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135 thoughts on “The Cure

  1. rwk says:

    @Quill
    The purpose of the link was to point out that PTs can and do perform high velocity thrust technics.
    Period.

  2. NMS-DC says:

    @pmoran

    Strongly associated with does not equal causation. The five year SMT safety study will likely prove to be the gold standard in this area. Until then, I’m comfortable with the research, and I use my clinical judgment if, who and when I do upper cervical manipulation.

    The WHO paper also said that neck manipulation was safe. And SMT may be no better but its just as effective. And, as a clinician who works on necks and back all day long, I can tell you from my experience that some patients benefit moreso from mobilization, others from adjustments, others from soft tissue work (all in conjunction with exercise).

    @Nybrgus

    RE: PTs manipulating subluxations. The APTA tried, and no, they were refering to vertebral joint dysfunction, i.e. vertebral subluxation not the orthopedic type. You know as well as I do you’re not going to manipulative a partially dislocated joint which is partially unstable. In fact, instability is an absolute contraindication to SMT.

    “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.”

    RE: 90% of visits for DCs for MSK-related complaints source

    Haldeman S, Underwood M (2010) Commentary on the United Kingdom Evidence
    Report about the Effectiveness of Manual Therapies Chiropractic & Osteopathy
    18:4 (25 February, 2010).

    RE: PCPs: primary care, portal of entry provider: PCP means direct access and abiility to diagnose. I diagnose MSK disorders and rule out issues that are not amenable to chiropractic care. I have to be able to perform a reasonable DDx, but in MSK. I’ve caught cases of cholelithiasis and knew that their right infra-scapular pain wasn’t costo-vertebral joint dysfunction or serratus posterior superior trigger point. That’s my job.

    RE: Overlap with PTs. Two points. 1) Not moreso than MD and DO in the States. 2) DCs are hands on body mechanics, with a holistic viewpoint, addressing primarily MSK disorders. That’s not PT. 3) PTs as a profession aren’t all in the ortho-MSK branch, as I’ve mentioned before there’s other branches (neuro, cardiopulmonary) in specialization. And if the outcomes for PT or MD in dealing with MSK, especially spine were that great there would be no patient-driven need for DC. Also patient satisfaction with DC care surpasses MD or PT care. In summary: DCs are experts in SMT and manual therapy. We provide over 90% of manipulations in North America. If one profession is doing 90% of a service and are considered to be experts at it, and its proven to be effective, why would they be “duplicated”? Not going to happen.

    RE: Scope of practice is defined on a state by state, provincial level. If you refer back to my post regarding focus/clinical competencies it focuses on NMS diagnosis and NMS management.

    RE: DCs who do not focus their practice primarily on MSK are practicing in the fringe, anyone who is practicing within MSK realm is practicing contemporary chiropractic medicine. The evidence will bear out what, if any, non-msk responds to manual or holistic interventions. Until then the evidence is low and treatments in these cases are experimental. We agree.

    Re: Reseach investigating the effects of manipulation and manual therapy, and its effects on the neurological isn’t bad science so long as it’s not bad methodology with bad hypotheses and bad conclusions. Developing a broader knowledge base in the basic sciences of manipulation is not bad science. It’s just scientific investigaton plain and simple.

  3. NMS-DC says:

    @nybrgus

    “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.

    PCPs/portal entry for MSK. Direct access. That is what PCP means (legislatively where I’m from). You don’t need a referral to see a DC. PTs (vision 2020) are trying to get this access too. It’s reasonable. Public should have equal access to PT, PCP/portal entry.

    RE: Studies showing effectiveness, cost effectiveness circa 2009:

    Do Chiropractic Physician Services for Treatment of Low Back and Neck Pain Improve the Value of Health Benefit Plans?

    Direct quote:

    1) Chiropractic care is more effective than other modalities for treating low back and neck pain
    2) When considering cost effectiveness and cost together chiropractic physician care for low back and neck pain is highly cost effective. represents a good value compared to medical physician care

    Source: http://bit.ly/rVmum3

    SBM is not informed on contemporary chiropractic practice. I’m here to help bridge the gap and prevent the spread of misinformation, acknowledge gaps in professional practice and literature, and overall debate with skeptics collegiately about the science and practice of contemporary chiropractic.

  4. nybgrus says:

    @ rwk:

    It even sounds as you’ve softened up a little

    No I have not. I still find no reason for chiropractors to exist, especially in their current form.

    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.

    Any such errors are immaterial to the main crux of the discussion. Such as my admittedly poor analogy to PTs. That has been used as a rhetorical device and not an actual point of discussion re: chiropractic. Yet, as we can see everyone seems to focus on that. I have learned my lesson and will completely eschew the point of PT from now on since it is completely immaterial to the discussion.

    The purpose of the link was to point out that PTs can and do perform high velocity thrust technics.
    Period.

    The purpose of the link was to provide a tu coque argument and further distractor from the core issue at hand. Period.

    Strongly associated with does not equal causation.

    Strongly associated + high degree of plausibility + paucity of evidence for efficacy of manuever = shouldn’t be used.

    In fact, instability is an absolute contraindication to SMT.

    And yet you quote at me the fact that congress allows for medicaid/medicare reimbursement for chiro manuevers as evidence for the utility and efficacy of chiro. Yet the specific wording was such that it must be a subluxation visible on xray which you are now saying is a contraindication for SMT.

    Thus further demonstrates my point that the entirety of the profession uses the term “subluxation” loosely and changes the precise definition depending on context in order to maintain their perceived validity.

    RE: 90% of visits for DCs for MSK-related complaints source

    That is not what you have been saying. You have said that:

    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.

    Once again you are switching around and conflating things. This further falls into the category of argumentation that jhawk attempted – that your patient base makes it OK that you practice the way you do. That is not of interest in this discussion.

    I diagnose MSK disorders and rule out issues that are not amenable to chiropractic care. I have to be able to perform a reasonable DDx, but in MSK. I’ve caught cases of cholelithiasis and knew that their right infra-scapular pain wasn’t costo-vertebral joint dysfunction or serratus posterior superior trigger point. That’s my job.

    Yet it still has not been established that 4200 hours of training is sufficient to act as a PCP. I get that “it is your job.” I am claiming that you are not trained well enough (especially compared to the ~15,000 hours minumum for an MD to perform the same job) to act as PCP.

    RE: Overlap with PTs.

    I agree to let this one drop. It is distracting and completely pointless. Address the material issues I have raised re: the training, licensing, and examination of DCs. In particular the fact that while you claim that chiro is not based on vertebral subluxation theory your licensing exam still tests you on it in order to grant licensure.

    If one profession is doing 90% of a service and are considered to be experts at it, and its proven to be effective, why would they be “duplicated”?

    I have yet to see that it is “proven effective.” And just because 90% of a service is delivered by people considered to be “experts” at it means nothing. Acupuncture comes to mind, so does homeopathy. Those are both services provided by “experts” and each has a plethora of data attempting to prove efficacy… yet they are both BS. Chiro in this case is “duplicated” because the only bits that actually are of utility are so small that it makes more sense to absorb them into PT than maintain an entire profession that fancies itself a physician, diagnostician, and PCP.

    Scope of practice is defined on a state by state, provincial level. If you refer back to my post regarding focus/clinical competencies it focuses on NMS diagnosis and NMS management.

    That is my point – there is no uniformity in scope. And also, according to your own licensing exams it does not limit itself to MSK. Obviously the focus is there, but it is expected that you should also be able to see and treat children and infants. That makes no sense whatsoever.

    DCs who do not focus their practice primarily on MSK are practicing in the fringe, anyone who is practicing within MSK realm is practicing contemporary chiropractic medicine.

    But your own frakkin licensing exams and basic competencies include these “fringe” practices! It cannot, therefore, be considered “fringe.” And by doing otherwise, you are demonstrating yet again that you act in a manner discordant with your training and licensure. You are failing to make compelling arguments.

