-established principles,” but I’m afraid the legislation would chill similar practices because the doctor couldn’t point to any placebo-controlled trials or Cochrane Review, and therefore would be taking the chance that a negative finding could be made against the doctor.

  2. windriven says:

    I love it but echo your belief that efforts to curtail quackery will be a “long, contentious, expensive and laborious process.”

    My suggestion would be to start a little smaller: bar Medicaid reimbursement using the language of your bill. States everywhere are faced with huge budget problems and Medicaid is a huge portion of that problem. For the FY 2012 cycle in Oregon, Medicaid is expected to consume 26% of the state budget*.

    I don’t know how much the average state spends on quackery through the Medicaid program but I suspect it would be an easier sell to legislators to save some money by refusing to fund unproven treatments than by banning them outright. There will still be resistance from the quack community but legislators would have an easy fig leaf to hid behind: desperate finances.

    Preventing Medicaid funding of quackery would be a wedge in the door. Just a thought.

    In any event, I’m prepared to help if I can. I can probably get whatever bill you finalize introduced in my state, WA.

    *sunshinereview.org

  3. rork says:

    Our laws are famous for not needing to be logical, I know, but “proven ineffective” could use definition. I’ve always wanted to know how to prove a null hypothesis. People with actual theories of learning are of no help, so I’ll ask the lawyers, who are less encumbered.

    You might be outlawing research we do on human subjects.

  4. Jann Bellamy says:

    @SkepticalLawyer

    “As written, the legislation might outlaw any practice that was not supported by a Cochrane Review, at least if someone could prove that it violated “well established” principles. I don’t think you meant that.”

    Yes, I do mean that, because I don’t think healthcare practices which violate “well established principles” should be allowed unless they meet a high level of evidence that they work.

    In reading your comments — and I appreciate your thoughtful response — I think we disagree as to whether the definitions are precise enough to guide the conduct of health care practitioners. I would like to hear from the practitioners themselves on this and hope some will weigh in. As I understand it, the phrase “implied mechanisms or putative effects contradict well-established laws, principles, or empirical findings in chemistry, biology, anatomy or physiology” is understandable to anyone trained in science and a fairly low standard — it covers “therapies” like homeopathy, chiropractic “subluxations,” reiki, reflexology, irridology and the like, where prior plausibility is missing.

    I share your concern about casting too wide a net and a possible chilling effect. I would think that in prescribing this drug for your son the physician could at least describe how its “implied mechanisms or putative effects are in accordance with well-established laws” etc. — otherwise, why would someone have tried it in the first place? But maybe the discovery was accidental. Perhaps instead of “in accordance with” we should substitute “implied mechanisms or putative effects do not contradict” etc. Again, I hope practitioners will weigh in on this. The purpose of the post is to try to construct a workable statute and your comments are helpful.

  5. Jann Bellamy says:

    @ rork

    “but ‘proven ineffective’ could use definition”

    Help me out here then — how would you say it?

  6. WilliamLawrenceUtridge says:

    @SkepticalLawyer

    Your example about your son doesn’t really compare. A known quantity of a specific molecule is being used. We know molecules interact with each other and specific molecules have effects on the human body. Not knowing exactly how a molecule works for a given condition isn’t the same thing as proposing a completely novel interpretation of biology. Put another way, even if we don’t know how a drug works in specific, we can be sure it works through alteration of known, existing, material forces. That’s wholly different from proposing hitherto unrecognized and unmeasurable energies (acupuncture, homeopathy), invisible joint misalignments (chiropractic), or novel reinterpretations of quantum theory to justify pre-existing beliefs (acupuncture and homeopathy again).

    For something like chelation or the Gonzalez protocol where there is a superficial gloss of actual, recognizable biology using compounds that are explained as working with material forces (even though the specifics of the protocol don’t match up to the specific of how cancer starts, grows and kills), you’ve got a bit more of a problem.

  7. CarolM says:

    “bar Medicaid reimbursement using the language”

    Oh, the wailing and gnashing of teeth that will ensue..because low income are cut off from state-of-the-art quackery! “Women and minorities hardest hit” etc.

  8. JPZ says:

    @Jann Bellamy

    I appreciate how much thought went into this post, and I can support much of your intent. From my perspective as a scientist who also works on FDA compliance issues, there are still some significant issues to tackle in this proposed legislation:

    “…which undermines the legitimate public interest in a scientifically literate citizenry.”

    (OK, this one is off-topic) There are school boards, state legislators and presidential candidates who would disagree – and not because of CAM. That doesn’t make them right, though.

    “…implied mechanisms or putative effects contradict well-established laws…”

    Well-established medical procedures have been overturned by better medical procedures, and yesterday’s heresy can become tomorrow’s standard of care. And, I agree with a previous commentator that this could affect off-label treatments.

    “1) not supported, to a reasonable degree of scientific certainty, by good quality randomized, placebo-controlled trials…”

    The FDA defines this as supported by a minimum of two RCTs – one if the evidence is overwhelming. I am not the person to ask if a state legislature can override federal agencies.

    “2) not supported, to a reasonable degree of scientific certainty, by a Cochrane Collaboration Systematic Review or a systematic review or meta-analysis of like quality.”

    Cochrane reviews are based on RCTs. Your 1) and 2) are pretty much the same, and 1) is closer to the federal standard. I read Cochrane reviews and frequently cite them, but I am not too keen on putting Cochrane reviews on such a high pedestal. Their system can bias out worthwhile data.

    “…reasonable degree of scientific certainty”

    There are a lot of different ways to define this criterion. I would think the legislation would want to include as clear cut a definition as possible.

    “…said diagnosis, treatment, operation or prescription is not effective for said human disease…”

    Perhaps I am misreading this phrase, but does this ask someone to prove a negative?

    “…generally accepted meaning in the scientific community…”

    This one is tricky. Wouldn’t chiropracters be the only ones who could provide a single, agreed upon definition of “subluxation.” You would have trouble getting a single answer from physicians other than maybe “phhht.”

    “Good quality, randomized placebo controlled trial,” shall mean a trial meeting the following minimum criteria:”

    This section is the big problem from my perspective. The sample size of a study is derived from well-accepted statistical procedures. There is nothing magical about n=50, in fact, I just reviewed a study with n=26 that very clearly showed using statistics that it was an adequately powered trial. Drop out rates are a function of treatment side effects, the population under study (I’ve worked with urban poor on studies, and the drop out rates can get to 30-40% because of things like they can’t pay for their cell phone or they move to another town for a job – not because of the quality of the study) and many other factors. There is nothing magical about 25% – the issue is figuring out why subjects dropped out (obligatory plug for the CONSORT guidelines). And “high impact” score is a relative term depending on which scientific field. Nutrition journals have appallingly low impact scores if you compare them to immunology journals.

    I hope these observations help. Rather than specify so much in the legislation, would it be better to lay out the requirement for science-based healthcare and allow the rest to be worked out in rule-making?

  9. Jann Bellamy says:

    @JPZ:
    Thanks for taking time to comment — your thoughts are very helpful. The intent is to make practitioners stop using scientifically implausible diagnostic methods and therapies, so maybe the legislation should just stop there: a diagnostic method, therapy, etc. can’t be “implausible because its implied mechanisms or putative effects contradict well-established laws, principles, or empirical findings in chemistry, biology, anatomy or physiology . . .” The language about trials (in the first section) is there to stop the would-be Galileos from arguing that they should be able to use their implausible therapies, the reply to which is, ok, just show us that they work. Perhaps the second section re: scientifically plausible therapies etc. which don’t work (e.g. chelation) should be left out altogether.
    I don’t see any conflict with federal law — if the FDA approves drugs and medical devices for particular uses then I don’t see how the statutory standard would be violated. If the issue came up, federal law would control.
    I don’t think the chiropractors would be a problem. They don’t even have a plausible hypothesis of what a “subluxation” is. And you don’t need a physician to say that. A neuroscientist could testify that it’s nonsense.

  10. JPZ says:

    @Jann Bellamy

    Thanks for your reply! I appreciate your help with understanding legislative language – which is challenging even when I am reviewing FDA and USDA regulations. It doesn’t help that I occasionally have unbidden thoughts like: Why do they always start with “Whereas…”? Is there anything wrong with using, “Yo, check this…” instead? :)

    I had a thought on enforcement. State law creates and empowers professional boards to regulate industries and issue appropriate licenses. If you apply the science-based standard to any board providing licensure for “medical services” (would have to be carefully defined, e.g. “health and wellness” could apply to fitness instructors), then a board that does not meet the standard is dissolved and existing practitioners are banned from practice because there is no oversight board for regulation.

  11. pmoran says:

    Won’t work. Not a snowball’s chance in hell, in my opinion. The scientific arguments are too sophisticated for the average legislature and too much in conflict with the more normal, compassionate human instinct to give treatments some benefit of the doubt if people claim to be being helped by them. Aside from which, placebo responses confer some vicarious credibility upon any treatment for subjective complaints.

    I would hope that doctors would object to it, too, as it posits a too naive model of medicine, one which ignores the complexity of daily medical practice.

    I assume that the stocks of pharmacists would be decimated according to the same standard, would they? If not, why not?

    Better to focus directly on the harm rather than the science.. If you can find enough cases of serious harm from any category of practitioner then you will have a case for some kind of legislative intervention, although even then airing of the cases through the media and through the existing legal system probably exerts as effective a “control” as is ever likely to be achieved now that medicine of any kind can be easily accessed globally.

  12. JPZ says:

    @pmoran

    Kick the official state evaluation and recommendation over to the State Board of Public Health so that the Legislature only needs to choose whether or not to act on the recommendation. Get the state Surgeon General to endorse it as a kick start. The BoH can seat reiki masters, acupuncturists, et. al. on the review board so that each evaluation has a surplus of CAM experts for insights. Quantify economic harm and tart it up with individual testimonials from people physically harmed because they did not act quickly enough on real medical conditions. Bonus if you can find a legislator or senator who is or has a family member whom has suffered economic or physical harm from the practices. I agree that legislation is a fickle beast, but this is only medium-hard in my estimation.

    The majority of physicians will get behind it for the benificent reason of saving patients from harm or maybe a few will view it from the crass perspective of eliminating the competition. I am not sure why pharmacists would care. Any proof to address a science-based standard for a state board is going to be provided by the professional associations (AMA, ADA, AOA, etc.) in boiler plate format. That makes it a cake-walk for any science-based profession. CAM practices with some but minimal support may breeze through too in some states, but not all will – and the standard will have been set.

    Focusing on “harm” is reactive, not preventative. Given the ratio of cases reported versus actual cases, you are letting a lot of people get hurt until the harm signal reaches above the noise enough for attention. I agree that media attention can be a shortcut in this process, but it is fickle. In terms of using harm from the CAM procedure as the enforcement standard, you also open the door to a discussion of medical errors. Will the fickle public and media give more notice to gentle reiki or the guy who got the wrong leg removed? You line yourself up for a fight at every individual enforcement, and the court of public opinion is a lousy place to fight where there are plenty of people to squee about CAM and tell stories about this one horrible doctor they had.

    There are a lot of things to fix with this proposal, but I disagree that it is DOA.

  13. windriven says:

    @JPZ

    You can kick the can down the road but at the end of the day it is the legislature that has to act. Make it easy for the legislature and you make it easy to attain passage. I’d go after it through Medicaid because it is is a thorn in every legislator’s side. But let’s not argue over strategies. One single approach, no matter what it is, isn’t going to win the day. We will need to mount the attack from multiple directions because you can rest assured that quacks will come out of the woodwork to protect their turf.

    It is always easier for a legislature to do nothing than to do something – unless there is a public bruhaha that demands action. So go see your state representative and your state senator and tell them that you want to assure that medicine adheres to scientific principles. They will hear you out, nod politely, tell you that they’ll discuss your marvelous idea with their fellow legislators, and then not think of you again until it is time to solicit for their campaign fund.

    Giving a legislator one good reason to act isn’t enough when an array of MDs, chiroquacksters, hand wavers, needle twiddlers, prayer sayers, water succussors, and chicken bone rattlers will be banging on their door arguing that the proposed law will damn humanity to pain, suffering and an early grave – and there darned well won’t be a farthing for them come re-election time. We need a dozen reasons and a hundred directions of attack to push it through.

    Look folks, its been almost 100 years since Scopes and there are still schools all over this country teaching “creation science”. Let’s help Bellamy get draft language written and then go out and make it happen.

    Or is this just a debating society?

  14. Quill says:

    To me as a proposal it seems fair and a place to begin examining the language and principles. As a practical political matter if some version of it goes forward into the legislative process it will anxiously unite CAM practitioners and supporters as nothing else has. And with all their money and influence it will be a very expensive argument, the outcome of which is not at all certain.

    That being said, since the “intent is to make practitioners stop using scientifically implausible diagnostic methods and therapies” this “cure” is aiming to be a wide, sweeping prohibition on many things a lot of people like. Good luck with that.

    Thinking of other possibilities (such as causing problems for some doctors treating rare diseases) and using the proposal as currently written, it is plausible if not probable some enterprising Scientologists would go after the entire field of psychiatry to say nothing of the chance to gleefully deny anyone with a PhD in psychology or PsyD a chance to make an honest living.

    To me, the reason that so much of CAM is so appealing to so many people is the lack of basic scientific literacy and critical thinking skills in the population. Better education to make better choices seems preferable to me than enacting more legislation. However, since I’m a former teacher and not a lawyer it may just be my bias showing.

  15. JPZ says:

    @windriven

    I missed out on where I kicked it down the road. The easy part for the Legislature is being given an up or down vote based on the recommendation of another government agency. If someone comes screaming into their office afterwards, they can deny everything and blame it on the Dept of Public Health being deceptive. If they come screaming in before, then the legislator can say the matter is under consideration by the best experts in the state. If they later initiate an investigation – poof, the basis for the complaint evaporates in the face of evidence several months later.

    A single, focused legislative approach doesn’t work? I think right to life and defense of marriage laws in several states would seem to support the claim that they do.

  16. weing says:

    I am not sure that will work. Our legislative process is corrupted by the money of various lobbies, and CAM appears to have a lot of money since R&D for them is simply lobbying and advertising. I think we need to begin with ourselves. We need to clean up our own house first, and eliminate CAM from our hospitals and medical schools. We have to say no to the money of the likes of Donna Karan and Christy Mack. They have succeeded in legitimizing this nonsense, we have to reverse this trend ourselves. There will always be con men trying to con people out of their money. Let’s make it more difficult for them by showing that this nonsense has no place in legitimate medicine. We can show the public what real gold looks like and behaves like so that they won’t mistake it for fool’s gold. We could then work on removing the term “medicine” from CAM as that term implies legitimacy.

  17. JPZ says:

    @weing

    Money from CAM versus money from the medical profession supporting the science-based standard? I don’t think this legislation will be hampered by money if that goes well.

    I know I am making a LOT of assumptions, but selling assumptions well is a rather time honored tradition in politics. The trick is to look at your story and figure out if you can sell it to legislators in such a way that NOT acting upon this issue has a down side. That was one of the points of my post to pmoran.