    Reseach investigating the effects of manipulation and manual therapy, and its effects on the neurological isn’t bad science so long as it’s not bad methodology with bad hypotheses and bad conclusions.

    It is bad science. You are taking the conclusion that SMT “works” and then finding data to support that. First you must establish that SMT has utility – which has yet to be adequately demonstrated. Then work from there. Sorry, but it is still bad science.

    Chiropractic care is more effective than other modalities for treating low back and neck pain
    2) When considering cost effectiveness and cost together chiropractic physician care for low back and neck pain is highly cost effective. represents a good value compared to medical physician care

    This proves nothing. As we have demonstrated acupuncture is also pretty cost effective and on par in terms of effect size. Yet that is BS too. And why would we have an entire profession built around the cost effectiveness of a single intervention?

    SBM is not informed on contemporary chiropractic practice.

    I can only laugh at that, as I have managed to demonstrate that you are not informed on the realities of your own practice.

  5. rwk says:

    @nybgrus
    I’m trying to figure out how much of your last post was directed at me as all I was pointing out was that
    PTs do perform High Velocity Low Amplitude thrusts. One of the commentators emphatically stated they wouldn’t
    dream of doing such a thing.

  6. pmoran says:

    I’m trying to figure out how much of your last post was directed at me as all I was pointing out was that
    PTs do perform High Velocity Low Amplitude thrusts. One of the commentators emphatically stated they wouldn’t dream of doing such a thing.

    Some orthopoedic surgeons perform spinal manipulation (SMT), neck manipulation, also, even (horrors!) under anaesthesia. I once worked with one that did. To my mind, it is not that difficult a procedure unless you buy into fancies concerning identifying and correcting specific subluxations. Chiropractors have produced little evidence that technique matters.

    How effective SMT is other than as a popular placebo is still uncertain. I accept that there may be a small subgroup of patients who are especially responsive to it but overall the evidence is weaker than chiropractors make out.

  7. pmoran says:

    .RWK: 1) Chiropractic care is more effective than other modalities for treating low back and neck pain
    2) When considering cost effectiveness and cost together chiropractic physician care for low back and neck pain is highly cost effective. represents a good value compared to medical physician care

    Source: http://bit.ly/rVmum3

    That paper refers to a single study suggesting that mobilisation (” — low velocity passive movements within or at the limit of joint range of motion”) is helpful with neck pain. It specifically precluded the use of neck manipulation: “Spinal manipulation (low amplitude, high velocity techniques) was not provided”.

    So this, too, provides no support for a procedure that may rarely cause stroke, and also no support for any “chiropractic” tradition.

    It found only one study among many that suggested that spinal manipulation was cost-effective for low back pain. Presumably cost-effectiveness will depend upon local circumstances, and the study design does not preclude placebo responses, other non-specific influences or reporting biases as being responsible for the benefits shown.

    I don’t mind that to a degree, but more rigid styles of EBM/SBM probably should object, giving a higher value to recent Cochrane reviews suggesting that spinal manipulation is of little intrinsic worth.

  8. nybgrus says:

    @rwk:

    I’m trying to figure out how much of your last post was directed at me as all I was pointing out was that
    PTs do perform High Velocity Low Amplitude thrusts.

    It is addressed at any chiro here. None of you can address my points in any reasonable fashion. Every single one spends time nit picking irrelevant details. The big questions haven’t been answered. It is tooth fairy science to the max.

    I don’t even have to get to the actual robustness of the limited evidence base to demonstrate chiropractic is fatally flawed. Pmoran is taking is one step further and demonstrating there really isn’t much use and definitely no validity to it.

    There has yet to be any meaningful refutation of that from anyone here. There also has yet to be any acknowledgement of the abysmal state of chiropractic nor any call for meaningful advancement.

    I won’t hold my breath.

  9. jhawk says:

    @nybgrus

    Regarding the nbce exam you said 30% of one section and 32% of another section focus on subluxation theory. Parts 1,2 and 3 have 1460 questions, your 30 and 32 percent add up to 68 questions which is less than 5% of the exams. It is actually less than 5% when you add in part 4 which is the practical portion but I could not find how many questions were asked. The chiro fringe take this 5% as important and the rest do not.

    you said: “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 understand you have an opinion that chiro’s are not educated enough to act as PCP but the regulatory boards and licensing agencies disagree with you and license chiro’s as PCP’s. Since NMS conditions are within our scope of practice, we can legally specilaize in them.

    you said: “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. ”

    See above, under 5% is considered of the rails. For what is worth, my school did not have a class on any of this 5%. We used a board review book to get this info and then purge it.

    you said: “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. ”

    Once again for the rails see above. As to how do you know which DC follows the evidence. This is simple, it is the same as you finding a competent MD, DO, DDS, PT in your area. You see who sends referrals and letters to you. You ask other MD’s in your community. You ask your patients. I sure as hell do not refer my patients to an MD just becasue they have an MD behind their name. I have to make sure that MD, DO, DDS, PT is good at what they do not just that they have had an education that puts letters behind their name.

  10. jhawk says:

    @ JPZ

    English is my first language so I guess I am obtuse! Also, NMS-DC did not contact me and I have no idea who he is.

  11. rwk says:

    @jhawk and MSK-DC
    It’s obvious that we’re wasting our time here. People like nybgrus who are book smart because they’re still
    in training aren’t the slightest bit interested in what we are saying. It’s all sport to them. They keep saying the same things including gross errors without ever correcting themselves. But then, they know our profession better than we do! Beware.

  12. pmoran says:

    Nybgrus:Pmoran is taking is one step further and demonstrating there really isn’t much use and definitely no validity to it.

    I am not being so dogmatic, Nybgrus. I have allowed that spinal manipulation may be of value to patients “as a popular placebo”, also that there may be a “small subgroup of patients with low back pain” who are especially responsive to it. Both possibilities are consistent with the available evidence.

    That is still a weak basis for the existence of a whole profession, especially with neck manipulation being under a cloud and not desirable as the first line of treatment for anything.

    Evolving into physical therapists does not really solve any of chiropractic’s future problems. It merely pits them against a mainstream group that is equally capable of learning to manipulate backs should that find a more secure place within standard practice.

    Chiropractors have a rosier future either as they are now, as basically, “mainly CAM with chronic but futile mainstream pretensions”, or in vastly reduced numbers as moderately credible low back pain specialists.

    It is not doing chiropractors a kindness to hold out any hope at all of their field ever being likely to be accepted as a fully fledged evidence-based area of medicine. Also, well-trained MDs make enough errors in diagnosis and treatment that no one anywhere should ever dream of ever actually reducing the training requirements for unsupervised primary care medical practice. Primary care looks easy to chiropractors and naturopaths, but it is in reality one of the more difficult fields of medicine.

    It is understandable that those who have invested most of their lives in chiropractic might interpret the evidence to their own advantage. Chiropractors have all my sympathy when they are honest and sincere about what they do — not so much when they want to be regarded as evidence-based without doing the hard yards. They need to be much more ruthless when evaluating the evidence; they need to go to primary sources and not trust
    their own propagandist’s versions of the evidence.

    They also need to understand the biases that inevitably exist within the evidence base itself. We in the mainstream have had that thrust down our throats recently, haven’t we?

  13. nybgrus says:

    @jhawk:

    Regarding the nbce exam you said 30% of one section and 32% of another section focus on subluxation theory. Parts 1,2 and 3 have 1460 questions, your 30 and 32 percent add up to 68 questions which is less than 5% of the exams. It is actually less than 5% when you add in part 4 which is the practical portion but I could not find how many questions were asked. The chiro fringe take this 5% as important and the rest do not.

    You want to know how much of my licensing exams are based in magical thinking and disproven BS? Zero.