  18. rwk says:

    Why haven’t you asked DOs to change their name ? Look up the definition from any of the majority of
    sources including their own.

  19. windriven says:

    @JPZ

    By kicking the can down the road I mean taking the proposal to third parties and charging them with selling the legislature. Your assumption is that the State Boards of Public Health share your enthusiasm for this and that among all of the competing issues on their plate, this is one that they’ll spend political capital on.

    When you want to accomplish something you have to talk to the decision maker.

    It is a great strategy to marshal support from every likely supporter – like the Boards of Public Health. But don’t expect them to fight the battle for you in the legislature.

    Neither right to life nor defense of marriage laws are good analogies because both resulted from intense public campaigns. In fact defense of marriage laws in some states were actually passed via voter initiatives. I’d ask you to look instead at the legislative response to the recent economic collapse. A good deal of damage resulted from the Gramm-Rudman dismantling of the firewall between commercial and investment banking that was imposed by Glass-Steagall after the Depression. It seems a no-brainer to reimpose that separation. But Dodd-Frank does no such thing. Do you think Wall Street lobbyists have anything to do with that? And who was lobbying in favor of reimposition?

    My point remains – the legislatures of the various states are where the laws get passed. The forces of quackery will be fighting for their financial survival. They will lobbying to keep their families fed. Don’t expect Public Health or any other group to fight this for you. They aren’t going to have the same passion. Enlist them to help; Public Health and every other person and entity that you can get. But plan on carrying the ball yourself.

  20. Jann Bellamy says:

    @ Quill:
    “if some version of it goes forward into the legislative process it will anxiously unite CAM practitioners and supporters as nothing else has. And with all their money and influence it will be a very expensive argument . . .”

    It might be worth every penny just to see exactly what arguments CAM practitioners put forth, in public, as to why their therapies, etc., can’t meet a basic test of scientific plausibility. While some acupuncturists are up front about the lack of “Western” science supporting what they do, chiropractors and naturopaths claim that what the do IS science-based. As do “medical acupuncturists” (M.D.s who use acupuncture but don’t buy into the “qi”) and homeopaths. They would all be put in the awkward position of aruguing that “we can’t do what we do if it has to be scientifically plausible even though what we do is scientifically plausible.”

    @JPZ:
    Not sure I follow the system you are proposing but in this draft legislation the Dept. of Health enforces the science-based standard — so maybe we are not too far apart. The legislature would have to give the Dept. the statutory authority to do this though.

  21. marcus welby says:

    We have allowed politicians to determine what is approved healthcare for our citizens. That is clear from the Legislative Alchemy series. Now the special interest protection industry featuring money, political contributions, and anecdotal citizen testimonials has dug their foxholes and stored ammunition. We do not have Complimentary and Alternative engineering, or aviation, or architecture; we need a legislative effort like the one proposed here to make the point that CAM support by politicians or academics is not benign (see today’s headline re: Steve Jobs’ treatment in the Times). Sticking to the message of this proposed legislative wording, that officially sanctioned medical treatment must be science-based, would be a rallying cry.

  22. daijiyobu says:

    Readers of this SBM post may highly enjoy [in the upsetting kind of jaw-dropping way], this current absurdity

    (see http://www.aanmc.org/the-schools/nuhs–ill/national-university-of-health-sciences–message-from-the-president.php ):

    a university labeled science in content [of full USDE status],

    with programs in chiropractic- naturopathy- acupuncture
    [a triple crown of academic woo, teaching homeopathy within naturopathy of course],

    whose president is a DC [and therein hugely science-qualified],

    telling us on an ND schools’ consortia site that incorrectly labels naturopathy “science-based”,

    that that triple crown of woo is not only science but truly “evidence-based treatment.”

    -r.c.

  23. JPZ says:

    @windriven

    “Neither right to life nor defense of marriage laws are good analogies because both resulted from intense public campaigns. In fact defense of marriage laws in some states were actually passed via voter initiatives.”

    It is important to admit when you are wrong. I gave some terrible examples there! You are right and thanks for calling me on it.

  24. JPZ says:

    @Jann Bellamy

    My thought process got a little disjointed between all the replies. What I am thinking is:

    1) Proposing this legislation to the State Legislature will face the hurdle of getting Legislators to understand why it is important (to pmoran’s point). The majority of Legislators won’t want to understand a science-based standard or worse, won’t trust it because it does emphasize science. Many decision-makers reluctant to make a decision can be motivated by having something or someone to scapegoat if the decision turns out to be a bad one. Having the state’s surgeon general on board makes it easy for Legislators to say they were acting on the advice of another state agency. Support from the Dean or President from one of the state’s medical schools is another person the Legislators can point to who has statewide credibility. These are just tactics (and there are many more) to help achieve legislative passage. No one approach is going to do it (to windriven’s point).

    2) Once the legislation passes (no small feat), the state Dept of Public Health (DoPH) will have a legislative mandate to review the charter for licensing boards that fall under the definition of “medical service providers” laid out in the legislation. The boards for physicians, pharmacists, etc. will submit a pdf file prepared by the national professional organization and have one meeting for a high level review of the content of the document with the DoPH. After hearing any objections, the charter has an up or down vote, and it is done. Minimal work for science-based professions, and DoPH is not likely to have much patience for conspiracy theorists objecting to the validity of medicine.

    3) Boards for CAM providers will follow the exact same procedure, but either the DoPH will raise objections on their own (hopefully) or skeptical physicians/physician groups will raise scientifically valid objections. Hearings with many CAM experts will take place to address objections and frame the support for the CAM practice (to the point you made to Quill), and it will become clear the standard is not being met for many CAM practices. The danger here is that the CAM groups do rally, fire up the faithful, set off a media frenzy, and go after Legislators to repeal the law (to Quill’s point). I am afraid that, at this point, the process will be a standard political battle with money flowing in from out of state, commercials and political grandstanding.

    4) Assuming the law is still intact, licensing boards for CAM practices that do not meet the science-based standard are dissolved. I think there is an advantage to placing the enforcement at the level of the licensing board’s charter. It is the only method I can think of where one administrative action stops every questionable CAM practitioner in the entire state – both practicing and in training. I don’t think states have parity on licenses like this either. Some CAM-related boards will get through the system via spin doctoring, hard sell or other tactics but not all will. Expect their professional societies to go to Hatch-Harkin to try and get federal override of the state law.

    5) In parallel, I think there will need to be modification and expansion of state laws preventing the practice of medicine without a license. You need parity between the definition of “medical service provider” in both laws. Not all CAM practices have licensing boards, so this enforcement would have to go to the individual basis. Some states use RICO enforcement to shut down unlicensed practitioners.

    The more I think about the idea, the more I think it has a chance (barring screw-ups or game changers like a governor’s spouse who swears by reiki or something). The biggest hurdle is framing the issue in such a way that Legislators who aren’t science savvy can’t ignore it. Best of luck!

  25. “Although it is reasonable to assume that correct diagnosis of a real disease or condition will be at times foregone and effective treatment delayed in these visits, we don’t really know the full extent because no one appears to be looking at this issue in a systematic way, although we do have anecdotal reports. As well, it is reasonable to assume that these unnecessary treatments for imagined conditions will be injurious in and of themselves in some cases. Again, all we have are anecdotal reports, as no one is collecting the data in any systematic way.”

    Seems to me before one starts drafting legislation, one would want to have some grasp of the actual cost in dollars and negative health outcomes of the problem. That way one could examine the projected cost of the legislation and compare it to possible benefit (with more than anecdotal evidence). One could also prioritize this item against other items such as education, vaccination programs, police, fire, roads, etc.

    State budgets are currently being cut, Medicaid benefits are being cut, I do suspect windriven’s idea of barring Medicaid reimbursement would be a positive move. Although I’m don’t know how much Medicaid is currently paying for scientifically implausible treatments. Anyone have a number for a particular state?

  26. Jan Willem Nienhuys says:

    Somehow I am reminded of the story about the attempt to legislate the value of pi
    http://en.wikipedia.org/wiki/Indiana_Pi_Bill

    Strictly speaking, that bill was supposed to establish that the schools of Indiana could use the method described in the bill without have to pay a fee to the inventor.

    But the pi bill shows the consequences of the idea that scientific truths can be determined by law.

  27. weing says:

    micheleinmichigan,
    CAM is for people who have more money than sense, that’s not the medicaid crowd around here. I don’t have any data though.

  28. nybgrus says:

    I’ve been following this series (leg alchemy) with much interest. I haven’t contributed much since honestly I don’t know enough about politics and legislatures/legislation to be of much help.

    It seems to me though, that from a non-legalese perspective (i.e. I don’t have any idea how legal language susses out in practice), what Jan proposes works. Essentially it is a demand that any treatment or intervention provided which could be construed as a patient-practitioner interaction must either be scientifically plausible or have robust data demonstrating it does something more than placebo.

    Perhaps there is a simpler way to write the legal language to reflect that?

    As for enforcement, it seems to me to hit it where it counts – dolla dolla bills y’all. We don’t need criminal prosecution since that costs time, money, and then incarceration. Fines. Massive. Freaking. Fines. And a proviso such that the State can garnish any wages and have access to any accounts the offending practitioner has in order to extract said fines. The State is motivated since it is gaining a revenue stream, and the pracitioners will either be out of business or be motivated to amend their practices (i.e. the medical acupuncturists) in order to preserve their livelihood.

    (perhaps I was a bit overzealous in the fines part, but something along those lines seems to me like a good punitive recourse. Who enforces that exactly I’d defer to the likes of JPZ since I know very little about that)

  29. weing, the article suggested that OUR money was being spent. I figured that meant medicaid. but I guess It was rather vague.

  30. NMS-DC says:

    To the author, Jann Bellamy

    Clearly you don’t understand the science of manipulation (aka chiropractic), and the research is conclusive. Manual therapy helps improve people’s function, reduce their pain, and reduce their pain medications. The fact that you don’t understand that mainstream chiropractic is manual therapy for primarily for neuromusculoskeletal conditions. Chiropractic doctors will always acknowledge that the effect of spinal manipulation can be greater that simply the segments adjusted and. again, certain populations will have have positive effects beyond improve spinal/joint function.

    Spinal manipulative therapy is a proven natural healing art and your personal bias’ and beliefs systems shouldn’t affect rational, logical, and scientific judgment. Contemporary chiropractic medicine is valid and appropriate for neuromusculoskeletal conditions and to say otherwise is to ignore the science of chiropractic. Consequently, it’s legal and professional status, and subsequent integration into the mainstream health care systems, will require this forum, who allegedly provide, rational, cohesive, thought to acknowledge that chiropractic profession as evolved to the point where is has established legitimate expertise over manual therapy, which in turn is effective in dealing with pain. The health care system is reforming and let me assure you, that the chiropractic profession has more than enough “evidence” that supports the core clinical act, manipulation, is cost-effective and beneficial. Outside the USA, there is ground-breaking research on manual therapy regarding how it affects the tissues and overall function. I should add that this research is being by done by chiropractic scientists (DC/PhD) and is general multi-discplinary in nature.

    Evidence-based medicine has required that all health care professions demonstrate clinical expertise in a domain of medicine. Chiropractic’s is specifically manual medicine. The chiropractic paradigm of wellness, prevention, and holistic outlook is where health care is going. The education system of chiropractic has continued to evolve, and has embraced research as a means of communicating the full benefits of manual therapy. Furthermore, those who truly understand neuroscience will, once given the opportunity, to read the research and begin to understand and appreciate that the effectiveness and mechanisms of spinal manipulation is decisively neurological in nature, a stance chiropractic medicine has always asserted.

    This board only emphasizes the fringe practices of all medicines. That’s fine. But just because that are fringe practices amongst chiropractic shouldn’t discredit the basic fact that SMT, used for back and neck pain, and manual therapy for MSK conditions in general is a scientifically valid and defensible concept.

    I am looking forward to hearing your responses and hope you keep it based on science and not dogma.

  31. pmoran says:

    Heh, heh! That was quick!

  32. nybgrus says:

    I’m thinking maybe a Poe?

  33. Harriet Hall says:

    “has embraced research as a means of communicating the full benefits of manual therapy.”

    Research as communication rather than as scientific inquiry? Interesting…

  34. nobs says:

    C’mon Harriet—> Your reply is parsing word choices? This IS a blog afterall, not an indexed peer-revied journal. A very pedantic reply indeed. Interesting…

  35. nybgrus says:

    @nobs:

    I think you missed the point. Besides the fact that, in context, it seems to indicate that chiropractic has a set of conclusions that it is using research to justify (i.e. bad science), the entirety of the post is laughable.

    Pmoran noticed it. I can’t tell if NMS-DC is a Poe or not. And Dr. Hall decided to nit-pick one bit that jumped out at her for the same reason (please correct me if I am wrong Dr. Hall).

    The post is a Gish-gallop of tripe that has been addressed so many times here, both in posts and in comments (myself included) that I reckon none of us has the energy or desire to rehash it in response to such a bombastic post. It is clear that whether Poe or true believer, any response will be met with more of the same and end with NMS-DC declaring a Black Knight victory.

    Dr. Hall’s response, IMO, is a non-response for exactly that reason. So to criticize her for it misses the point that none of the 3 of us care to engage in it. So really, nothing interesting at all.

    PS – sorry for putting words in your mouth and assuming your intentions Dr. Hall. I hope I’m not too far off the mark, but for whatever reason I felt the need to speak up, so my apologies for being presumptuous.

  36. weing says:

    Well, does NMS want to clarify that statement? Has chiropractic embraced research to study the effectiveness and mechanisms of spinal manipulation? There is plenty of research on communication, period. Our politicians, pharmaceutical companies, and other manipulators have been utilizing this research for a long time. There is a difference. We Maybe they are doing both, which is fine with me. Hmmm. Maybe SBM should also embrace this research for communicating its benefits to the public and politicians?

  37. BillyJoe says:

    “I’m thinking maybe a Poe?”

    Or Poe’s Corollary? ;)

  38. nybgrus says:

    @BillyJoe:

    Perhaps. LOL. With the internet, everything is possible.

  39. marcus welby says:

    NMS-DC: ” and the education system of chiropractic has continued to evolve”

    But since 1895, little has changed and nothing of value has been discovered. The statutes regarding chiropractic in every state still define it in terms of the subluxation, something chiropractors themselves bill for and diagnose often but cannot agree on a definition for and many admit there is no such thing. There is no reproducibility of the subluxation:
    Thus, shown the same set of xrays of the spine, no agreement on a diagnosis of which vertebral segments are subluxated, nor clue as to whether the affected segments have already been “adjusted”… Is this xray indicating subluxations before or after adjustment? No clue.
    So after 116 years, the chiropractic belief system still has magic as a core construct.

    As to manipulative therapy, physicial therapists avoid the high velocity high amplitude neck manipulation which on rare occasions results in vertebral artery dissection, strokes, and even death, thus are safer if one feels spinal manipulation therapy is appropriate. Note here that in Germany, I understand, some MDs, especially orthopedists, do neck cracking also and strokes due to their VAD have also been documented.