    No one here has been able to address why your licensing and basic practice principles are based in magical thinking, but it is OK for the so called “90%” to practice otherwise and that’s ok. Once again, I’ll re-iterate:

    If my medical school taught me the homeopathy was valid or that the germ theory of disease was BS I would leave that medical school.

    I understand you have an opinion that chiro’s are not educated enough to act as PCP but the regulatory boards and licensing agencies disagree with you and license chiro’s as PCP’s. Since NMS conditions are within our scope of practice, we can legally specilaize in them.

    And hence the legislative alchemy series. Do you not understand that legislation and licensing agencies mean nothing without the actual science to back them up? The entire purpose of Jan’s series was to demonstrate that since chiros cannot gain legitimacy via actual science they do so via legislative means by duping stupid lay people into believing the mumbo jumbo.

    And you can specialize in NMS? Fantastic. How in any way does that enable you to be a PCP? As a physician friend said to me last year when I was a touch overwhelmed by how much I had to learn, “Become a specialist, that way you don’t have to know as much.” Pmoran said it well – being a GP/PCP is very hard to do well because you have to know so much about so many things! Having less training, part of which (and the fundamental basis of which) is in magical thinking, and then stating expertise in NMS disease in now way, shape, or form makes one qualified to be a GP/PCP.

    See above, under 5% is considered of the rails

    No. No. And, No. When part of your licensing exam is magical thinking you don’t get to say that those who believe in what you are testing in to be frakking licensed are off the rails. And you don’t get to make up random numbers to describe how many of them actually do, even though that is completely immaterial to the discussion.

    You may consider them off the rails – your profession does not. Period. Stop dancing around the issue.

    For what is worth, my school did not have a class on any of this 5%.

    And as an objective viewer, I am supposed to know that how? You are yet again demonstrating the lack of uniformity and willy-nilly make up whatever pleases you nature of chiropractic. So what did you do for that 5%? Did you just say, “Nah. Gonna lose those points.” If I were you I would be furious that I was being examined on bullshit for my licensing exam. But then again, I don’t just care about having the title of “doctor.”

    As to how do you know which DC follows the evidence. This is simple, it is the same as you finding a competent MD, DO, DDS, PT in your area.

    See above. No, actually I’ll repeat it. No. No. And, No. Can you seriously not see the distinction between having to find the competent DC out of the basic default of incompetence vs finding the best MD out of a slew of competent ones?

    For MDs you have to avoid the bad apples. For DCs you have to dig through and thoroughly examine each one to find the good apples. And we haven’t even been able to demonstrate those apples are that good to begin with.

  14. nybgrus says:

    @rwk:

    It’s obvious that we’re wasting our time here. People like nybgrus who are book smart because they’re stillin training aren’t the slightest bit interested in what we are saying.

    No… I am interested. None of you have said anything interesting is the problem. I have spent copious amounts of time reviewing the documents you each have provided, and found them, well, worthless. And none of you has had any rebut. None. Everything is a trivial aside, or a pedantic nit-pick, or a straight up denial of evidence and blatant logical fallacy. I’m here. I’m interesting. But you have nothing of substance to provide me.

    It’s all sport to them.

    I wouldn’t call shooting fish in a barrel sport.

    hey keep saying the same things including gross errors without ever correcting themselves.

    I’ve corrected myself. Read through my comments.

    Talk about the pot calling the kettle black. Except it is more like the pot calling the polished sterling black.

    But then, they know our profession better than we do! Beware.

    The only completely and unequivocally true thing you have said. And that is pretty sad.

  15. NMS-DC says:

    @nybrygus

    “No… I am interested. None of you have said anything interesting is the problem. I have spent copious amounts of time reviewing the documents you each have provided, and found them, well, worthless. And none of you has had any rebut. None. ”

    This answer is the defining point of this thread. Your arguments are based on your belief system and personal philosophy, not on understanding. You asked for basic science research done by chiropractic scientists (DC/PhDs). I provided it. You asked for for clarification re: role of DC as a PCP I explained to you regarding our role of PCP/portal entry for neuromusculoskeletal complaints. You asked for proof of effectiveness and cost-effective of our primary treatment methods (SMT, manual therapies) I provided it. You asked for a logical explanation regarding segmental joint dysfunction and rationale for doing manual therapies (manipulation and mobilization) I provided for it.

    You have provided 0 scientific sources, published literature or anything pertaining to your points that chiropractic care is not a legitimate profession for MSK disorders. You have provided no evidence that demonstrates that chiropractic care is ineffective or cost prohibitive for MSK disorders. You have provided nothing but personal anecdotes and your interpretation of literature which is worthless. The only thing you have shown is professional arrogance. You have a beef with state laws? Write your congressman. But your assertions that chiropractic medicine has not contributed to the basic sciences is ridiculous and that chiropractic care is not valid for neuromusculoskeletal conditions is beyond any logical comprehension.

    You sir, have brought nothing to the table besides empty rhetoric. DCs and MDs are being taught side by side in Switzerland and Denmark. More proof that contemporary chiropractic education has evolved to the point where is can stand side by with medicine. You focus on internal/visceral disorders, we focus on neuromusculoskeletal ones. Your training emphasizes pharmacology, mine emphasizes manual medicine. Your model is a biomedical one, mine is a biopsychosocial. Your viewpoint is reductionistic mine is holistic. Make no mistake, NYBGRUS, and all you skeptics out there who share conflate a personal belief system as a means of discrediting modern chiropractic. The evidence is overwhelmingly against you. I look forward to your reply and please provide evidence that demonstrates your claim that chiropractic is neither valid, effective or cost-effective for MSK disorders. Thanks.

  16. NMS-DC says:

    A picture is worth a thousand words. A video? Skeptics, cynics, and general public please take a look at this clip provided by the University of Zurich in Switzerland where the chiropractic department is part of the medical school. It is a great example of contemporary chiropractic both in terms of education and practice.

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

    If there are any questions related to the material in the video, I’d be more that happy to address them.

    NMS-DC.

  17. NMS-DC says:

    @pmoran.

    1) The evidence does not support your assertion that spinal manipulation is placebo.
    2) DCs not not need to evolve into PTs. They have their own area of expertise (spinal and joint function) and their own expertise in treatment (manipulative and manual therapy).
    3) As long as chiropractic educations continue to embrace the principles of EBM and research there is no reason to think that they would not be “accepted”.
    4) I agree about that the profession needs to stamp out the charlatans who claim SMT as a cure all and make outlandish claims. There is an upcoming “changing of the guard” as recent graduates and current students who have studied in the EBM era take positions in state/national associations and disciplinary boards.
    5) Your assertion that there is weak basis for the existence of the profession is weak. On the contrary, no intervention has been studied moreso than spinal manipulation during the last 30 years and the evidence regarding SMT of the neck still favours it’s use. Refer to the WHO Neck Pain Task Force, unless you believe that document is not scientific or well-regarded. Furthermore, not all patients who present to DCs with neck will automatically undergo a HVLA thrust manipulation. There are red flags to screen for and absolute contraindications where mobilization, soft tissue therapy, or some other intervention might prove to be more appropriate.

    Regards,
    NMS-DC

  18. nybgrus says:

    @NMS-DC:

    Oh please.

    Your arguments are based on your belief system and personal philosophy, not on understanding

    If that makes you sleep better at night, go on believing it.

    You asked for basic science research done by chiropractic scientists (DC/PhDs). I provided it.

    No, I asked for examples of research proving the utility of chiropractic manipulation. You failed to provide any, and I dissected each one and demonstrated why.

    You asked for for clarification re: role of DC as a PCP I explained to you regarding our role of PCP/portal entry for neuromusculoskeletal complaints.

    No, you skirted the issue by changing the focus to NMS complaints. My question is why your training is sufficient to allow you to act as PCP. Patients don’t diagnose themselves and then accurately select who to see. Otherwise GPs and PCPs would be obsolete and people could go straight to nephrology, endocrinology, etc.

    The only excuse you have given is that most of your patient population does self-select. In other words, you get lucky that you don’t have many patients coming to you with non-NMS complaints. That still does not address the core issue – the lack of qualification you have to accurately and adequately diagnose and refer non-NMS cases. So don’t delude yourself into thinking you have addressed that issue. You danced around it with a little special pleading and a cop out that because most of your patients are self selected you can act as PCP.

    You asked for proof of effectiveness and cost-effective of our primary treatment methods (SMT, manual therapies) I provided it.

    Actually I didn’t ask for that. And pmoran demonstrated why those claims are weak at best. I am not interested in cost effectiveness. Placebo and massage are indeed cost effective, but they do not validate the entirety of your profession. I am interested in the science behind what you do… and that is painfully lacking.

    You asked for a logical explanation regarding segmental joint dysfunction and rationale for doing manual therapies (manipulation and mobilization) I provided for it.

    Interestingly enough, while pmoran has been demonstrating such evidence to be weak, I have not cared much about it. I have even conceded that in a very narrow scope some of chiropractic does have efficacy. My critique has been everything outside that scope which no one here has demonstrated to be valid.

    Furthermore, your demonstrations have been examples of bad science. Taking a conclusion that is unproven (SMT is useful for [X]) and then finding completely unrelated data to try and explain it. That is what acupuncturists do. And reiki masters. And homeopaths. The fact that you can’t see that…. is probably why you are in chiropractics in the first place.

    You have provided 0 scientific sources, published literature or anything pertaining to your points that chiropractic care is not a legitimate profession for MSK disorders

    Nice straw man. My thesis was not that chiros are not legitimate for MSK disorders (I think that is true enough, and once again others have been demonstrating that). I have graciously granted you that for said narrow scope you may indeed be legitimate. But I have demonstrated that the scope is poorly defined, much too broad, and the parts that are legitimate are by accident not design. I have also demonstrated that there is no way to tell what sort of basic training a DC has just by title, since the very accreditation documents specifically leave that out of the calculus for accreditation. Furthermore, I demonstrated that your own licensing exams still require you to be tested on the magical thinking of subluxation theory.

    Once again, you keep dancing around the issue and have yet to even begin to answer why it is OK to practice in a manner discordant with your basic founding principles (as I demonstrated clearly from your own professional, accreditation, and licensing documents).

    You have provided nothing but personal anecdotes and your interpretation of literature which is worthless.

    I have offered no personal anecdotes whatsoever. And my interpretation of the data provided is indeed quite valid. The fact that it disagrees with yours doesn’t change that.

    But your assertions that chiropractic medicine has not contributed to the basic sciences is ridiculous and that chiropractic care is not valid for neuromusculoskeletal conditions is beyond any logical comprehension.

    Considering you have shown a complete lack of logical thinking, I hardly think you are one to speak. But I won’t bother going down the “he-said she-said” road with you. You have yet to address any of the core points of my thesis and have yet again demonstrated why our initial reaction to your post was one of blowing you off. Because we knew that it would end exactly as it just has. Keep sticking to your ideology and make sure those blinders are securely in place.

    You sir, have brought nothing to the table besides empty rhetoric. DCs and MDs are being taught side by side in Switzerland and Denmark.

    And homeopaths are on the UK NHS. And reiki practitioners are “treating” cancer patients at Memorial Sloan-Kettering. And UCSF has an “integrated medicine” department. And naturopaths and acupuncturists are licensed in numerous states. And they are all BS, same as a chiros working with MDs in Switzerland.

    And you have the gall to say I am full of empty rhetoric? You can’t even see your own logical fallacies spewing forth. You also completely and utterly miss the entire point of the legislative alchemy series and prove it even better. You can’t fall back on science, so you go to the whiny claim, “But… but… we are licensed and the state says we can do it!” That is the entire point – the licensure is not deserved and the states are wrong. Same as they are with the reiki at MSKCC.

    More proof that contemporary chiropractic education has evolved to the point where is can stand side by with medicine

    Hardly. You need to learn what “proof” actually is.

    You focus on internal/visceral disorders, we focus on neuromusculoskeletal ones.

    It’s like talking to a creationist and I should know better by now. I’ve demonstrated to you why that is false. Keep saying it as many times as you like, that won’t make it true or legitimate.

    Your training emphasizes pharmacology, mine emphasizes manual medicine.

    That is so wrong, it isn’t even wrong.

    Your model is a biomedical one, mine is a biopsychosocial.

    Really? So every single week when I have to discuss every single pathology and intervention from a biopsychosocial aspect, and every exam where the specifically states learning objectives and the defined and accredited curriculum states unequivocally that I need to understand everything in a biopsychosocial context I am in fact imagining all that? Or the 6 week long written project I had to do last year that was graded not on the actual medicine but on the biopsychosocial framework and life history of selected patients was.. what exactly?

    You are so grossly and insanely wrong I can’t even begin to write enough to explain it.

    Your viewpoint is reductionistic mine is holistic

    And the CAM lingo BS comes out. Not even wrong is the best descriptor for that statement.

    Make no mistake, NYBGRUS, and all you skeptics out there who share conflate a personal belief system as a means of discrediting modern chiropractic

    Oh I am not. Science is not a belief system. The fact that you cling to your pre-concieved notions and magical thinking in your profession is.

    The evidence is overwhelmingly against you.

    You are so blind to reality I don’t even know where to begin. It is amazing how much these sorts of conversation always converge. Whether it is a theist, a creationist, and acupuncturist, and homeopath, or any other form of quackery or pseudoscience, it is always the exact same rhetoric.

    I look forward to your reply and please provide evidence that demonstrates your claim that chiropractic is neither valid, effective or cost-effective for MSK disorders

    I would look forward to you actually addressing the points I have been making, but as I said before – I won’t hold my breath. And I won’t be addressing that point, since it is completely immaterial to my argument.

    If there are any questions related to the material in the video, I’d be more that happy to address them.

    See above where reiki is being practiced at MSKCC. Do you believe in reiki, NMS-DC? Do you see how your “proof” of chiro is exactly the same “proof” for reiki? And notice I put proof in quotes.

    I won’t even bother addressing the utter tripe you put forth towards pmoran.

    I am also tired of having the same creationist style “debate” with you and will find myself once again just ignoring ideologues like you. As JPZ said – we have addressed this 300 times before and now that I have hit 301, nothing has changed.

    But keep on believing NMS-DC. Just know you are wrong, no matter how hard you believe otherwise.

  19. jhawk says:

    @nybgrus

    “You want to know how much of my licensing exams are based in magical thinking and disproven BS? Zero”

    Based? My previous post points out that the chiro’s licensing exams are not based on any of this. It is no where near the foundation of our education. How can less than 5% of all our education be our base? I am intersted in your thoughts on DO’s as their national boards have a section on OMT and a section on osteopathic principles. Does this null and void the rest of their education? Also, does this mean that since I took a theology class in undergrad that my BS degree is null and void? My point is that this base you speak of is more of an elective chiropractic history class.

    “And hence the legislative alchemy series. Do you not understand that legislation and licensing agencies mean nothing without the actual science to back them up? The entire purpose of Jan’s series was to demonstrate that since chiros cannot gain legitimacy via actual science they do so via legislative means by duping stupid lay people into believing the mumbo jumbo.”

    I think you are forgetting about your profession here. You are also regulated by boards and licensing agencies which one could argue were set up for the same reason since there is only a 40% efficicay rate today and was most likely extremely lower in the past when these agencies were put into place. This is such a ridiculous argument on both sides as there is absolutely no evidence for such assumptions by either party but I wanted to show how ludicrous your argument sounds. And WOW, “stupid lay people”.

    “And as an objective viewer, I am supposed to know that how? You are yet again demonstrating the lack of uniformity and willy-nilly make up whatever pleases you nature of chiropractic. So what did you do for that 5%? Did you just say, “Nah. Gonna lose those points.” If I were you I would be furious that I was being examined on bullshit for my licensing exam. But then again, I don’t just care about having the title of “doctor.”