    So chiropractic remains outside science. Marketing plus placebo.

  40. windriven says:

    @NMS-DC

    I wonder if you would explain for us how subluxations, the cornerstone of chiropractic theory, affect function of, say, the pancreas? Please include any supporting studies that you believe to be credible.

    If chiropractic has abandoned the notion of subluxations as relevant to medical conditions other than certain musculo-skeletal pain issues, please direct us to relevant documentation of this change.

  41. NMS-DC says:

    Harriett

    “Research as communication rather than as scientific inquiry? Interesting…”

    Obviously scientific inquiry. But, also as a means of taking those investigations, which are increasingly being done by multi-disciplinary teams, including DC/PhDs are helping bridge the gap as to elucidate the mechanisms behind the effectiveness of spinal manipulation and manual therapy.

    To suggest chiropractic remains outside science is absurd, and quite frankly, demonstrates a rudimentary knowledge of what is going on, in the big picture. Just because some of you choose to stick your head in the sand whenever there appears to be legitimate advancement and evolution of the profession, through contributions to the chiropractic (manipulative) sciences doesn’t mean it’s not happening. The chiropractic expertise is in spinal manipulation and manual therapy. This is our professional domain.

    Whether it is called joint dysfunction, osteopathic lesion, chiropractic lesion (subluxation) is irrelevant. It is a manipulable lesion and that all professions who practice in the domain of physical medicine, and use manipulative therapy acknowledge they’re adjusting a specific target site in the spine or other dysfunctional articulations. The chiropractic assumption was that benefits of SMT were derived from the nervous system. This has been demonstrated conclusively to be the mechanism of action.

    But, as I can see, again, not one of the rational skeptics here can acknowledge the basic fact that mainstream chiropractors use SMT primarily for back and neck pain, and manual therapy for MSK conditions in general, is a scientifically valid and defensible concept. Resorting to straw-men arguments and red herring tactics is pretty weak for a scientifically-inclined board. It also proves my point that you guys will never see chiropractic medicine as a legitimate health profession under any circumstances. And that my friends, is simply dogma.

  42. Harriet Hall says:

    nybgrus said
    ” it seems to indicate that chiropractic has a set of conclusions that it is using research to justify (i.e. bad science), the entirety of the post is laughable.”

    Yes, that was my point. He makes the same claims that have been rehashed and refuted ad infinitum on SBM and I have no desire to get into another discussion – been there, done that. If he wants to review all that we have written on chiropractic and then thinks he has something new to say that he can back up with references, then and only then will he merit an answer.

  43. Harriet Hall says:

    @ NMS-DC,
    You have apparently missed my previous comments where I acknowledged the benefits of SMT (as opposed to “chiropractic”) and where I said I approve of chiropractors who reject the subluxation concept and limit their practice to short-term treatment of musculoskeletal conditions. Such chiropractors are few and far between, and you have presented no evidence to suggest otherwise. 37% of 4,835 full-time American chiropractors who responded to a survey by the National Board of Chiropractic Examiners (NBCE) said they used applied kinesiology in their practice. Nuff said.

  44. rwk says:

    harriet Hall said

    Yes, that was my point. He makes the same claims that have been rehashed and refuted ad infinitum on SBM and I have no desire to get into another discussion – been there, done that.

    Ok, but every other week there’s a post here about us crazy chiropractors. Are you done yet?

  45. NMS-DC says:

    @Harriett Hall

    Why do you make that distinction? Chiropractors deliver >90% of all manipulations in North America and have, by far, the most training in manual therapy. The profession has already rejected and does not promote a monocausal concept of subluxation-induced disease (Bergmannn and Peterson, 2010). An interesting article by Villanueva-Russell (2011) stated that “73% of chiropractors saw themselves as back pain/musculoskeletal specialists”. http://bit.ly/pBfyqB. So, few and far in between? No. What reference to you base your assertion on?

  46. Harriet Hall says:

    NMS-DC:
    You came into this conversation late. I have no desire to repeat what I’ve already explained. Do your homework. Start here: http://www.sciencebasedmedicine.org/reference/?p=44

  47. NMS-DC says:

    I will do my readings. Just provided you evidence that your statement was false, however. To repeat, 73% of current, practicing DCs, in the USA see themselves as back/MSK specialists (VR, 2011).

    I agree that AK is dubious. That doesn’t discredit the fact that DCs who treat MSK with manipulation and forms of manual therapy are reasonable. Also, I would be willing to bet that % of AK practitioners is a) greatly reduced outside the USA b) will be on the downward slide as EIM filters down into practicing clinicians and the emergence of the “new generation” future DCs who are currently in school.

    And you edited your previous comment which might make my comment look out of context (adding the 37% stat of AK from the NCBE). Please, in the future, for transparency, acknowledge that your comment has been edited. I’m trying to foster an honest debate here and we need to have a level playing field if we’re really doing this in the hopes of gaining a greater understanding of each others positions.

  48. Jann Bellamy says:

    @NMS-DC

    “The profession has already rejected and does not promote a monocausal concept of subluxation-induced disease (Bergmannn and Peterson, 2010). An interesting article by Villanueva-Russell (2011) stated that “73% of chiropractors saw themselves as back pain/musculoskeletal specialists”. http://bit.ly/pBfyqB.”

    If the majority of DCs practice as “back pain/musculoskeletal specialists” and have rejected the idea of “subluxation-induced disease” then why don’t you all get together and ask the state legislatures to amend the chiropractic practice acts to exclude subluxation-based diagnosis and treatment and limit chiropractic practice to what is basically physical therapy.

  49. Quill says:

    I rather like hearing “chiropractic” described as the “science of manipulation.”

    Of course this has nothing to do with its adjustments but rather everything to do with how it is packaged, marketed and sold.

  50. Harriet Hall says:

    @ NMS-DC “Just provided you evidence that your statement was false, however. To repeat, 73% of current, practicing DCs, in the USA see themselves as back/MSK specialists”

    ROTFL. You call that evidence? If that’s the best you can do, you might as well quit right now. Some of those who “see themselves as back specialists” claim to be putting bones back in place and also treat nonmusculoskeletal conditions and use all kinds of nonsensical diagnostic and treatment methods.

    Acknowledge that my comment has been edited? I thought of something I wanted to add immediately after I wrote it, so I added it. I can’t even imagine how you could think that made your comment seem out of context.

    To others who are following this discussion: I know I shouldn’t allow myself to be baited. I’ll bite my tongue and stop now.

  51. NMS-DC says:

    Hi Jann

    The situation in the USA is rather unique, because like you mentioned at the time, subluxation was a legal tactic used by early chiropractors to defend themselves against being jailed for practicing medicine. The laws, as you present them and I understand them, are outdated because they don’t accurately reflect the current practice of chiropractic medicine. However, we all know that change, especially in legal/political/scientific circles can take a long time to occur. The research that is currently being done will take awhile to filter down to the practicing clinician and then even longer to affect health care policy.

    What I can tell you, unequivocally, that the research of DC/PhDs has gotten us a seat at the table in terms of health care policy reform, at least in Canada. There has been a threshold which has been crossed and a legitimate research culture has been imbued within the profession. As this site likes to discuss, and rightfully criticize fringe practices of all medicines, I’m merely trying to point out that, generally speaking, the majority of chiropractors practice physical medicine in a completely reasonable and scientifically defensible way. There’s always room for improvement, of course, and these are occurring in terms of educational reforms, commitment to scientific research to the advancement of the basic sciences in manual therapy, and health care policy development that is patient-centered, cost-effective and collaborative. I mentioned these themes in 2006 when I first graduated and they have only evolved, matured and been refined since then. Science and research is essential to chiropractic. Patient safety is essential to chiropractic. There is a groundbreaking research product that will investigate this issue being done by the colleges of medicine, osteopathy, physical therapy and chiropractic. Considering that DCs provide >90% of manipulations, it has the biggest implications for chiropractic clinical practice. http://bit.ly/pBfyqB

    There is some really groundbreaking research being done by chiropractic scientists in terms of spinal function and measuring, yes, measuring segmental dysfunction reliably besides manual palpation. There is an instrument designed by a DC/PhD and PhD in engineering, at the University of Alberta which is going into clinical trials that promises to change the way chiropractic doctors, and any professional that deals with spinal conditions diagnose, treat and evaluate effectiveness of their treatments. http://www.vibedx.ca/

    Contemporary chiropractic can maintain its roots (holism, structure/function interdependence, the role of manipulation as it relates to the nervous system) and be intelligently integrated into mainstream health care delivery models due to the proof of expertise over a certain domain of medicine (manual/manipulative therapy) in a specific arena (primarily neuromusculoskeletal). That is where this whole thing is going, regardless of what the fringe of chiropractic and the fringe of medicine thinks. Questions are always welcomed.

  52. BillyJoe says:

    Poe’s Corollary it is. :D

  53. NMS-DC says:

    @Harriett,

    “NMS-DC “Just provided you evidence that your statement was false, however. To repeat, 73% of current, practicing DCs, in the USA see themselves as back/MSK specialists”
    ROTFL. You call that evidence? If that’s the best you can do, you might as well quit right now. Some of those who “see themselves as back specialists” claim to be putting bones back in place and also treat nonmusculoskeletal conditions and use all kinds of nonsensical diagnostic and treatment methods.”

    You said, specifically, that DCs who practice and MSK-oriented approach was far in few in between. I provided you with a reference and stat that rebutted your assertion.

    Non-MSK makes a very small % of patients who actually see a chiropractor. I need to dig up the reference but I believe it was less than 5-10%. The research in this area is still in its infancy and I agree that the claims made are way out of proportion with the literature. EBM, societal, health care reforms and internal pressures within and outside chiropractic have reached a tipping point where we need to prove our effectiveness and explain the science behind our treatment manual approaches. What has become clear, is that chiropractic is credible, valid and established in dealing with MSK. Outside that arena those claims cannot be made scientifically at this point and is experimental. As of 2007, this is what we have, although it is a bit dated will be refreshed within the coming year:
    http://www.ccgpp.org/2.pdf

    Also, keep in mind, Harriet, that chiropractic practice in the USA differs significantly in terms of diagnostic approaches and practices compared to their Canadian counterparts and internationally. I will dig up a reference for this as well as it very current (2011) and believe it was produced by the CCA.

    Still, it is being investigated, but what has been found, however that the effects of spinal manipulation are far more wide reaching that improving segmental joint kinematics. There is research being strictly on the investigating the mechanism of actions and effects of SMT on the autonomic nervous system. This research is pretty cool because it a) demonstrates that joint dysfunction, segmentally, produces reflexive changes in ANS functioning and b) spinal manipulation appears to be able to modulate these processes. It’ll take a good 10 years, in my opinion, to really get a good grip at the how SMT is much more than simply pain control, but improved functioning of the nervous system specifically as it relates to autonomic, neuromuscular, viscero-somatic, and neuroimmunological processes. Also, this research is being done by DC/PhDs in colloboration with PhDs in neuroscience and neurophysiology. We’re just scratching the surface here.

  54. NMS-DC says:

    @ BillyJoe

    I know it’s a lot to process; you’re probably experiencing some serious cognitive dissonance… (chiropractic science is not an oxymoron?!) You might want to take a nap now, I’m sure you head is hurting, there’s been a lot of words that have more than 2 syllables going around this thread.

  55. NMS-DC says:

    @ Jann

    Relevant:

    http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp

    Ernst, and his dogmatically blinded followers hate this chart is that it shows that a huge chunk of orthodox medicine are not evidence based (much of the use of anti-depressants falls into this category but I digress). The double standard at this forum is that it assumes that conventional, mainstream medical approaches are all scientifically rigorous and effective when it actually is only closer to 33%. 51% of medical procedures are found to be of unknown effectiveness. The research will guide clinicians and health care policy makers to be making more informed decisions on patient management and that’s as true for chiropractic as it is for medicine, dentistry or any other regulated health care professions.

    @Harriet:

    I read your introduction to chiropractic. The premises are all factually wrong, which isn’t surprising given it’s not cited. The whole sub-page is essentially a biased sample and it does not present a point/counterpoint. If you are in fact trying to do a fair and balanced review of chiropractic medicine, it would be helpful to present the other side of the coin in terms of research but also present the MODERN state of the chiropractic profession INTERNATIONALLY (education, research, practice habits) as opposed to a out-dated, misleading and historically inaccurate portrayal of chiropractic. You and I likely agree on many, many things regarding chiropractic medicine, but my interpretation is that everyone here is throwing out the baby with the bathwater when trying to portray fringe chiropractic practices as the majority. A real disservice to intelligent readers. Some of the posters here are rather religiously tied to their opinion on chiropractic, which is their right, but it doesn’t mean their opinion is informed. People like yourself, Homola, Ernst, Colqhoun and others are unlikely to be be swayed by any level of evidence no matter the circumstances but it does prove that you are being intellectually dishonest by ignoring evidence which is contrary to your belief system.

  56. pmoran says:

    NMS-DC:Relevant:

    http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp

    Ernst, and his dogmatically blinded followers hate this chart is that it shows that a huge chunk of orthodox medicine are not evidence based (much of the use of anti-depressants falls into this category but I digress).

    I think you missed the fact that that graph includes a lot of CAM and experimental treatments.

    The accompanying text says :-

    “Included within the category of Unknown effectiveness are many treatments that come under the description of complementary medicine, for example, acupuncture for low back pain and echinacea for the common cold, but also many psychological, surgical, and medical interventions, such as CBT for depression in children, thermal balloon ablation for fibroids, and corticosteroids for wheezing in infants.”

    When normal medical practice is looked at closer to 80% of the methods used are found to be based upon solid evidence.

    Nevertheless, I agree that Jann’s legislation is based upon the assumption that there is a clear dividing line between effectiveness or ineffectiveness. I don’t think it is as routinely clear as we skeptics typically suggest, yet Jann’s legislation would have some poor patsy having to pronounce upon myriads of individual remedies and clinical settings. Physiotherapy sports medicine and some other mainstream areas might take substantial hits.

    What chiropractors have been especially good at is inconsistent use of standards of evidence. Anecdotal evidence is fine when clinical benefits are being claimed but not when serious risks might exist, such as stroke from neck manipulations. It should be the other way around.

  57. NMS-DC says:

    @pmoran

    “Included within the category of Unknown effectiveness are many treatments that come under the description of complementary medicine, for example, acupuncture for low back pain and echinacea for the common cold, but also many psychological, surgical, and medical interventions, such as CBT for depression in children, thermal balloon ablation for fibroids, and corticosteroids for wheezing in infants.”

    You can’t blame CAM for “diluting” this graph. Like you acknowledge there are “experimental” medical treatments in here as well that see to be getting the free pass from many on this site. But I will stick to chiropractic since it’s my area of expertise.

    “When normal medical practice is looked at closer to 80% of the methods used are found to be based upon solid evidence.”

    You didn’t reference this, so it’s anecdotal. You can’t pull stats out of thin air, Paul. Also, what constitutes “normal” medical practice. What about off-label prescriptions? You see how quickly and murky it gets when we apply EBM evenly across the board for all health care interventions.

    Yes, admittedly, there are inconsistencies with “styles” and “variability” of chiropractic, especially in the USA. But the fringe are a minority, and increasingly so. There is much more homogeneous agreement as to the chiropractic identity internationally, and the accrediting body on chiropractic education has made it very clear the scope of practice and where their expertise lies (see 3.1.1) http://bit.ly/o5pqid. You know that there is legitimacy achieved when the WHO recognizes the profession and establishes basic requirements in safety and training:
    http://bit.ly/cDxfba.

    Regarding stroke and neck manipulations, the gold standard, in terms of literature is the 2008 WHO Joint Task Force in Neck Pain. The summary can be found here. http://bit.ly/90deAm In plain English is that there is no difference in stroke rates in those who present to chiropractic doctor or a medical doctor. But, again, it’s an important issue and since DCs delivery 90% of SMTs it patient safety in all manipulative procedures is imperative, particularly for chiopractors. So, a 5 year study is being done presently with investigators coming from various disciplines like medicine, chiropractic, osteopathy and physical therapy. http://bit.ly/pBfyqB.

    Thanks for a level-headed response.

  58. nybgrus says:

    Ok, but every other week there’s a post here about us crazy chiropractors. Are you done yet?

    I reckon we’ll be done when chiropractors aren’t so crazy anymore and their basic foundation of practice isn’t based in magical thinking.

    And I believe it was with you and another chiro here that I posited the scenario of a man coming in and asking you to explain what red flags you might spot and how you would decide to refer him on for something outside the scope of practice of DC. I did so because you (in the plural) claim to be able to diagnose and accurately and adequately treat or refer. I got no answer. Interesting.

    @NMS-DC: you truly have no idea how science works or what it means. The amount of handwaving and special pleading in your posts is truly amazing. Reminds me of religious apologists and creationists. You know that the creationists do “science” as well? And they even have research centers and write articles – they have written numerous pieces on flood “science” and why radiometric dating is false. But, just like you, their basic premise is false and instead of letting research guide the answers, they have a set of conclusions (in your case, chiropractics works and so does SMT) and then they do “science” to show how and why they work. There’s a term for that: bad science.

    Anytime you have to twist and bend and include this or that caveat (look at the international chiro scene not just the US scene… blah blah blah) you are trying to prove a foregone conclusion. And that is always…… bad science. So don’t think that just because you can write the words “chiropractic” and “science” next to each other it means anything. Because the creationists write “science” after their work too.

    I would go through and list every logical fallacy you have made (including your recent tu coque which pmoran addressed), but I’m afraid I don’t have the time and my poor keyboard would break typing so much.

  59. NMS-DC says:

    @nybgrus

    I have presented nothing but coherent and logical viewpoints backed with references. Special pleading? handwaving? Red herrings on your part and do nothing to add to the discussion we are having here. Are you completely ignoring the fact that there are DC/PhDs doing basic science research as we speak on manual therapies and spinal function in conjunction with other disciplines? Is that bad science? What should I call a DC/PhD if not a chiropractic scientist?

    “just, just like you, their basic premise is false and instead of letting research guide the answers, they have a set of conclusions (in your case, chiropractics works and so does SMT) and then they do “science” to show how and why they work.”

    This illustrates how you don’t understand my argument nor to you understand how scientific research even works. Why are you putting brackets around “science” anyways? Do you have an issue with the references I’m providing? If not, what exactly is your problem with my argument?

    “Anytime you have to twist and bend and include this or that caveat (look at the international chiro scene not just the US scene… blah blah blah) you are trying to prove a foregone conclusion.”

    There is no twisting or bending, merely presenting information. You seem to be bending and twisting my words and trying to discredit me alone with weak straw man arguments. What foregone conclusion am I trying to prove? You are inferring I’m making logical fallacies, but fail to mention any of them specifically. I’m eager to learn.

  60. David Gorski says:

    Are you completely ignoring the fact that there are DC/PhDs doing basic science research as we speak on manual therapies and spinal function in conjunction with other disciplines? Is that bad science? What should I call a DC/PhD if not a chiropractic scientist?

    I agree. “Not a chiropractic scientist” would be a good term for them, or just “not a scientist.”

  61. JPZ says:

    @NMS-DC

    “…my interpretation is that everyone here is throwing out the baby with the bathwater when trying to portray fringe chiropractic practices as the majority.”

    Not everyone. You appear to be experiencing something that micheleinmichigan pointed out to me when I first began commenting on this blog (I have controversial views on SBM as well). Many of the people who have responded to your posts have had the discussion about whether chiropractery is efficacious many, many times. They have examined their opinions in light of the science and refined their POV many, many times. You are, in effect, embodying the sum total history of those arguments when you present well-known views, so people will tend to be talking about things you didn’t say (which was very frustrating for me at first), and some people will be dismissing some comments out of hand because they don’t want to go over it for the 301st time (I admire Harriet’s patience greatly).

    My advice: Focus on what makes your viewpoint about chiropractery different from the field at large. If you believe in a subset of chiropractic practices that you would consider science-based, FOCUS on that portion or you are going to get beaten over the head again and again with the subluxation angle. Admit that questionable practices are wrong and draw the discussion back to what you feel is science-based. If you are right, the worst that has happened to me here is that your comments get dismissed as old news, i.e. you are right, but I already knew about that piece of evidence.

  62. nybgrus says:

    @NMS-DC:

    You are not eager to learn. I’ve touched upon the foregone conclusions you are trying to reach. And as I said – I simply don’t have the time or desire to go through piece by piece and dissect and destroy your arguments. It is boring and tedious since it has been done ad nauseum. Dr. Hall makes the exact same point.

    I put science in quotes (not brackets) because what you are citing and referencing in not science. It is “science” the same way creationists have their “science.” Go read some of Sam Homola’s posts on the topic – he is a chiropractor that writes for SBM and actually gets our respect.

    And Dr. Gorski beat me to it – yes, that is precisely what I am saying. The DC/PhDs are also not scientists. The same way that the creationist “scientist” PhDs are not scientists. Did you know that the local Natural College here has a degree in homeopathy… and part of their curriculum is to train their students in research methodology and ethics? Do you know how incredibly ridiculous that is? It isn’t science – it is cargo cult science. Aping the motions of being scientific without actually being scientific. But you are clearly a true believer (Poe’s corollary, eh BJ?) so of course none of this makes sense to you. But as I said – I have no desire to educate you since I can absolutely guarantee you have no desire to actually learn.

    You make reference to the VibeDX as if it means something. Here is a reference to the Lymphstar Pro device. It too is a complete load of garbage. So just because you have a device that is trying to demonstrate validity but hasn’t yet (a but it will! it will I swear! We have DC/PhDs working on it!) means nothing. It is yet another example of bad science – working from conclusion and product towards evidence.

    and JPZ makes a very good point. And as a chiropractor Sam Homola does exactly what he advises. He points out the failings of chiropractics and disavows them. He posits forward thinking on how to make the practice actually science based and how to change the practice regulations and licensing terms. That is the discussion you should be having. Not trying to defend the entirety of chiropracty as some persecuted field and declaring the fundamental basis of chiropractic understanding of pathology as “fringe.” Go read his stuff and come back and we will see if you are actually eager to learn or if you are just trying to defend your already decided upon conclusions.

    BTW – JPZ, you do have some controversial thoughts here, but you do also change your view and present actual science. The areas where we (the group) tend to disagree are usually areas where it is reasonable to have disagreement. Thanks for making the point that we are not dogmatic and “closed minded” here. As a supplement industry advocate you should be exactly the person who would claim that… and yet you aren’t. Take a lesson from that NMS-DC.

  63. nybgrus says:

    Happened to come across this just now. Seems to fit nicely and be very applicable to NMS-DC

  64. JPZ says:

    @nybgrus

    I don’t have the history that you, David and Harriet have had with this subject. I have been exhausted by other over-discussed topics in nutrition, so I have a glimpse of what you are feeling. My naive impression was that NMS-DC was annoyed being tagged with all of chiropractery and wanted to share some aspects (s)he found science based (while under fire). Or, I am completely wrong, and my lack of insight into chiropractery has blinded me to obvious deficiencies.

    I suppose that NMS-DC will prove that out.

  65. NMS-DC says:

    Wow! A lot of discussion being generated in this thread, but it’s late so I’ll be brief with my replies and we can elaborate later on if need be.

    @Weing

    Yes, the chiropractic profession has embraced research, specifically the effectiveness and mechanisms of spinal manipulation and manual therapies. This is the science of chiropractic.

    @Marcus Welby

    I’m not familiar with the legal statues in the USA, indeed seem not to reflect modern day chiropractic practice, but not because of the absence of segmental joint dysfunction/subluxation. The scientific and legal definitions of chiropractic need to be congruent and that’s probably not the case, but that’s why things change and evolve. Chiropractic has embraced research and has contributed to the basic sciences of the mechanisms of spinal manipulative therapy. To say there is no progress in education is ridiculous and you should read the CCEI standards I attached that are approved by the World Health Organization. Are you now doubting the intellectual integrity of the WHO? Bottom line: chiropractic is not outside science. Explain that to the DC/PhDs who in research positions in universities all across the world. Time doesn’t stand still Marcus. It’s been a solid 25 years now of academic research into SMT done by DCs and other health professions. Chiropractic has contributed to health care by researching and understanding the effects and effectiveness of spinal manipulation. And that’s just fact.

  66. NMS-DC says:

    @nybgrus

    I do disavow fringe practices in chiropractic. All of them, in fact. Read my posts, specifically where Harriett asks me about Applied Kinesiology. There are some outdated, quackery treatments that a minority of chiropractors use, no doubt, and as the profession reaches another level of maturity with respect to EBM these practice traits will shift, because there won’t be any evidence for it and it will not be be covered for reimbursement in private or public health plans. But you can’t argue their use of SMT and/or other manual therapies for back and neck pain.

    I know of Sam Homola writing’s very well. I respect Dr. Homola’s efforts to stamp out quackery. But, he is of an different era, in terms of education, in terms of the context of his practice (prior to Wilk vs. AMA) etc… You could even say that Sam and I share the same view: chiropractic is not without merit but needs to embrace research and science to justify its survival. I’m here to share with you advances in chiropractic sciences (research) and then you claim it cannot be “science” because it is “chiropractic”. Ridiculous argument, a logical fallacy in fact. A chiropractor who has obtained his PhD and works in a university setting conducting research on the neurophysiology of spinal manipulation cannot be called a chiropractic scientist.

    @jpz

    If you have specific questions I will give you specific answers. I’m not excusing quackery in chiropractic by any means or unethical practices or outlandish claims. I’m saying that there has been enough of a change in the academic culture at chiropractic institutions that recent graduates, current students and future chiropractors will have very solid and scientific understanding of how their bread and butter, spinal manipulation, works and who will best benefit from its application and what specific “doses” or treatments if you will produces the best outcomes. Another big shift in the profession, academically, is embracing a multi-disciplinary model of care, so that rather than being isolated, there is embracing of integrating into mainstream health care. With that privilege comes more scrutiny and the fringe of the profession (fundamentalistic/religious chiros) are either going to have to prove their claims through research or their practice style/habits will get left behind because of EBM. EBM changed everything for chiropractic because it represented a way for the majority of the profession, who are sensible, to gain credibility in academic/scientific circles and influence health care policy by demonstrating effectiveness and an expertise in a specific domain of health care, spinal manipulation and manual therapy. The goal is full and equitable access to chiropractic care. We are the experts of spinal manipulation as related to proper neuromusculoskeletal functioning. If there are additional, non-msk benefits that are proven, gravy. If not, fine, those patients make up less than 10% of chiropractic visits.

  67. NMS-DC says:

    Edit:

    “A chiropractor who has obtained his PhD and works in a university setting conducting research on the neurophysiology of spinal manipulation cannot be called a chiropractic scientist.”

    I meant to put Wow. At the end of that sentence, but couldn’t edit my actual post. It was an attempt at sarcasm. Of course they are chiropractic scientists. This is fact, not fiction.

  68. NMS-DC says:

    @DavidGorski

    Sorry I don’t feed trolls.

  69. windriven says:

    @NMS-DC

    Can you explain the ethics of licensing a profession under a different pretense than the practice of that profession? That seems to lie at the core of your argument.

    I don’t suppose that anyone here would argue that chiropractic does not offer some benefits in MSK issues. But are those benefits better in outcome or different in execution that treatment by a physical therapist or even a masseur?

  70. marcus welby says:

    Note some differences between physical therapists and chiropractors:
    Physical therapists do vastly more than spinal manipulation therapy, which is a small portion of their practice.
    Scientifically based rehabilitation from injury..exercise supervision for joint and musculoskeletal restoration such as progressive resistance exercises and active range of motion.
    Gait training in those who are troubled with ambulation for a variety of reasons.
    Balance assessments and rehab.
    Teaching transfer techniques for arising from bed, chair, wheelchair, auto.
    Wheelchair prescription and use, use of adaptive devices like walkers, braces, crutches, canes, etc.
    Stroke treatment and rehab. which may include some patients who have sustained their stroke as a result of VAD from neck cracking.
    Spinal injury rehab., home assessment for fall prevention and adaptive modification recommendations.
    The spinal manipulation therapy utilized by PTs is gentle and never high velocity, as they are trained in the risks to the vertebral arteries when these arteries exit the bony confines of the C-2 vertebra.

    The focus of physical therapists is on guiding the patient to recovery, rather than marketing a largely placebo benefit.
    Chiropractic meetings, I am advised, are largely about marketing techniques.

  71. JPZ says:

    @NMS-DC

    “@DavidGorski

    Sorry I don’t feed trolls.”

    David Gorski, MD, is the Managing Editor of this blog. I too felt his comment was a bit dismissive in tone, but he is one who may not want to have his 3001st re-hashing of chiropractery. A person with a Ph.D. in neurophysiology from a reputable school who wants to use well-validated techniques to test if chiropractic techniques have some benefit beyond physical therapy would appear to be doing science. But, the way you said it, it could also be read as a chiropracter with a Ph.D. in history doing poor quality science to “prove” chiropractic techniques work. The onus is on you to make a clear, science-based case.

    You can defend chiropractery as a whole, but your stats are going to be scrutinized (mine are as are those of the blogging staff here), and you are going to get beaten over the head with subluxation and physical therapy comparison arguments that you can’t dodge, and the commentators have practiced. Or you can defend your viewpoints with good-quality studies that demonstrate a clear superiority of chiropractic treatments to other therapy. You have been trying to do both which means you run the risk of all your arguments being lumped together and dismissed.

    I think windriven hit the nail right on the head:

    “Can you explain the ethics of licensing a profession under a different pretense than the practice of that profession? That seems to lie at the core of your argument.