    I said: “For what is worth, my school did not have a class on any of this 5%. We used a board review book to get this info and then purge it. “For what its worth” was placed here because I knew it was only anecdotal and I haven’t spent my spare time researching if every other school had one or two classes on this topic.

    Thanks. I will answer more later.

  20. jhawk says:

    @nygbrus

    I would like to add a little evidence for the effectiveness of SMT to the discussion.

    A study showing not only the effectiveness of SMT but the effectiveness of maintenance SMT that I have not seen posted here. http://www.ncbi.nlm.nih.gov/pubmed/21245790

    Also, I don’t remember seeing the American college of physicians and American Pain Society recommendations posted here which lists spinal manipulation as the only option for acute LBP if usual care does not work. http://www.annals.org/content/147/7/478.full

    I would also like to contend that LBP studies using SMT will show better than the now moderate results when clinical prediction rules are used by the researchers. Taking a group of people with LBP and performing SMT on them without Dx the cause of the LBP is like taking a group of people with a fever and giving them antibiotics. It works for the ones that have a bacterial infection but not the ones with a viral infection, heat exhaustion, RA, malignancy, etc.

    I apologize for the double post.

  21. pmoran says:

    NMS-DC
    pmoran.
    1) The evidence does not support your assertion that spinal manipulation is placebo.
    ——————
    I went on to accept that it may work for a subgroup of LBP. But the evidence that it truly works better than placebo for that is also not strong because of inconsistency in the studies and the difficulty of blinding such procedural methods of treatment within sham-controlled trials, making some positive studies inevitable.

    There is also little doubt that it works mainly as placebo when performed for non-specific headache or migraine. Just about anything that can be presented as credible to the subjects will produce similar results with placebo-responsive and self-limiting conditions.
    .
    2) DCs not not need to evolve into PTs. They have their own area of expertise (spinal and joint function) and their own expertise in treatment (manipulative and manual therapy).
    ——————-
    Anyone can learn spinal manipulation. There is nothing uniquely chiropractic that can sustain a separate evidence-based profession by that name.

    3 ) As long as chiropractic educations continue to embrace the principles of EBM and research there is no reason to think that they would not be “accepted”.
    ——————-
    Well, you may be right, but if so it will be the result of political pressure rather than any clear public need within a truly evidence-based system, other than possibly as an option for low back pain.

    4) I agree about that the profession needs to stamp out the charlatans who claim SMT as a cure all and make outlandish claims. There is an upcoming “changing of the guard” as recent graduates and current students who have studied in the EBM era take positions in state/national associations and disciplinary boards.
    —————————
    Lots of luck with that.

    5) Your assertion that there is weak basis for the existence of the profession is weak. On the contrary, no intervention has been studied moreso than spinal manipulation during the last 30 years and the evidence regarding SMT of the neck still favours it’s use.
    Refer to the WHO Neck Pain Task Force, unless you believe that document is not scientific or well-regarded. Furthermore, not all patients who present to DCs with neck will automatically undergo a HVLA thrust manipulation. There are red flags to screen for and absolute contraindications where mobilization, soft tissue therapy, or some other intervention might prove to be more appropriate.
    ———————————
    I have read that. It did not find SMT more effective than several other treatments of neck pain, and it was either naive, biased, or misled concerning the meaning of the Cassidy study. There is also no way of predicting risk of stroke.

    I am not saying that SMT has no place in neck pain if someone wants to try it when prepared to take the risk, but it definitely should not be performed ithout due consideration and proper informed consent.

    Peter

  22. nybgrus says:

    this is getting tedious so I will be brief:

    Based? My previous post points out that the chiro’s licensing exams are not based on any of this. It is no where near the foundation of our education. How can less than 5% of all our education be our base?

    It was explicity defined as the foundational principle of chiropractic in your accreditation documentation until 2007. Now it is implicitly defined as such since the “foundations and history of chiropractic” are a necessary component for accreditation and, as per your licensing exams, that is defined as vertebral subluxation theory.

    I am intersted in your thoughts on DO’s as their national boards have a section on OMT and a section on osteopathic principles. Does this null and void the rest of their education?

    I think it is a shame they still have it. It certainly makes me think less of them. However, the remainder of their education is sufficient in quantity and style (and uniformity) to adequately prepare them for residency. After succesful completion of a residency, they are essentially on par with a physician. Chiros do not complete residency. And if DOs did not, I would not endorse them in any way, shape, or form.

    Also, does this mean that since I took a theology class in undergrad that my BS degree is null and void?

    If the theology class were required and taught as part of the foundational principles of your BS degree… then yes.

    My point is that this base you speak of is more of an elective chiropractic history class

    Even if you were right, there is no way of discerning those who view it that way from the true believers. And history has demonstrated to us that those guys disfavor the “mixers” like yourself. And your own professional bodies throw a fit when vertebral subluxation theory is tossed out. I’ll quote your own profession’s stance on the matter again for your edification:

    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.
    [from the ACA]

    I think you are forgetting about your profession here. You are also regulated by boards and licensing agencies which one could argue were set up for the same reason since there is only a 40% efficicay rate today and was most likely extremely lower in the past when these agencies were put into place.

    No, I am not forgetting it. Your numbers are BS to start with. And more pointedly my profession is science based – we do science and then make conclusions (with the exception of “integrated medicine” which, as you may notice, I am wanting to stamp out completely as well). Chiro has the conclusions and then tries to find evidence for its existence. One is self correcting and growing, the other is self fulfulling and ideological. One is good science, the other is bad science. My licensing bodies are based in science, my exams are 100% based in science, my education is uniform, and that is completely different from chiro.

    But nice try with the tu coque argument. You realize that even if you were 100% right in what you say, that would not make your stance correct? That’s why it is called a logical fallacy.

    And WOW, “stupid lay people”.

    Not necessarily stupid (though yes, many are). But when someone has a license they assume it is based on something other than political posturing. They are wrong when it comes to chiro.

    We used a board review book to get this info and then purge it. “For what its worth” was placed here because I knew it was only anecdotal and I haven’t spent my spare time researching if every other school had one or two classes on this topic.

    Once again the issue is raised – how do you justify practicing in a manner inconsistent with your licensing?

    As for your article – it demonstrates nothing. Chronic LBP is extremely amenable to placebo and expectancy effects for reasons I’ve written about many times (recently in an explanation to JPZ). But even if it was demonstrating real and true efficacy, I still fail to fathom how you think you can justify the extistence of an entire profession that is supposed to be able to act as PCP based on the fact that they can do one thing well. One can literally count the purportedly effective chiropractic interventions on their fingers. If I grant you the equivocal studies I might have to use my toes. But that does not justify an entire profession, nor the responsibility of acting as a PCP.

    So everything else aside, no one has managed to address the fact that your training, however wonderfully science based and however minimally involving vertebral subluxation theory, is insufficient to justify acting as a PCP. Period.

  23. JPZ says:

    @nybgrus

    Another fact-filled, educational post as always. As I have said before, I know very little about how chiropractic education and principles work, so I am also learning a lot from the posts from jhawk and NMS-DC as well. What I am picking up on so far is that they think you are nitpicking minor details, and you are citing what you believe to be fundamental flaws in the concept and practice of chiropractery. My impression is that you are citing specific evidence and general knowledge, and they are citing exceptions and personal perspectives as actual chiropracters. I hope I am not off base in my viewpoints.

    “If the theology class were required and taught as part of the foundational principles of your BS degree… then yes.”