    I don’t suppose that anyone here would argue that chiropractic does not offer some benefits in MSK issues. But are those benefits better in outcome or different in execution that treatment by a physical therapist or even a masseur?”

  72. NMS-DC says:

    @windriven

    The expertise of DCs is spinal manipulation specifically, and manual therapies generally. Chiropractors do mobilisations, soft tissue massage, nerve flossing, etc, which PTs and MTs. But would you say that PTs are experts at spinal manipulation? Is their professional identity tied to it? After chiropractic literally means done by hand.

    The question of professional redundancy is a fair question, but the reality is there is so much MSK issues and chronic pain syndromes going around that everyone can have a piece of the pie. Also, we know that PTs all don’t work as MSK therapists, some are cardiopulmonary, some are neuro-rehab, some are geriatric based, etc… And, besides, if PT/MD colloboration was working so well to begin with why would anyone ever see a DC? The truth to that question is we offer a service that public finds beneficial. So, no, PT and MT don’t overlap enough to make us redundant. Lastly the research (Cochrane) states for LBP that SMT is just as effective as common medical management, physical therapy, etc… If people want an adjustment instead of dose of NSAIDs, pain killers or stint in rehab, if the evidence is equal to those interventions shouldn’t they be able to choose?

    I may not have answered your question “ethics of licensing a profession under a different pretense” but I’m not sure as to what state/jurisdiction you are referring to nor the specific statute that you and other disagree with.

    @Marcus

    The literature is clear that the effects of SMT aren’t placebo based.

    @JPZ

    “A person with a Ph.D. in neurophysiology from a reputable school who wants to use well-validated techniques to test if chiropractic techniques have some benefit beyond physical therapy would appear to be doing science. But, the way you said it, it could also be read as a chiropracter with a Ph.D. in history doing poor quality science to “prove” chiropractic techniques work. The onus is on you to make a clear, science-based case.”

    Absolutely. I assumed (incorrectly) that the forum would understand that the majority of the PhDs are in the basic clinical sciences related to chiropractic (neuroscience, biology, kinesiology, biomechanics, epidemiology etc). Further to that point is that they are working in public universities along other researchers exploring to issues pertinent to chiropractic practice and public health (i.e. reducing the burden of back and neck pain costs on the health care system).

    I can come here and give pubmed links left and right of research being done by DC/PhDs all day but my main argument that the chiropractic profession has developed a sustainable research culture based on science. Not bad science, not pseudoscience, just science. Plain and simple.

    The profession is unique because it will be the first CAM profession to be integrated into mainstream health care over the next decade or two and it will set the template for other CAM professions to follow suit. It’s exciting times to be part of change not only within the profession but as health care reform sweeps across North America.

  73. nybgrus says:

    @JPZ: BTW, Gorski is also a PhD and clinical researcher. And yes, your characterization is spot on – he was dismissive and rightly so. But most certainly not a troll by any stretch.

    @NMS-DC:

    Lets get to the nitty gritty (BTW, feel free to answer my challenge to you on the thread you necromanced over here).

    Chiropractors do mobilisations, soft tissue massage, nerve flossing,

    There is no good evidence for neural flossing as being effective. In fact, I could find very little data on it overall. The mechanism as described by Gonzalez indicates that the theory revolves around fibrous tissue restricting motion of nerves and thus causing a chronic pain which is relieved upon mobilization. It is often used in the context of soft tissue injury as well. Unfortunately there is an extreme paucity of data, and the one review I could find in the Journal of Sport Rehabilitation (PDF concluded “efficacy… is not clear. More research is necessary to determine the population that may respond optimally to this treatment.” [Emphasis mine]

    Furthermore the mechanism of injury does not make sense in describing the type of pain/condition it is attempting to, and neither does the treatment mechanism describe a particularly plausible MOA for relief. Granted, not as outlandish as homeopathy, but the a priori likelihood is reasonably low. Taken in a Bayesian context, I’d feel pretty safe in saying that “neural flossing” is wishful thinking and placebo response.

    But would you say that PTs are experts at spinal manipulation? Is their professional identity tied to it?

    When the entirety of your professional identity is tied to one thing not only are you extremely limited in what you can and should be doing, but you are very likely to fight tooth and nail to preserve that at all costs. After all – if that goes, what do you have left?

    First off there is no good data demonstrating any particular use of spinal manipulation. If you have some please link it for evaluation – do not just assert that there are “many many DC/PhDs out there proving it.” (I’ll get to the LBP in a bit).

    But more to the point – what is the point you are trying to make in comparing PTs to chiros here? You are saying they are not expert in spinal manipulation. Besides having yet to prove that being an expert in spinal manipulation is useful, I could and would argue that they are as expert as they need to be. Are chiros expert in the myriad other things that Marcus Welby listed? If your point rests solely on such a comparison, then PTs win quite easily on that one. You may wish to rethink that line of argumentation.

    The question of professional redundancy is a fair question, but the reality is there is so much MSK issues and chronic pain syndromes going around that everyone can have a piece of the pie

    Once again, you not only miss the point but belie the basis of chiropractic – getting a piece of the pie. We here don’t care on hoot if there is enough pie to go around. We only care about whether you deserve a piece of that pie.

    You have to prove that chiropractic has better (or at least equal) outcomes to PT – something that has not been done. Furthermore, you have to answer windriven’s comment directly – you eschew subluxation theory, yet the core tenet of chiropractic is subluxation theory. So how do you justify practicing in a manner inconsistent with the training, testing, and legal documentation of your professional body? Can you imagine if I, as a physician, went against germ theory and began treating miasms? Or a homeopath who never used infinitely diluted “medicines” but used actual medicine? You see that at the core this is an argument for chiros to go to PT school.

    Of course, the issue is (which I raised and RWK failed to answer, so I leave to you) is that you claim the ability to diagnose and treat. Yet chiro training only provides that privilege if your fundamental theory for the pathogenesis of disease is sound and the treatments arising from it effective beyond placebo. Subluxation theory is not sound and treatments such a neural flossing and high velocity spinal adjustment do not meet these requirements. So you are left holding the bag as to why we should recognize your ability to adequately and accurately diagnose and treat, or refer when necessary. And if you can’t diagnose and treat, then you are once again working in a manner inconsistent with your professional training and being over-privileged at the same time. In that case, once again PT wins hands down.

    So, no, PT and MT don’t overlap enough to make us redundant.

    Once again, the core issue is not how much you overlap. It is whether the parts where you don’y overlap are legitimate and evidence based. In PT – yes. In chiro – no. Your argument is entirely equivalent to saying that MD and homeopathy don’t overlap, so homeopaths aren’t redundant. This is true – but I am not arguing redundancy I am arguing validity. And once you strip away the parts of chiro that don’t overlap and are not evidence based, you are left being very limited and redundant.

    Lastly the research (Cochrane) states for LBP that SMT is just as effective as common medical management, physical therapy, etc

    It is also known that acupuncture and sham acupuncture work as effectively (and often more effectively) than standard of care. We have established that is entirely do do placebo effects and JPZ and I had a discussion on the topic just recently. The point being is that establishing that single statement as being true, regardless of the fact that it is entirely a placebo response, does not a profession capable of diagnosis and treatment make.

    If people want an adjustment instead of dose of NSAIDs, pain killers or stint in rehab, if the evidence is equal to those interventions shouldn’t they be able to choose?

    The health freedoms gambit. When your tack has a name, it is probably a fallacy. And that holds true here. People also have the right to choose homeopathy, reiki, acupuncture, etc but that doesn’t make them valid. And if your only holdout for validity is the placebo response of patients with LBP, once again – pretty darned thin and very unconvincing.

    I may not have answered your question “ethics of licensing a profession under a different pretense” but I’m not sure as to what state/jurisdiction you are referring to nor the specific statute that you and other disagree with.

    Then answer it. It has nothing to do with states, jurisdiction, or statutes. It has been firmly established that every single professional body for chiropractics, every single chiropractic school, and the assessments for chiropractics utilize subluxation theory as the central basis of chiropractics. If you eschew that theory as being false (which is true) but still practice as a chiropractor whose professional oversight body still has the language of subluxation theory in use, then you are practicing something different to what your license says you are supposed to be practicing. So address the ethics of that.

    The literature is clear that the effects of SMT aren’t placebo based.

    Reference needed. Simple assertions don’t fly here, especially since myself and the authorship here have asserted otherwise with references.

    Absolutely. I assumed (incorrectly) that the forum would understand that the majority of the PhDs are in the basic clinical sciences related to chiropractic (neuroscience, biology, kinesiology, biomechanics, epidemiology etc).

    Yes, that is a false assumption. And one you have yet to dispel. As I said, I can show you a link to a homeopathy research program nearby me. These are not people with separate PhDs that are valid, but research degrees conferred by the homeopathic institution. Those are not valid. So if it is the chiropractic college that is conferring both the DC and the PhD, that is also not valid. As JPZ said, if the PhD is separate, from a legitimate institution, and in a relevant field that is different. I have yet to see that.

    I can come here and give pubmed links left and right of research being done by DC/PhDs all day but my main argument that the chiropractic profession has developed a sustainable research culture based on science.

    Then you need to do so. And even without that, your arguments have failed to establish that there is a sustainable research culture based on science. Everything you have written has demonstrated that chirpopractery is fundamentally tied to spinal manipulation and neural mobility and that the research is attempting to prove that to be valid. That is bad science. Period.

    The profession is unique because it will be the first CAM profession to be integrated into mainstream health care over the next decade or two and it will set the template for other CAM professions to follow suit. It’s exciting times to be part of change not only within the profession but as health care reform sweeps across North America.

    Once again, an evidence free assertion. And actually one at contention with the evidence. Chiropractors are making less and less money, there are fewer and fewer of them, and enrollments are down.

    So now that I have actually dissected out everything perhaps you would like to respond with something more than vacuous pontification about the wonderful state of the “science” of chiropractics and actually demonstrate that it exists. Ask anyone here – if you demonstrate actual, valid, good studies I will change my opinion, regardless of how much it goes against what I currently think.

    Also, please address the ethics regarding the difference between the practice of chiro and the training and licensing of chiro as windriven pointed out.

    Also, please address the issue of how you can know to diagnose, treat, and refer as per the scenario I gave in the Legislative Alchemy II thread.

    I have put some time and effort into this one, so if you expect any respect or hope to ameliorate your position here you should do the same. Besides, if you care about your profession and truly have evidence of its validity that should not only be something you want to do, but easy as well.

    I await your response.

  74. nybgrus says:

    ack. apologies for the bad html – must have missed a tag somewhere.

  75. NMS-DC says:

    @nybgrus

    Thanks for your detailed rebuttal. But, you completely misrepresented by point of view so I’m going to be clear so you don’t make inferences again:

    1) I do not support subluxation theory. The profession does not support subluxation as the cause of disease. Every profession that provides SMT (chiropractic, osteopathy, physical therapy, medicine) is manipulating an area of the spine that is dysfunctional (aberrant biomechanics). The concept of subluxation is not unique to chiropractic. Its
    equivalents are the ‘osteopathic lesion’ in osteopathy, and the‘segmental blockage’ of the European manual medical school. You are confusing subluxation DOGMA with subluxation, the functional spinal joint dysfunction aka manipulable lesion.

    2) I diagnose and treat MSK. That’s our clinical realm of expertise. This is well established in the literature. See the CCEI for exact details.

    3) People can choose reiki or homeopathy, but you are making an an logical fallacy. I said people can choose treatment methods that have proven effectiveness. SMT is proven to be effective for back and neck pain and certain forms of headache.

    4) The DC/PhDs do not have their degrees conferred by a chiropractic institution, it was done in public university. There is no chiropractic school that offers a PhD.

    5) Regardless of your assertion that DCs are making less money, and enrollment is down, is not what we’re debating. We are debating whether or not chiropractic has made any contribution to science. Yes, hands down.

    Nitty gritty

    SMT isn’t placebo based:

    “The evidence suggests that effects of spinal manipulative therapy is primarily neurophysiologic, most likely mediated by intense stimulation of large myelinated fibers in the capsular and/or periarticular tissues.” http://1.usa.gov/oOZobj

    Evidence for manual therapy effectiveness:

    http://www.ncbi.nlm.nih.gov/pubmed/20184717

    RE: the Bronfort et al. study: Relative to neck pain there is reference to new clinical practice guidelines from the Orthopaedic Section of the American Physical Therapy Association recommending use of “cervical manipulation
    and mobilization procedures to reduce neck pain based on strong evidence”.

    This is mentioned here to draw attention to the fact that there is significant inconsistency between the various
    reviews of the scientific evidence. Bronfort et al.’s review is conservative – here more conservative than the APTA on
    the value of manipulation/mobilization for neck pain. Think about that for one second. PTs CPG is saying the evidence is STRONG for SMT and MOB for neck pain. No wonder why they’re trying hard to incorporate SMT as fast as possible into their educational curricula: it works (for neck/back pain)

    Ok, good studies, with a chiropractic scientist as a lead author. I’ll include a diversity of research (not just SMT) but stuff pertinent to the neuromusculoskeletal system or pain sciences. I’ll leave it 5 just for brevity

    1) Extracting phase – dependent human vestibular reflexes during locomotion using both time and frequency correlation approaches. http://www.ncbi.nlm.nih.gov/pubmed/21868684

    2) Identification of spinal tissues loaded by manual therapy: a robot-based serial dissection technique applied in porcine motion segments. http://www.ncbi.nlm.nih.gov/pubmed/20881661

    3) Tuning the gain of somato-sympathetic reflexes by stimulation of the thoracic spine in humans. http://www.ncbi.nlm.nih.gov/pubmed/21184812

    4) Changes in the flexion-relaxation response induced by hip extensor and erector spinae muscle fatigue.
    http://www.ncbi.nlm.nih.gov/pubmed/20525336

    5) Capsaicin-induced central sensitization evokes segmental increases in trigger point sensitivity in humans.
    http://www.ncbi.nlm.nih.gov/pubmed/20015704

    And more, more, more…

    Lastly:

    Practice of chiro: management of back pain, neck pain and headaches that make up 90% or more of all patients who seek chiropractic care. http://www.ncbi.nlm.nih.gov/pubmed/20184721

    Training of chiro: (international standards, 2011) http://bit.ly/nnlJpf

    3.1.1 achieves a fundamental knowledge of health sciences, with a particular emphasis on those related to the neuro-musculoskeletal system;

    3.2.2 achieves particular expertise in diagnostic imaging, orthopedics, pain management and rehabilitation of the neuromusculoskeletal system;

    Summary: Contemporary chiropractic is concerned diagnosis, treatment and prevention of disorders of
    the neuromusculoskeletal system and the effects of these disorders on general health. I am trained to diagnose NMS disorders and I use SMT as well as other forms of manual therapy, exercise, patient education, and therapeutic modalities (US, TENS, Laser) to help people move and feel well. This is what is common for 90% of DCs. What is bad science, nybgrus is to focus on the 10% whose practice styles are fringe (treat non MSK) and to completely assume that the other 90% of us are somehow unethical, incompetent, uneducated and don’t understand basic science.

    Basic premise: Contemporary chiropractic care is VALID for NMS disorder management and that manual therapies, including SMT are effective in treating back and neck pain, certain forms of headaches and to a lesser extent (so far) extremity MSK complaints (based on the evidence).

    Looking forward to your reply.

  76. JPZ says:

    @NMS-DC

    “I may not have answered your question “ethics of licensing a profession under a different pretense” but I’m not sure as to what state/jurisdiction you are referring to nor the specific statute that you and other disagree with. ”

    I thought I would supplement nybgrus’ comment on your statement by adding that the Association of Chiropractic Colleges defines the chiropractic paradigm in its bylaws including subluxation (http://www.chirocolleges.org/paradigm_scope_practice.html). I had the impression that ACC provides the common ground on defining chiropractic education.

  77. NMS-DC says:

    @jpz

    Thanks for your question and I’ll try to be clear. The ACC represents the 19 (17 US, 2 Canada) DCs schools in North America and was formed in 1996 to try to get “everyone on the same page”. The ACC paradigm doesn’t have any power with respect to outlining specific academic criteria. That is left to the CCE-US which has to get it approved by the US Department of Education, and in Canada we have our CFCREAB that sets minimum standards with education curricula and competencies. Both need to be part of the CCEI which is the international standardization of chiropractic education. The ACC, in functional terms, is a place for presidents of chiropractic schools to meet to discuss strategic planning in terms of research and they hold an annual research conference with students and faculty producing research related to chiropractic. Some of it is very good and eventually makes into a peer-reviewed journal, while others are emergent chiro students who are getting their feet wet with research and this provides them with a good experience to learn more about research and make some networking opportunities.

    So, it seems like the elephant in the room at this point, eh… You all want me to discuss subluxation, bring you up to speed about what the hell is going on with this construct? I have to admit, almost all of the readings I see here refer to a) antiquated notions of chiropractic derived from the early years and b) promulgation of principles (i.e. subluxation cause disease) that is not congruent with contemporary chiropractic education and c) saying that subluxation/joint dysfunction does not exist. Yet some here are willing to believe in “osteopathic lesions”, “segmental blockage” and segmental spinal joint dysfunction. News flash! They’re all the same thing, just have a different name! Remember that time when the APTA wanted to correct vertebral subluxations? It’s getting kinda messy now eh… http://bit.ly/oLeDoR

    Dr. Karel Lewit a very prominent European neurologist has written a great textbook called Manipulative therapy for MSK. http://amzn.to/ox0j9N In it, he talks about vertebrogenic disorders (conditions that arise from the soine but may exude their away from the site of the manipulable lesion/subluxation. So, here is this well-respected neurologist who is making these claims that segmental joint dysfunction can lead to all kinds of crazy things like otitis media, enuresis, etc.. Now, I also know that DOs also claims that SMT can affect certain non-MSK. So, what’s going on? How can 3 different professions be claiming, to an extent, that SMT isn’t simply for pain control but can somehow affect distant tissues that are segmentally (neurlogically) innervated. It seems like its something worth investigating.

    Disclaimer: I do not treat non-MSK, not for philosophical reasons but primarily because I’m not comfortable with the level of evidence (at this point) and b) my practice is more geared towards NMS management and sports performance training.

  78. nybgrus says:

    I appreciate the response. I’ll go through point by point:

    First off, I fail to see how I misrepresenting anything you wrote, considering I quoted it block by block and addressed it directly. So I will once again respond to you in the same manner.

    The profession does not support subluxation as the cause of disease

    How do you reconcile that with the American Chiropractic Association (largest body representing your profession in America) stating:

    The document removes all references to the term “subluxation” – a core element of the practice of chiropractic that has been integral since the profession’s beginnings over 100 years ago. While the term “subluxation” and its role in the practice of chiropractic is sometimes misunderstood or not fully appreciated by all parties involved in medical related research and the delivery of health care, the term is one which is explicitly recognized in federal law (Section 1861(r) of the Social Security Act) and has been widely recognized by the courts, state legislative bodies and licensing authorities. The elimination of any reference to this term in the proposed standards will be viewed by many within the profession as a counter-productive action that will, in the long-term, likely weaken the profession’s collaborative strength and historic identity. We would propose placing “subluxation theory” back into Section 2, H. Educational Program for the Doctor of Chiropractic Degree and Vertebral Subluxation Complex into Section 3 Initial assessment and diagnosis as a required component.

    in regards to the CCE standards that removed mention of it?

    You are confusing subluxation DOGMA with subluxation, the functional spinal joint dysfunction aka manipulable lesion.

    Orthopedic subluxation – i.e. the actual dislocation of joints that can be verified on imaging – is very different from the subluxation theory the ACA wants to put back in the CCE standards for accreditation. Which I did read through BTW. And essentially, the document establishes accreditation for any DCP that is internally consistent and meets some minimum requirements they set forth. In other words, I find it to be a document that means very little. For example it states:

    The Council values educational freedom and institutional autonomy. The CCE does not define
    or support any specific philosophy regarding the principles and practice of chiropractic, nor do
    the CCE Standards support or accommodate any specific philosophical or political position.
    The Standards do not establish the scope of chiropractic practice

    So each institution can do as it pleases, and if they like subluxation theory, that is all well and good for them. Even moreso, the accreditation does not establish what the scope of practice of a chiropractor is. So how is someone like me supposed to look at anyone with a DC after their name and have any clue of what their training actually involved or what their fundamental understanding of the pathogensis of disease is?

    This is further reinforced later in the document where it is stated:

    The Council specifically reviews compliance with all accreditation requirements.
    • It is dedicated to consistency while recognizing program differences

    Consistency within each program, but each program can be different.

    The CCE Standards also state:

    Practice primary health care as a portal-of-entry provider for patients of all ages and
    genders.
    • Assess and document a patient’s health status, needs, concerns and conditions.
    • Formulate the clinical diagnosis(es).
    • Develop a goal-oriented case management plan that includes treatment, prognosis, risk,
    lifestyle counseling, and any necessary referrals for identified diagnoses and health
    problems.
    • Follow best practices in the management of health concerns and coordinate care with
    other health care providers as necessary.
    • Promote health, wellness and disease prevention by assessing health indicators and by
    providing general and public health information directed at improving quality of life.
    • Serve as competent, caring, patient-centered and ethical healthcare professionals and
    maintain appropriate doctor/patient relationships.
    • Understand and comply with laws and regulations governing the practice of chiropractic
    in the applicable jurisdiction

    But, since no scope of practice is defined, no consistency across all DCP programs is required, and the minimum requirements are just a list of basic sciences disciplines how can anyone know what the level of competence and training for an individual DC is in regards to diagnosis, treatment, and referral?

    Interestingly, one of the minumum teaching Standards is:

    Foundations – principles, practices, philosophy and history of chiropractic

    Yet without a clear guidelines as to what the philosophy of chiropractic actual is and the clearly stated acceptance of variation amongst the programs just so long as they meet these vague minimum guidelines, once again, how am I supposed to know what that means? The history of chiropractic is clear – vertebral subluxation theory as the fundamental cause of disease, both MSK and visceral. So left broadly like that, the CCE document is worthless in doing anything except creating an internally consistent DC program.

    I diagnose and treat MSK. That’s our clinical realm of expertise. This is well established in the literature. See the CCEI for exact details.

    I just referenced the exact details. Nowhere in the CCE document does it make reference that the clinical realm of expertise is limited to MSK issues. In fact, the document specifically states that:

    A Doctor of Chiropractic practicing primary health care is competent and
    qualified to provide independent, quality, patient-focused care to individuals of all ages and
    genders by: 1) providing direct access, portal of entry care that does not require a referral from
    another source; 2) establishing a partnership relationship with continuity of care for each
    individual patient; 3) evaluating a patient and independently establishing a diagnosis or
    diagnoses; and, 4) managing the patient’s health care and integrating health care services
    including treatment, recommendations for self-care, referral, and/or co-management.

    So the Standards say that a DC should be able to be a primary health care provider that does not require a referral from another source. That means you should be able to adequately and accurately diagnose and refer patients on your own. Yet, you just stated that your realm of clinical expertise and the entirety of your practice (and 90% of chiros out there) is MSK issues. So how does that work when a patient comes in with a headache and its actually a stroke? Or what about when a patient comes in with flank pain that turns out to be a psoas abscess, ureteric calculus, or retrocecal appendicitis? How do you differentiate those based on your training? Perhaps you specifically can but there is nothing in the CCE Standards for accreditation that indicate a requirement for that training, and based on the ACA and ACC both demanding that vertebral subluxation theory (not to be confused with orthopedic subluxations) be the founding principle of chiro and the pathogenesis of disease, you can see that there is no way for anyone to know what the actual qualifications and ability of a person with DC as their title is.

    People can choose reiki or homeopathy, but you are making an an logical fallacy. I said people can choose treatment methods that have proven effectiveness. SMT is proven to be effective for back and neck pain and certain forms of headache.

    I have made no logical fallacy. The evidence for reiki and homeopathy re: headache, neck, and back pain are exactly on par with the evidence (and outcomes) for chiropracty. In other words – it is all a combination of placebo response and massage therapy. You have yet to give me evidence otherwise.

    The DC/PhDs do not have their degrees conferred by a chiropractic institution, it was done in public university. There is no chiropractic school that offers a PhD

    Fair enough. I’ll accept that a DC/PhD isn’t de facto incapable of science. However, Luc Montagnier won the Nobel prize and is now saying that DNA can teleport via leaving imprints in water thus proving homeopathy. So the point is moot until specific examples come up (which you provided and I will address).

    Regardless of your assertion that DCs are making less money, and enrollment is down, is not what we’re debating. We are debating whether or not chiropractic has made any contribution to science. Yes, hands down.

    Fair enough about the money, enrollment, and what not (which is not just an assertion the numbers are clear from 9.9% of people seeing a chiro in 1997 to 4.4% in 2010). But you still have yet to demonstrate that chiropractic has made any contribution to science. You do have a few articles that demonstrate that chiropracters have individually made contributions, but not the profession as a whole.

    And now down to the nitty gritty again:

    “The evidence suggests that effects of spinal manipulative therapy is primarily neurophysiologic, most likely mediated by intense stimulation of large myelinated fibers in the capsular and/or periarticular tissues.”

    Yes, that article demonstrates that when you stretch and move a nerve, stuff happens. Color me unimpressed. Nobody is contending that there aren’t any effects to spinal manipulation (SM). The question is what are those effects and are they clinically useful. In the very same article you reference the conclusion is:

    Spinal manipulation-evoked modulation of central sensitization is an important, and perhaps foundational, scientific tenet which has the potential to establish chiropractic as an essential player in the future of mainstream health-care.
    [emphasis mine]

    OK – so all this establishes is 1) that chiropractics is indeed working from spinal manipulation backwards to try and justify its existence (we call that bad science) and 2) a very minor facet of chiropractics is being used to justify the entirety of the profession which, as I have outlined above, can have essentially anything included in its training and scope of practice. Furthermore, this article does not demonstrate what the actual effects on disease processes are – it just speculates that since stretching out and moving nerves affects pain modulation chiropractics must be good.

    Evidence for manual therapy effectiveness: [Bronfort]

    That is evidence for massage and placebo effects of manual therapy on very specifically MSK pain that is amenable to massage and placebo effects. It is not evidence for the entirety of chiropractics. Nobody here is contending, BTW, that manual therapy (i.e. massage and reduction of orthopedic subluxations) would not be useful for mechanical MSK pain. What we are contending is that chiropractics claims to be much more than just that and there is no uniformity in that claim. The further claim that I make, as does Marcus Welby, is that when restricted to actual evidence based practice, almost the entirety of what is left of chiropractic becomes overlapped with PT. The difference is that PTs don’t fancy themselves as primary care providers nor capable of diagnosis.

    Think about that for one second. PTs CPG is saying the evidence is STRONG for SMT and MOB for neck pain. No wonder why they’re trying hard to incorporate SMT as fast as possible into their educational curricula: it works (for neck/back pain)

    Nobody is debating that here. But if that is all you do or wish to do as a chiro, why not just go to PT school? Why demand the right to diagnose and act as PCP when you have such a limited scope of evidence base behind your practice? That is the debate.

    Extracting phase – dependent human vestibular reflexes during locomotion using both time and frequency correlation approaches.

    I was probably not clear, so I apologize. I never said that no chiro could ever do good quality research. But they do so in fields that do not conflict with their basic tenet of subluxation and they do so individually. This article demonstrates nothing about the profession as a whole, nor does it proffer any evidence for chiropractic.

    2) Identification of spinal tissues loaded by manual therapy: a robot-based serial dissection technique applied in porcine motion segments.

    Same as above. However this one is an attempt at trying to demonstrate something about chiro, but fails to do anything interesting. It demonstrates that forces are applied during SM and where. That is interesting, but it fails to demonstrate any legitimacy to using SM in the first place. However, it did demonstrate that the IV disk sustained the most force. What is the benefit of that? Besides potentially herniating a disk with weakened annular fibers, I fail to see how a temporary deformation of the disk can lead to any lasting or clinically relevant effects. Furthermore, the article clearly states:

    …only conditions involving these tissues may be influenced by manual therapy.

    Further reinforcing the notion that DC’s cannot a PCP make.

    Tuning the gain of somato-sympathetic reflexes by stimulation of the thoracic spine in humans.

    I actually pulled up the full article for this one. It does demonstrate a slightly interesting effect. Namely that sympathetic tone and response can be modulated via stretching and pulling nerves. It does not demonstrate any long lasting effects from this, any clinical application, or any improvement in pathological processes. It simply demonstrates that it happens. There were also limitations with the study as the authors themselves point out. So once again, I fail to see how this demonstrates any proof for chiropractics as a profession.

    Changes in the flexion-relaxation response induced by hip extensor and erector spinae muscle fatigue.

    A biomechanics article. Interesting indeed. Also fully within the purview of PTs. Also does not demonstrate a validity for chiro as a profession or a PCP.

    Capsaicin-induced central sensitization evokes segmental increases in trigger point sensitivity in humans.

    Same as above.

    Practice of chiro: management of back pain, neck pain and headaches that make up 90% or more of all patients who seek chiropractic care.

    First off, before you continue slinging around that “90% or more” number, I need a reference. Considering that I have handily demonstrated there is no uniformity to chiropractic training or accreditation, I’d be surprised if the number were that high or if you can even find data to back that assertion up.

    But, to get into the article itself:

    there is evidence to support the use of manual therapies for a range of, primarily musculoskeletal, disorders for which it is biologically plausible that they might have a specific effect

    • there is not evidence for their use for a range of other disorders for which a biologically plausible mechanism for a specific effect is unclear

    Thus, for example, the evidence supports use of manual therapy for non-specific low back pain and it does not support its use for enuresis or otitis media.