    Um, I went to a religious undergraduate school and had a required religion course or two. I don’t have the impression that it undercut my knowledge of science nor my inheirant skepticism, but maybe that is why my attempts to faith heal rats after dissection never works. LOL ;)

  24. nybgrus says:

    @JPZ:

    Thank you kindly. You are pretty spot on with your assessment IMO. I am trying to speak to the entirety of chiropractic instead of individual experience to demonstrate that fundamental flaws and lack of uniformity that make chiropractic something I cannot trust as a (future) physician. Furthermore, I attempted to outline why the training of chiros which is science based is insufficient to grant them the privilege and responsibility of acting as PCP and handling diagnosis and referral.

    As for the theology classes… to be honest, I would consider any degree from a religious undergrad institition such as say, Erskine, to be quite suspect. Notice though that I added the clause “…as part of the foundational principles of your BS degree…” Merely taking a theology course as a side note is distinctly different (I myself took a course in modern South Asian religion in my undergrad). But places like Erskine undermine the scientific process by putting theology above fact in their curricula. So if I were in a position to hire someone for a scientific project, I would not dismiss them out of hand for having a degree from a religious university, but I would certainly be a bit more suspect. If the candidate proved to be quite promising I’d like to think I would do a bit of extra research into the curriculum and find out if it is benign or more like Erskine. But maybe I’d be to busy and skip over the religious degree for the easier route.

  25. nybgrus says:

    hmm… that “theology above fact in the curricula” should have been a link… hopefully that fixed it.

  26. NMS-DC says:

    Nybgrus

    One one hand your say:

    “No, I asked for examples of research proving the utility of chiropractic manipulation. You failed to provide any, and I dissected each one and demonstrated why.”

    And then on the other hand you say:

    “Interestingly enough, while pmoran has been demonstrating such evidence to be weak, I have not cared much about it. I have even conceded that in a very narrow scope some of chiropractic does have efficacy.”

    You are contradicting yourself and being intellectually dishonest at the same time. You aren’t credible at this point.

    More incoherence on your part:

    “No, you skirted the issue by changing the focus to NMS complaints. My question is why your training is sufficient to allow you to act as PCP. Patients don’t diagnose themselves and then accurately select who to see. Otherwise GPs and PCPs would be obsolete and people could go straight to nephrology, endocrinology, etc”.

    Ok, so your point is chiropractic is not a PCP but a specialty, like dentistry, optometry, etc…? You are then acknowledging that it is itself a medical specialty, in limited scope but with expetise over a certain domain of medicine. Chiropractic medicine “specialty” being diagnosis and management of NMS disorders by manipulative/manual therapies and other conservative therapies. That is the scope being promoted in the current education system.PCP=direct access. That the definition I’m using. DCs are PCPs/portal of entry providers who must be able to sufficiently differential diagnose NMS issues from non NMS are make the appropriate referral when that case arises. That is the argument I am making. You are not opposed to this. So what exactly are you arguing about? Direct access to DCs? Common. You’ve already acknowledged a limited scope (NMS) is valid and credible, and that “a narrow scope of chiropractic does have efficacy”.

    So, limited medical specialty is your argument I got.

    “The only excuse you have given is that most of your patient population does self-select. In other words, you get lucky that you don’t have many patients coming to you with non-NMS complaints. That still does not address the core issue – the lack of qualification you have to accurately and adequately diagnose and refer non-NMS cases.”

    When a profession is emphasizing neuromusculoskeletal diagnosis and treatment and 90% of patients are selecting DCs for management of spinal and NMS disorders it’s not by coincidence. Your argument that I’m somehow “lucky” that I don’t see more non-NMS is really, REALLY grasping for straws now. You’re on the slippery slope, nybrgus…

    “That still does not address the core issue – the lack of qualification you have to accurately and adequately diagnose and refer non-NMS cases.”

    This is a troll comment that doesn’t need addressing any further. DCs are well trained at NMS-diagnosis and know when to refer out.

    Still a lot of hot air…

    “Pmoran demonstrated why those claims are weak at best. I am not interested in cost effectiveness. Placebo and massage are indeed cost effective, but they do not validate the entirety of your profession. I am interested in the science behind what you do… and that is painfully lacking.”

    Pmoran did not say that at all. What he said was, that he believed the effectiveness of SMT to be placebo based. If your not interested in cost-effectiveness in the health care system that’s actually a terribly naive and misguided way of looking at health care economics.

    More brilliance my nybgrus”

    “Furthermore, your demonstrations have been examples of bad science. Taking a conclusion that is unproven (SMT is useful for [X]) and then finding completely unrelated data to try and explain it. That is what acupuncturists do. And reiki masters. And homeopaths. The fact that you can’t see that…. is probably why you are in chiropractics in the first place.”

    No, you asked me to provide you proof, in form of basic science research, by DC/PhDs as proof that chiropractors were legitimately conducting scientific study. And the only rebuttal you have is bad science? Are you going to tell that to the editors of Spine, who regularly publish DC/PhDs?

    “Nice straw man. My thesis was not that chiros are not legitimate for MSK disorders (I think that is true enough, and once again others have been demonstrating that). I have graciously granted you that for said narrow scope you may indeed be legitimate.”

    So let’s recap so far so people at home can keep score

    1) you contradict yourself saying show me the utility of chiropractic manipulation and then acknowledging chiropractic does have efficacy

    2) saying that DCs are legitimate for MSK but then saying we don’t have the diagnostic skills for MSK

    3) The basic training DCs receive is determined by the CCEI and it’s there for you to see. There are still some schools, in the US, that have a more philosophy driven curriculum, but that’s not my argument. I’m talking about contemporary chiropractic and chiropractic sciences.

    4) Your analysis of the literature isn’t valid because your rebuttal is simply “it’s worthless” and “bad science” and that you “have not cared much about it”. Trolling.

    “I have offered no personal anecdotes whatsoever. And my interpretation of the data provided is indeed quite valid. The fact that it disagrees with yours doesn’t change that.”

    No your opinion nybrygus doesn’t change scientific fact. You are ignoring the research done by DC/PhDs because you don’t believe that chiropractic is a legitimate profession on any grounds which is the point. And not about the science its about the philosophy. You disagree with fundamentally with the concept that spinal manipulation is a natural healing art, despite the fact it has been proven to be so. Pmoran attributes this to purely placebo effect, which proves his ignorance as there is an established body of literature on the biological mechanisms spinal manipulation in which biological mechanisms for the effect of SMT on joint dysfunction. That is the chiropractic science in a nutshell.

    Slding still futher down the slope…

    “Keep sticking to your ideology and make sure those blinders are securely in place.”

    What ideology is that? That chiropractic medicine is a valid specialty for NMS? You agreed with me on this Already. See above thread.

    Then you go and make a the the most outlandish statement of the thread comparing DCs to Reiki practitioners. Last time I checked, I didn’t see Reiki practitioners recognized by the WHO. There is no depth or breadth to Reiki research, if there even is any to begin with. There is over 30 years of research on spinal manipulation. You are so far in left field nybrgus you’re literally embarassing yourself if this is your strongest argument.

    “And they are allBS, same as a chiros working with MDs in Switzerland.”

    Just because you personally think its BS doesn’t mean you get to ignore the fact that chiropractic has legitimately developed into a specialized branch of medicine and is now practicing along side at medical school in Switzerland. Spinal manipulation and NMS research is real science and it’s being done by DC/PhDs. The WHO Neck Pain Task Force proves, without a doubt, that chiropractic scientists are making an impact internationally and respect for their expertise in NMS disorders. Ironically enough, nybrgus, the scientific secretariat for that report was chiropractor, Dr. David Cassidy, DC/PhD/Dr. Med Sci (http://www.nptf.ualberta.ca/governance.htm). Whoops. There goes all your argument down the drain that chiropractic does not contribute to health care sciences and that it is not scientific. In what domain of medicine are Reiki practitioners scientific secretariats, nybrgus? Game over, check mate.

    And now the really comical stuff:

    “Hardly. You need to learn what “proof” actually is.”

    Actually I just showed you “proof”. DCs and MDs are being trained together, in medical school, in Switzerland, in the basic sciences, before specializing in their branch of medicine. Are you calling that program bogus?