    Once again, this supports a very narrow scope of practice for chiropractors. One that is not enforced by the CCE nor endorsed by the ACC or the ACA. So here is that question, once again, that you refuse to answer:

    If your evidence base dictates a narrow scope of practice, and you adhere to that, but your licensing and professional bodies have a different standard, how is it ethical to practice in such a manner?

    Furthermore, all the evidence you have given me so far falls exactly in line with what I already know – manual therapy for mechanical problems works. But how does that translate to having the right to diagnose and act as a PCP? Why can a PT or an RN not diagnose or be a PCP, but you can?

    Chiro can become incorporated into actual medical care if it reforms, changes the CEE, ACA, and ACC guidelines and statements and works exclusively under the proviso of an actual medical doctor. But at that point there is very little difference between a chiro and a PT, so I would reckon an equivalency or merger would be in order. But you guys have to get there first.

    Conclusion:

    There is evidence for manual therapy for MSK related disease only. There is also no standard for scope of practice, extent (beyond bare minimum), or type of training in DCP. This is not evidence for acceptance of chiropractors as primary care physicians.

    I have also seen no evidence that any chiropractor would be able to adequately and accurately diagnose non-MSK pathology. This is further evidence that chiros cannot act as PCPs.

    What is bad science, nybgrus is to focus on the 10% whose practice styles are fringe (treat non MSK) and to completely assume that the other 90% of us are somehow unethical, incompetent, uneducated and don’t understand basic science.

    No, I am focused on a simple question: “What does it mean when someone has DC after their name?” You have failed to demonstrate any sort of uniformity in that, and assert without evidence that 90% of DCs are evidence based and limit themselves to adequate and accurate treatment of MSK disorders. You have also failed to address how you can ethically justify practicing that way, when it has been demonstrated that by all accounts, rules, and professional standpoints that is fundamentally different from the relevant accreditation and professional bodies of chiropractic.

    What is further bad science is evidenced by a few of the articles you presented in which effects of SM are studied without having first established their use in pathology. Chiros manipulate spines, so the research tries to find effects of SM and then fills it in with coincidental evidence of efficacy. This limited evidence is then used to assert the validity of chiropractic as a whole which, as it stands, is not correct. In other words, you have clearly demonstrated that a conclusion is made, and research is being to to try and support it.

    And you still haven’t addressed my hypothetical patient scenarios. However, perhaps a better question at this juncture is, do you think that chiros can adequately act as primary care providers? If not, then why do they have a license that legally allows them to do so?

    Oh and just to address a point you made in your most recent post:

    Yet some here are willing to believe in “osteopathic lesions”, “segmental blockage” and segmental spinal joint dysfunction

    No we aren’t. I think they are all the same garbage; or coincidentally correct with very limited application depending on your precise definition. Case in point:

    Remember that time when the APTA wanted to correct vertebral subluxations? It’s getting kinda messy now eh

    Not so messy. From your very own article:

    Physical therapists do not typically use the term subluxation, in part because the term is ambiguous and has a variety of different meanings. Medical dictionaries define “subluxation” to mean an incomplete or partial dislocation of a joint, and this is the definition that is generally accepted by physicians and most other health care

    Hence why I differentiate between orthopedic subluxation and vertebral subluxation theory – same as the APTA did. Be careful not to conflate things, NMS-DC. The term has become broadly used by chiros in order to maintain their conclusions and terminology once vertebral subluxation theory became a belief instead of actual science. When Congress approved medicare as payment for chiros they did so under the proviso that the subluxations can be demonstrated by x-ray to exist (once again from the same article you linked). In other words – orthopedic subluxations.

    So here we are, at the end of my long dissection. And I have demonstrated six things:

    1) There are certain interventions which chiros perform that, by accident, happen to work for actual disease processes.

    2) These interventions are limited to a very narrow spectrum of mechanical MSK pathology, which happen to overlap significantly with PT

    3) All bodies relevant to chiropractic licensure do not in any way enforce or define the limitation of the scope of practice of chiropractors to that narrow spectrum of evidence based practice

    4) Those chiros that do operate purely within the evidence based guidelines are doing so outside of the predominate professional bodies that represent them and thus cannot be accurately identified by their credentials alone

    5) There is no evidence that a chiropractor is sufficiently trained to act as a PCP, yet the CCE, ACA, and ACC all specifically state they can and should.

    6) Research specific to furthering chiropractics is, in large part, bad science since it takes the conclusions of chiropractics (MT and SM are useful) and then work backwords to try and show effects and utility.

  79. Quill says:

    NMS-DC states:

    …The profession is unique because it will be the first CAM profession to be integrated into mainstream health care over the next decade or two and it will set the template for other CAM professions to follow suit….

    This is encouraging as a chiropractic has stated that his profession is (a) definitely of the elastic world of CAM and thus not science based and (b) definitely not part of what most people call health care.

    Still no good answer to why the whole subluxation thing is still being mentioned in chiropratic colleges. You say that the Association of Chiropractic Colleges is, more or less, a trade group and state “The ACC paradigm doesn’t have any power with respect to outlining specific academic criteria. That is left to the CCE-US….”

    Ok then. So what exactly does the CCE-US have to say? In their current “Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status” dated 2007 they clearly state, as a requirement for any graduates of any accredited chiropractic institution that they:

    Develop a goal-oriented case management plan that addresses any subluxations or other neurobiomechanical problems….

    Also under “required clinical competencies” that “The student must demonstrate an ability to:”

    understand and select methods for evaluating posture, biomechanical function, and the presence of spinal or other articular subluxation or dysfunction….

    And:

    …select and effectively utilize palpatory and other appropriate methods to identify subluxations of the spine and/or other articulations….

    So by the most current definitions of the group you say is the authority for chiropractic in the US, they maintain not only a belief in subluxations but also require students to acknowledge, identify and treat them in order to graduate from their schools.

    This is not something antiquated or “out of the mainstream of chiro” or what have you but represents a significant part of the current thinking according to the body charged with maintaining educational standards. You can’t become a chiropractor at CCE-US schools unless you subscribe to the theory an practice of subluxations. Period.

    So windriven’s question to you “Can you explain the ethics of licensing a profession under a different pretense than the practice of that profession?” is answered. The answer is that the pretense has not changed despite recent attempts to claim it has.

  80. nybgrus says:

    Actually Quill those CCE standards are out of date. I address all of that in a post so long it has been held up for moderation.

    However, your point still stands quite nicely and my conclusions are the same. The difference in the latest CCE Standards is simply that it doesn’t mention subluxation theory explicitly. I address that as well.

    However, it is good to note that as recently as 2007 the CCE did include specific standards for subluxation.

    Of course, part of the issue at hand (which I also raise in my long post) is that subluxation is actually a medical term, and that chiros began using the terms interchangeably and vaguely so as to be able to say they are science based by using the medical definition when it suits them, but to then claim expanded rights to licensure, diagnosis, and increased scope of practice by utilizing the old framework of their profession which utilizes the old and non-science based version of subluxation without making that distinction. In other words having their cake and eating it too.

    But yeah, as soon as the comment comes out of moderation hopefully all that will be clear and addressed well.

  81. Quill says:

    Out of date, eh? Ah well. I was just going by what the CCE-US has published on their own website. I look forward to seeing what all you have to say about these things, especially their use of inexplicit language. I’m usually amused if not charmed when I see groups using “science-y” sounding language in an attempt to seem legitimate. At best they seem to have contracted a chronic case of Thesaurusitis and at worst I swear I can hear Orwell cursing.

    I looked up subluxation in the OED and was surprised to find its first recorded use was in 1688. Seems the chiro folks are missing out on the possibility of claiming “ancient knowledge” especially if they think stuff from 2007 is now “antiquated.” ;-)

  82. pmoran says:

    NMS-DC, you are puzzled as to why we are not impressed. I suggest that you are demonstrating how easy it is within medicine to find ways of sustaining pet beliefs.

    Clinical studies of procedural treatments like spinal manipulation are difficult — riddled with illusion and artefact, so you will always be able to find some studies that support efficacy over sham treatments with subjective and self-limiting states.

    So I ask, can SMT get patients with low back pain back to work quicker than other forms of management in a reasonably cost-effective way? Show me those studies! We tend to afford spinal manipulation some credibility in this area of practice, but the studies are not that impressive. Perhaps only a small subgroup of LBP patients do respond to it . Have chiropractors tried to find out which they are? Not to the degree that you would expect of a supposedly scientific profession.

    I put it to you that neck manipulation has not been shown to be definitely superior to other manual therapies for anything and it has at least the potential risk of causing stroke. Why would we respect a profession that continues to use it as the first line of treatment for a wide range of conditions? I would like to see some samples of studies showing that SMT is uniquely effective for something.

    “Pseudo-validation” is also possible with laboratory studies, so I am not sure why we are supposed to be impressed by DCs being involved in those — typically someone will wrench some poor animal’s spine and find autonomic effects that could have been equally produced by injury to any other joint, or pressing on the eyeballs, or squeezing the testes. This is then held to support the peculiarly chiropractic view that subtle, undetectable spinal lesions can produce illness through chronic neural imbalance but can be miraculously relieved by spinal manipulation that puzzlingly seems to work whatever joints are manipulated and no matter how dinky are the toys employed to do so. Show me some money in this arena, also.

    I personally don’t care what a professor of neurology says if neither of you can produce better evidence than we have yet seen from the chiropractic profession and some attempt at establishing scientific order out of what looks ot the outsider like quacky chaos.

    We are not just being bloody-mindedness. We have our own experience of a wide variety of spinal traumas, deformities and diseases without ever seeing “chiropractic” effects, also considerable experience of anatomy, neurophysiology, cutting autonomic nerves, blocking them with drugs and also our own studies of their effects. So to our mind your hints of big things to come in that arena are overly optimistic if not naive and self-servingly pretentious.

    There simply is no disease, injury or animal model that demonstrates anything approaching the “manipulable lesion” of chiropractic. There never was, in reality, a sound basis for such a hypothesis, not for the original BOOP model, nor any of the conceptual evolutions that have been forced upon it since.

    This is why we still find it difficult for us to take chiropractic science too seriously.

  83. nybgrus says:

    @Quill:

    I say out of date becaue NMS-DC linked me to the CCE from 2010 and Sam Homola has also reviewed the same document. Why the 2007 version is still there is beyond me. But it further lends credence to fact that the chiropractic profession is simply not uniform and has no real standards or description of scope of practice or methodology.

    @pmoran:

    Here, here. I said essentially the same thing in my long post still awaiting release, but with much more verbiage and referencing essentially everything NMS-DC stated as his evidence. It didn’t hold up very well. I would add to your tidbit about wrenching an animals back that another tack employed by NMS-DC (perhaps unwittinglly) was to demonstrate good science in fields other than chiropractic done by chiropractors as some metric of legitimacy. It isn’t, and as you said, he needs to show us the money instead of finding all sorts of isolated and tangentially related facts and hoping they add up to proof positive for chiropractery.

  84. marcus welby says:

    NMS-DC: I smile each time I read the use of the term “manipulable lesion” …..and I am serious in this question…do you have any better definition for “manipulable lesion” than “whatever I can get my hands on”…? Remember, we are science-based here, and that means we need to make a diagnosis where possible.

  85. NMS-DC says:

    @nybgrus et al.

    Thank you for your detailed responses (especially you nygbrus). Given that it is a work week and have to attend to practice and family matters I won’t be able to reply in detail at this point, but just wanted to let you know that I’m not running away from this thread There are some excellent questions raised, and they require detailed answers. I appreciate the overall tone of this thread, this is good debate. I think we can find some middle ground. Goodnight!

  86. Quill says:

    @ nybgrus:

    Thank you for the longer reply (the one that escaped the moderation queue.) I think you did indeed demonstrate those “six things” in a perfectly clear, unambiguous and unarguable way. Should be interesting to see what happens next.

    While we’re waiting (and apologies if this has been posted before) I hope y’all have seen the very talented comedian Eddie Izzard’s routine in his show “Dressed To Kill” where he talks about having to go see a chiropractor after a skiing accident:

    http://www.youtube.com/watch?v=mUwnkTnHrtI

  87. nybgrus says:

    @NMS-DC:

    As I’d said, and JPZ reinforced quite nicely – bring the science and the proper rhetoric and receive in kind. However, do beware the fallacy of the golden mean. Just because you and I have different opinions on something does not mean the answer lies somewhere in the middle.

    Also, to prevent this from ballooning into posts of cosmic proportions, perhaps focusing in on just a few things would be good. Like the notion of chiro as PCP, the uniformity of education and standards, and the training that would enable a chiro to diagnose non-MSK pathology and differentiate it from actual MSK pathology, especially when serious and can easily be mistaken for one another. From there, further discussion into the scope and role of chiropractics in health care is possible, but not before then.

    @Quill:

    Thanks for the kind words. It could have been better, but it did take me a while to read all that, write the response, and I was not about to spend time editing it after that. I figured the point was made reasonably well. I also am curious as to the response from NMS-DC. I’ll reserve any predictions since I think we all know what they are anyways.

    Also, I love Eddie Izzard. I have seened Dressed to Kill more times than I can count, but thanks for the reminder on the chiropractic bit. It gave me a nice nostalgic chuckle.

  88. pmoran says:

    NMS-DCRegarding stroke and neck manipulations, the gold standard, in terms of literature is the 2008 WHO Joint Task Force in Neck Pain. The summary can be found here. http://bit.ly/90deAm In plain English is that there is no difference in stroke rates in those who present to chiropractic doctor or a medical doctor. But, again, it’s an important issue and since DCs delivery 90% of SMTs it patient safety in all manipulative procedures is imperative, particularly for chiopractors. So, a 5 year study is being done presently with investigators coming from various disciplines like medicine, chiropractic, osteopathy and physical therapy. http://bit.ly/pBfyqB.

    Sorry, I missed this before. In equally plain English, the authors of the Cassidy study (the primary source of the data purported to show no difference in stroke rates) said “Our results should be interpreted cautiously and placed into clinical perspective. We have not ruled out neck manipulation as a potential cause of some VBA strokes.

    That study actually confirmed precisely what many other studies and anecdotal reports were suggesting — that strokes from vertebral artery dissection in younger patients were very strongly associated with chiropractic visits.

    All this study showed was a new association with doctor visits, which, of course, lacks the same plausible causal connection that neck manipulation has with vertebro-basilar stroke.

    i think that is probably due to paient self-selection. This patient population is 7-8 times more likely to consult a doctor than a chiropractor in any given month about anything, and almost certainly even more so with worrying symptoms, such as the unusual upper cervical pain +/- neurological symptoms of early vertebro-basilar stroke. There may be many other possible confounders in this unusual study design (unusual in that the influence being investigated cannot be directly controlled for.).

    The WHO task force (yes, I have read that paper, too) concluded that neck manipulation was not obviously superior to four or five other methods of managing neck pain. These others should not cause cause stroke, while also having less risk of aggravating neck pain as manipulation not infrequently will.

    Chiropractors should not be feeling too comfortable about their informed consent obligations in this matter. The truth will out.

  89. jhawk says:

    @nybgrus

    I would like to try and answer some of your questions presented to NMS-DC. Hopefully this is ok with you.