    Your training emphasizes pharmacology, mine emphasizes manual medicine.
    “That is so wrong, it isn’t even wrong.”

    Not even a coherent argument. You are disagreeing that your MDs expertise is pharmaceuticals and DCs is manipulative therapy? Are you for real nybrgus?

    And, on and on it goes. You don’t really have a real argument other that you feel DCs should be limited to NMS (we primarily agree on this) that DCs act moreso like a medical specialty (we agree mostly; DCs as PCP/PE for NMS is fair and valid too).

    So, in summary

    1) you admit DCs are valid practitioners for NMS
    2) you admit spinal manipulation has shown efficacy and cost-effectiveness.

    That’s a good start nybrgus. Do you admit that chirorpractic scientists are contributing to the basic sciences involving spinal manipulation/manual therapies?

  27. NMS-DC says:

    @Peter

    1)I went on to accept that it may work for a subgroup of LBP.

    The search demonstrates that it is effective for acute, subacute and chronic, non-specific, mechanical back pain and for neck pain. You are suggesting there is no biological plausibility for the effects of SMT other than placebo. There is flat out wrong. And you’re right about sham controls, but DC/PhDs have just developed a sham protocol for cervical manipulation and there is currently researching examining sham control and treatment group.

    2)Anyone can learn spinal manipulation. There is nothing uniquely chiropractic that can sustain a separate evidence-based profession by that name.

    Spinal manipulation is the core act of DCs. 116 years of being the only profession that has stood by their assertion that SMT was beneficial. Not like DOs who really are like MDs at this point. What makes it uniquely chiropractic, Peter, is that chirorpractic examines the effects of SMT on the nervous system. And given that the mechanisms of action of SMT are primarily neurological, it validated Palmer original premise. DCs are experts at spinal manipulation and we do 90% of them in North America. If you think that some other profession is going to be more dedicated in learning manipulative skills, more time investing in it’s research, and more time promoting it’s use, well, I guess we just have to disagree on that one.

    3 ) As long as chiropractic educations continue to embrace the principles of EBM and research there is no reason to think that they would not be “accepted”.
    ——————-
    Well, you may be right, but if so it will be the result of political pressure rather than any clear public need within a truly evidence-based system, other than possibly as an option for low back pain.

    The public will see DCs for spinal disorders and joint problems. That’s what we’re good at, that’s what the public perceives us being, that’s what our education emphasizes. That doesn’t mean we can’t do other things like promote wellness, health counseling, exercise therapy and education/prevention of spinal, joint and MSK disorders. The political pressure will not come from anything more than a developed body of literature has demonstrated that DCs are good in a certain area of medicine and that their treatment methods have been studied, validated, and are cost-effective. EBM changed everything for the chiropractic profession. It was do research and prove yourself or literally whittle away and die. Good thing that majority of the profession is sensible and chose a).

    ———————————
    I have read that. It did not find SMT more effective than several other treatments of neck pain, and it was either naive, biased, or misled concerning the meaning of the Cassidy study. There is also no way of predicting risk of stroke.

    I never claimed it to be more effective. I said effective or just as effective. The Cassidy study was a very good starting point, and like I mentioned before the University of Alberta and Canadian Institute for Health Research are doing a 5 year joint study with DCs, MDs, PTs and DOs regarding SMT safety. We can revisit this topic in a few years and see if you were standing on the wrong side of history or if I was. As a practicing clinician, I know the procedure is itself safe, but you have to marry that with good clinical judgment. Any DC who has caused harm to any patient with an inappropriate manipulation is an malpractice event. These happen. And yes, Peter, you have it absolutely right, DCs must obtain informed consent, just as any health profession should prior to administering an intervention. But that’s already been in place here for a long time. Certain US states really seems to be lacking on this which is terrible.

    Peter, I appreciate your reply. We can agree to disagree on topics but I really do appreciate your effort here. I’m going to dig a good paper on “SMT biological mechanisms” so you can get a better understanding that the effects aren’t simply placebo based (although I do agree that doctor/patient interaction can enhance or negative the patient’s experience with ANY given procedure).

    Also, you think that if chiropractic follows EBM, that it cannot be “chiropractic”? Is that correct? Can you please explain to me why you feel that way? Maybe that should be the content of my next post…

    NMS-DC

  28. nybgrus says:

    Keep telling yourself that NMS-DC.

    JPZ summed it up nicely. And you still haven’t addressed any core issues.

    I don’t care to dissect… again… all your BS, but one point stuck out nicely:

    PCP=direct access.That the definition I’m using.

    That’s not the definition that the CCE, ACA, or ACC use. Convenient that you get to make up whatever definitions you want to suit your needs.

    So go on living in your dream world. I am bored of dealing with you (and have much better things to be doing, like learning real medicine).

    Ciao.

  29. NMS-DC says:

    @nybgrus

    You aren’t bored, you just got completely owned. You said originally there was no merit to anything involving chiropractic and then you’ve admitted that it was fine for MSK disorders, fine in limited form and SMT was effective.

    The only thing you’re standing on is the PCP debate and that varies state by state and country by country. The definition of the CCEI is quite clear, but you personally refuse to allow any profession other than MD to be a PCP

    You’ve also managed to

    a) insult DOs
    b) denigrate PTs
    c) contradict yourself numerous times
    d) ignore scientific evidence to which you did not rebut with scientific evidence but with your personal conjecture which you deemed “valid”

    You have no real rebuttal to my main arguments and just because a lay person like JPZ thinks you’ve given coherent responses (himself a skeptic) doesn’t validate your stance. Go and learn your so called “real” medicine, your branch, pharmacology. There’s a lot more to medicine than pills, nybgrus. They have their role, and so does manual treatments. You’re already in trouble; you don’t know what you don’t know. Guys like you, who know it all, you’re the one’s who eventually get into trouble. I know my branch of medicine, MSK, very, very well and I my methods have research to support their use. DCs who practice MSK are on solid ground. Deal with it.

    To Harriet, Steven N, and all others who claim to be the purveyor of science in medicine: Don’t ignore science that you personally disagree with. It seems your stances are based on traditional chiropractic dogma as opposed to modern day education, science, research and practice. I want to debate someone who has an expertise in physical medicine someone who know NMS medicine well. Next time send someone ( a student troll) who isn’t tripping all over and contradicting themselves and insulting PTs (Marcus W) who frequent this board. Jann, I haven’t heard from you yet, it’s your thread, do you have anything to add?

    Peter, I await your answers and hope to collegiately continue our discussion.

    jhawk, ntw, and other DCs or DC students on this forum. Stay, you do not need to run from those members who try to bully you and denigrate you because you are a chiropractor. We have reached a level of professional maturity, especially in terms of scientific progress that not only can be show the skeptics that we are indeed committed to scientific research, but that our core method, spinal manipulation, is very valid and very much effective for our patients who look to us to get them moving and feel well. We can be the manual MSK specialists and promote wellness and preventative medicine. I first came on this board nearly 5 years ago, and nobody even believed that I was an “evidence-based chiropractor”. 5 years later, even the most ardent skeptic grudgingly acknowledges DCs have a role management in MSK disorders and that SMT has demonstrated effectiveness in cost effectiveness in dealing with spinal-related conditions. 5 years from now, when more DCs are working at Veterans Affairs, hospitals, community health teams and taking a lead role in NMS prevention/management I will look back at this thread and say “I told you so”. Onwards and upwards.

    NMS-DC

  30. JPZ says:

    @NMS-DC

    Well, I meant my comment about “actual chiropracters” to place yours and jhawk’s personal experience as more complete than anyone doing cursory and secondary reading such as myself. From that perspective, I hoped that you could enrich and expand upon the conversation here. And, in some cases, you have.