    Chiro as PCP: Chiropractors are technically considered PCP’s but the majority practice as portal of entry NMS physicians becasue of our training and education specialize in this area. Also, the public views us as back specialists or back crackers (or back quacks!) and so this becomes our patient population.

    Uniformity of education: Some schools are better than others as in all professions but all chiro students must pass all four parts of the national boards as well as be licensed in their chosen state of practice. There is a minimum of 4200 student/teacher contact hours while in school. As we all know, once you have your degree and license whether it be an MD, DO, DC, OD, DDS, etc. one can go in all directions (emperical evidence outweighs clinical decision at all costs to I haven’t read a research article since I graduated). I think the fringe tends to stick out more than the majority in all professions in this repsect.

    Dx non-MSK pathology: Most important part of this equation is to take a complete health history looking for red flags such as pt over 50, constitutional sx (fever,fatigue, wt loss, loss of appetite, malaise) prev hx of cancer, severe trauma, drug use, Bowel/bladder function changes, non responsive to Tx, etc. If these occur then the next step is either referring to PCP or specialist (my preference) or ordering lab, films, special imaging. This is a very important process to catch those with a sinsiter pathology but it must be noted that less than 2% of patients presenting with back pain have sisnister pathology (AHCPR guidelines).

    I hope this answers some of your questions.

  90. nybgrus says:

    @jhawk:

    It does… but not really.

    Look at what you are saying.

    Chiro as PCP: Chiropractors are technically considered PCP’s but the majority practice as portal of entry NMS physicians becasue of our training and education specialize in this area. Also, the public views us as back specialists or back crackers (or back quacks!) and so this becomes our patient population.

    So in essence, you are supposed to be PCPs by training and license, but you aren’t really since thats what you aren’t used for so it is OK.

    That doesn’t reconcile the fact that you are practicing in a manner inconsistent with with your training and licensing. It is just a fudge saying that it really isn’t that big of a deal because it just doesn’t come up that often. The question is not “Does you patient population make it OK?” but “Does your training and expertise fit your licensure?” The answer is still no.

    there is a minimum of 4200 student/teacher contact hours while in school.

    There is at least that minimum in medical school plus a multi-year residency afterwards. To be a PCP requires at least an additional ~8,000 hours of training.

    As we all know, once you have your degree and license whether it be an MD, DO, DC, OD, DDS, etc. one can go in all directions (emperical evidence outweighs clinical decision at all costs to I haven’t read a research article since I graduated).

    One can go in all directions? What does that mean? I can go into any specialty I want and I were Andrew Weill or Deepak Chopra I can go off the deep end as well. But I’m not sure what you mean.

    And “empirical evidence outweighs clinical decision at all costs” – also not sure what that means. Empirical evidence (aka scientific evidence) should guide clinical decision at all times. Also, you are using the fact that you haven’t read a research article since you graduate as a…. positive? What is your point there? Because it certainly isn’t a feather in your cap.

    Physicians must complete continuing education to maintain licensure. I’d be willing to bet more of it and more rigorous than DC’s do. Have any data on that for me? (not that it would really matter since DCs don’t do a residency after schooling anyways, but for curiosity sake).

    I think the fringe tends to stick out more than the majority in all professions in this repsect.

    I’m not talking about the fringe in chiro. I am talking about what it means to actually have a DC after your name. On the one hand it claims right to act as PCP and diagnose and treat. On the other, the training is vastly less than a physician. Also, you and NMS-DC are claiming that you focus on MSK issues and evidence base (which pmoran also demonstrated is weak at best). Yet that doesn’t address how I can differentiate that from DC’s who don’t. You mention specific licensing exams, yet I haven’t seen documentation for standardization of that. For MDs we need to sit the USMLE Steps 1,2 and 3. Those are uniform and test the same core knowledge across the entire profession. There is not a similar starting point for DCs. Yes, anyone can go off the rails after their degree. But I am talking about getting it in the first place and where the evidence is that DCs have sufficient training to act as PCPs. I have yet to see any.

    Dx non-MSK pathology:

    The CCE guidelines don’t have these in place as requirements. Your own list was very cursory, but of course this is a blog comment. But the ACA and ACC each demand that subluxation theory be the foundational basis of diagnosis and treatment in chiropractics. I have yet to see anyone here reconcile that with the claim that DC is limited to MSK disease and are qualified to act as a primary portal of entry for patients.

    Everything has demonstrated non-uniformity and vague guidelines such that if you were take a room of 1,000 DC’s you would have no possible way of knowing who would be trained to use vertebral subluxation theory as the basis of pathogenesis. Furthermore, the amount of training is not sufficient for adequate and accurate diagnosis as a PCP. Everything demonstrates quite clearly that the area and specific pathologies amenable to chiropractic treatment are extremely narrow in scope and very similar to PT.

    So no, I am sorry, but this does not really answer any questions nor demonstrate at all why a chiro is fundamentally different from a PT (if she/he follows the evidence base), why any chiro should have the privilege of being a PCP and the right to diagnose, especially non-MSK pathology, and even that the evidence base for chiro that is within that narrow scope is weak at best.

  91. jhawk says:

    @nygbrus

    “You mention specific licensing exams, yet I haven’t seen documentation for standardization of that. For MDs we need to sit the USMLE Steps 1,2 and 3. Those are uniform and test the same core knowledge across the entire profession. There is not a similar starting point for DCs.”

    Chiropractors take national boards parts 1,2 and 3 written and part 4 practical. Check out nbce.org. (national Board of Chiropractic Examiners)

    “Physicians must complete continuing education to maintain licensure. I’d be willing to bet more of it and more rigorous than DC’s do. Have any data on that for me?

    This differs from state to state but most states require at least 12 hours per year.

    What I meant by you can go in any direction you want is exactly what you first thought with the Andew Weill comment. Lots of doctors in all professions using many treatments that are evidence based and non evidence based and the fringe tend to get the press.

    “Also, you are using the fact that you haven’t read a research article since you graduate as a…. positive? What is your point there? Because it certainly isn’t a feather in your cap”

    definitely not what I meant to say. I meant there are docs with all licensures that give treatment that is not evidence based. There is a “to” placed in the sentence to show polarities of evidence used in practice.

    Thanks for your comments and I will get to the rest of your rebuttal at a later date.

  92. JPZ says:

    @jhawk

    The phrases you use are difficult to follow. Is English your second language? I only ask because I can easily understand the difficulty of expressing concepts in another language (I speak a couple), but obtuse language from a native speaker is another thing.

    Did NMS-DC contact you to provide a comment here? I have no problem with that, honestly. I think that all comments are welcome here (but I am not a moderator), but it would be good to know if you are speaking on behalf of someone else. It would not take away from your comments in the least (at least on my part), but I personally would like to understand the connections between commentators. For example, I do not know the commentator Angora Rabbit personally (at least I don’t think so), but I imagine, based on previous comments, (s)he and I run in the same scientific circles and probably attend the same conventions. It would be easy to assume we are somehow connected, but we are not (as far as I know).

    Thank you for commenting on SBM!

  93. nybgrus says:

    Chiropractors take national boards parts 1,2 and 3 written and part 4 practical. Check out nbce.org. (national Board of Chiropractic Examiners)

    I’ve checked it out. Interestingly enough, there is an “optional” exam on acupuncture certification as well.

    Additionally:

    Part II includes:
    General Diagnosis
    Neuromusculoskeletal Diagnosis
    Diagnostic Imaging
    Principles of Chiropractic
    Chiropractic Practice
    Associated Clinical Sciences

    [emphasis mine]

    Principles of Chiropractic. What could that be? Following the link for recommend texts we find:

    Gatterman, M. I. (Ed.) (2005). Foundations of Chiropractic: Subluxation (2nd ed.). St. Louis: Mosby.

    Which is a textbook precisely on the verterbral subluxation theory of chiropractics. And indeed, a review that references Gatterman (since I couldn’t quickly find a free online copy of the text itself) states:

    Currently, however, the foundations of chiropractic research are growing, and chiropractors are increasingly recognizing the need to contribute to the scientific knowledge base, examining basic mechanisms of subluxation pathology, manifestations of the “subluxation syndrome”, [83] and the processes involved in correcting these lesions.

    And from the NBCE brochure we see that subluxation theory forms 30% of the “Principles of Chiropractic” section on the exam. It also listed as the number one section under “Applied Chiropractic Principles” (which is 32% of the section) as “subluxation etiologies.” And that these are based on Gatterman’s text as it is referenced at the end of the document (I’ll link the reference in a separate post so it doesn’t get held up in moderation).

    This does not seem to help that case that NMS-DC and RWK have been making that subluxation theory is a “fringe” practice and that “nobody puts a gun to [their] head and makes them swear allegiance to subluxation theory.”

    It also further beggars the question – how can you justify practice with is different from your licensing?? Can any of the chiros here please just answer that question?

    I also registered for practice tests, but they want me to pay to get the sample questions. I’m tempted to do so since it is only $15, but the reality is I don’t think I need to further demonstrate that chiropractics, despite NMS-DC’s claim, is fundamentally based in subluxation theory – not just the “fringe.”

    This differs from state to state but most states require at least 12 hours per year.

    So without a residency and with only 12 hours per year of CEU’s we are expected to accept chiros as PCPs?

    What I meant by you can go in any direction you want is exactly what you first thought with the Andew Weill comment. Lots of doctors in all professions using many treatments that are evidence based and non evidence based and the fringe tend to get the press.

    And guess what happens to those MDs? They get written about and lambasted here. But the key difference is that our training is not based in such off the rails theory. Chiropractic is. You guys have to go through your education and then get on the rails. So I think your point fails here.

    And once again I’ll ask – since you start out off the rails, how can I know which person with DC after their name follows a solid evidence base? Do you see how the question and assumptions here are fundamentally different? With MDs you have to watch out for the fringe quack like Weill. With DC you have to try and find the ones that aren’t ascribing to quackery.

    I meant there are docs with all licensures that give treatment that is not evidence based.

    Fair enough – it wasn’t clear. I’ll give you the benefit of the doubt, but your point is still not solid. I’m getting tired of driving the point home again and again, so I’ll leave it at the fact that you have made a tu coque argument, which is fallacious.

    Thanks for your comments and I will get to the rest of your rebuttal at a later date.

    I look forward to it. And NMS-DC. Lets see if you (both) follow through.

  94. nybgrus says:

    Here is the link to the brochure I referenced above

    Also, I happened to notice that chiropractic is specifically tested for and has texts written on pediatric chiropractic. How many children have chronic lower back pain that needs treatment like that? It is a minor point in context of the whole thing, but it seems to me that seems relatively counter intuitive. I have also seen and heard stories of chiros practicing on infants. I can’t possibly imagine the justification for that. There is even a group that specializes in prenatal care and pregnancy. That doesn’t seem to fall in with the MSK focus of chiro.

  95. nybgrus says:

    dangit. Meant to have this in my last post and forgot. My apologies for spamming 3 comments in succession

    Also of note is that the term “diplomate” can no longer be used to describe a licensed chiropractor (according to the NBCE since 1983).

    Diplomate means:

    One who has received a diploma, especially a physician certified as a specialist by a board of examiners.

    Yet they can only claim “attainment”…. even though they still claim they want to act as PCPs, call themselves “doctor,” and diagnose, treat, and refer.

    I still have yet to see any justification for this. I’m wondering how many more nails I can fit into this coffin as I keep getting to smaller and smaller ones just to make them all fit.

  96. marcus welby says:

    A minor point, but please don’t equilibrate chiropractic with physical therapy. As noted in a prior comment, physical therapists are trained in a number of useful science-based rehabilitative methods and never to my knowledge utilize the dangerous high velocity neck cracking maneuver. Having taught a number of years at a PT school, I am aware of their curriculum and experience in hospitals and clinics. Chiropractic is more about marketing their spinal beliefs for treatment of subjective pain (which cannot be objectively measured by any known method) and for “maintenance of spinal health” which has no demonstrated supportive evidence. Agree there should never be chiropractic adjustment in children or obstetrics. Chiropractors have essentially no training in rehabilitation, gait training, wheelchair use, transfers, etc. as listed above.

  97. nybgrus says:

    I apologize for the equivalence Marcus. It really wasn’t intentional.

    My point was to state that those chiros who state they follow strict evidence base for MSK issues have effectively limited themselves to overlapping with much of what PT is. I agree that PT is significantly more than chiro (though of course chiros would say they are significantly more than PT but that bit is what is mostly woo).

    In my recent research, it seems that chiros are actually taught micro, some pharm, some physiology which to my understanding is more than what PTs are taught. However that knowledge is effectively useless since they clearly hinge much of their thought processes on subluxation theory and what knowledge they do have is insufficient to act as a PCP. So in essence it doesn’t really count for anything useful.

    The two main points I have been trying to make are that chiros are not equipped to be PCPs or diagnose disease and that the limited part of their practice that does actually have an evidence base (which would not include high velocity maneuvers) overlaps significantly with PTs. Well, that and the fact that subluxation theory is not the fringe of chiropractic – something I thing I have very adequately demonstrated.

  98. rwk says:

    @nybgrus
    I don’t mind well researched criticism. It even sounds as you’ve softened up a little. But some of these of the
    people on the anti-chiropractic side are way off and no one ( like yourself ) calls them on their errors.
    Marcus Welby says
    As noted in a prior comment, physical therapists are trained in a number of useful science-based rehabilitative methods and never to my knowledge utilize the dangerous high velocity neck cracking maneuver.

    What?
    http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Manipulation/WhitePaperManipulation.pdf

    And MW claims to have taught PTs?

    Even Jann Bellamy has acknowledged that PTs do HVT techniques.

    I’ll say some PTs do,some don’t. It depends on the state they practice in.

    If SBM participants want to have an honest dialogue with the DCs that have come to this site to foster understanding you have to be fair.

  99. Quill says:

    @rwk: if you’re going to post links citing a position, you might want to cite something that doesn’t further erode the credibility of those “DCs that have come to this site” for whatever their reasons. From the summary section of that paper:

    Based on the coordinated, strategic chiropractic legislative activities during the past 20 years, it is clear the chiropractic profession has established a national agenda to prevent PTs from using TJM. Their claims that PTs are not adequately trained and that patients are at risk receiving TJM from PTs have no factual basis. The practice of TJM by PTs is based on research evidence and is just one intervention among many used by PTs to relieve pain and restore function.

    Ironically, having yet another paper citing groups of chiropractors making yet another set of claims with “no factual basis” is certainly not “way off” by any measure but rather a continuing trend.

  100. marcus welby says:

    I stand corrected on PT’s sometimes doing neck cracking. I have stated here on comments previously that MDs in Germany have been guilty of causing strokes by neck cracking and now you have shown that sometimes, in some states, PTs are using this dangerous technique. I am enlightened. Yes, taught a 2 month course meeting 3 times a week for over an hour on orthopedics for PT and OT students. Was not aware of any neck cracking by them and have not ever encountered such in practice.

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