    Reading your last reply to nybgrus (admittedly, I have come to respect his point of view about my own SBM-branded-as controversial views, but I certainly don’t cut him any slack for bad logic or poor use of citations), you had a lot of contrasting interpretations compared to what I thought he said. If I may share my perspective on your numbered list.

    For example 1, if someone asks you (as a honest-to-goodness practitioner) to provide more evidence of efficacy in your field, that question-requesting-that-you-draw-on-your-knowledge-to-expand-the-groups-present-understanding-of-chiropractery does not invalidate the same person saying that publically available information confirms a narrow aspect of chiropractic practice. I would think that it was your responsibility to enlighten the group as to what lies beyond that narrow aspect, and a single citation provides pretty weak support (though the limitations of the 3 link rule drives me batty as well).

    For example 2, I missed where he said that you don’t have the diagnostic skills for MSK. Does this have to do with his claim that chiropracters are not PCPs? That would strike me as an extrapolation, unless I missed where he said it before.

    For example 3, I thought he said that these “philosophy-driven” folks want subluxations re-introduced into the curriculum. The link I provided (which you attributed to just the school presidents – an authoritative group in my opinion) I thought was very clear about the role of subluxation in chiropracter training. Personally, I think saying that there is a controversy in the profession and you support leaving it out just clears the air more.

    For example 4, I had the impression that nybgrus was shifting the burden of proof to you (which is pretty much standard here). I read his criticisms of individual citations you provided (sorry, I didn’t read the citations), but I don’t recall him throwing out the body of literature as a whole. But, I may have missed it.

    You know, that is just my 2 cents though. I don’t feel any need to defend nybgrus, in fact, I would be giving him a hard time if he sucker punched you with an argument (though his impatience and overall opinions come through strong enough). I admit to being largely ignorant of your field, but I do try and follow the arguments and learn a bit. I hope that helps.

  31. JPZ says:

    @NMC-DC

    You have been here five years, and you write this not-very-open-minded kind of post? I’ve been here less than a year, and I do my own share of being grumpy (OK, very grumpy at times), but I hope to chill out more if I stay four more years.

    “…you just got completely owned.”

    LOL, its “pwned” – oh wait, this isn’t a gaming forum. Why did you say that?

    “…a lay person like JPZ…”

    Do you really call us that? I am more familiar with it in a religious context. And I have taken nybgrus to task more than a few times (and he to me as well), which I sort of expected you would have seen in the last year.

    “To Harriet, Steven N, and all others who claim to be the purveyor of science in medicine: Don’t ignore science that you personally disagree with.”

    OK, three things. One, you ended on a preposition (just pulling your leg on that one). Two, my impression of Harriet has been that she doesn’t cut anyone slack, but she honestly listens to points of view she disagrees with (sorry, had to pull your leg again – don’t take it too seriously). Three, I am getting my own “silent treatment” over science-based arguments being trumped by personal beliefs – so, I am going to agree with you there.

    “Jann, I haven’t heard from you yet, it’s your thread, do you have anything to add?”

    I thought Jann was a lawyer. This conversation went way off the rails of the original post some time ago.

    “I first came on this board nearly 5 years ago, and nobody even believed that I was an “evidence-based chiropractor”. 5 years later, even the most ardent skeptic grudgingly acknowledges DCs have a role management in MSK disorders and that SMT has demonstrated effectiveness in cost effectiveness in dealing with spinal-related conditions.”

    My only advice would be for you to structure your argumentation much, much better. I am not a subject-matter expert here, but I can see when debates are not occuring on the same subject matter. By that I mean, for example, engaging in discussion from an individual viewpoint when the other commentator is discussing macro-level issues. If you feel that the other commentator has not supported their argument with evidence, then call them on it. If someone challenges your own viewpoint, come back with evidence fitting the scope of the challenge. As a nutritional product scientist here, I am not exactly rank and file here. It is not about them, and it is not about you – it is about engaging your audience well.

  32. nybgrus says:

    oh no, I am bored and tired of this. For the exact same reasons that each of us initially wanted nothing to do with a conversation with you. of course, I’m too often suckered in.

    If it makes you feel better thinking you have “owned me” and that you can speak hip like the youngsters these days, then by all means.

    I often use the term “lay person” to refer to someone not trained in scientific rigor. Though JPZ has a point. It is imprecise, since that would mean you would also be a lay person NMS-DC. However, JPZ is not “lay” by any stretch of the imagination. And he has managed to follow the conversation rather well. Of course I have probably been slightly inconsistent in my exact wording – this was all written without the benefit of going back and editing for flow. But the overarching theme of my argument was solid and unadressed – JPZ pointed that out nicely. And he most certainly never pulls punches with me nor would I ever imagine him defending me for any reason beyond seeing validity to my arguments – and I respect him for that. Yes my impatience and annoyance has come through clearly. But all you have managed to hang onto is nit-picking semantics and focusing on the tiny gems shining in a sea of garbage. Clutch them tightly NMS-DC. Staring hard enough clearly lets you avoid all that inconvenient garbage flying around in your “profession.”

    I’ll just leave it at that. I have real medicine to study.

  33. pmoran says:

    NMS-DC:The search demonstrates that it is effective for acute, subacute and chronic, non-specific, mechanical back pain and for neck pain. You are suggesting there is no biological plausibility for the effects of SMT other than placebo. There is flat out wrong. And you’re right about sham controls, but DC/PhDs have just developed a sham protocol for cervical manipulation and there is currently researching examining sham control and treatment group.

    SMT for low back pain is by far chiropractic’s most credible application. Yet, do you appreciate that the body of evidence supporting it is consistent with a range of levels of efficacy over placebo that includes zero?.

    The most recent 2011 Cochrane review of studies of SMT for chronic low back pain found only minor modest benefits over sham. These could easily be explained by the difficulty in blinding inherent in designing an adequate sham for such procedures. That would allow placebo responses to leak through.

    None of those studies had an adequate exit poll to determine how effective the blinding was. So after these many studies we still don’t know for sure whether it works for chronic LBP other than as placebo. Your saying that you (only now) have an adequate sham does not change that. It doesn’t prove that this is so, either, until it has been tested out by careful exit polling and other measures are adopted to prevent practitioner consciously or unconsciously cueing patients as to what treatment they are getting.

    A 2008 review found a modest advantage for SMT over sham of about 10mm on 100mmm scale (95% CI of -2 to -17) of SMT for acute LBP, but I would be surpised if similar considerations did not apply.

    Be grateful, then, that we are allowing that SMT may be helpful with low back pain. This is a possibility/probability judgement for present practical medical purposes, not the absolute, state-of-the universe, chiropractic-affirming one that you wish to represent it as.

    This kind of evidence has recently been weakened by experience within our own ranks concerning how easy it is is for clinical studies to produce spurious positive results, through poor study design and performance, researcher bias, conscious or unconscious fraud, placebo responses being allowed to leak through the blinding, publication bias, and even sheer chance. We have had to become ultra-suspicious of our own studies, so we are not inclined to be too sympathetic of chiropractors puffing up data that we have been able to examine and pronounce upon ourselves.

    WRT stroke neck manipulation the development of a voluntary reporting system for side effects from SMT will not supply the information we need. In fact I am not sure that any properly controlled prospective study can now be performed as it is unethical. The key guidance here is that SMT is not superior to several other forms of management, as you admit. (Incidentally, I suspect those are mainly placebo, too, not that that is necessarily a bad thing).

    I have previously indicated what I think of the “spine as a source of disease”, as in your “ What makes it uniquely chiropractic, Peter, is that chirorpractic examines the effects of SMT on the nervous system. And given that the mechanisms of action of SMT are primarily neurological, it validated Palmer original premise.

    This is mythology to me, not well-grounded science. Remember even homeopathy and moxibustion can produce a few positive clinical studies for the reasons I have alluded to above.

  34. JPZ says:

    @pmoran

    That was a very nice, well-structured explaination that I (as a lay person) could follow. Thanks!

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