Jun 02 2009
Adverse Effects of Chiropractic
There is a very good chance that you will feel worse after seeing a chiropractor.
According to a new systematic review, serious complications of spinal manipulation are rare, but 33-60% of patients experience milder short-term adverse effects such as increased pain, radiation of pain, headaches, vertigo and even loss of consciousness. The study, published in the journal Spine, involved searching PubMed and the Cochrane Library for the years 1966 to 2007. They identified additional studies by hand searching. They looked for all articles that reported adverse effects associated with chiropractic irrespective of type of design. They omitted any reports where patients had underlying diseases (osteogenesis imperfecta, expansive vertebral hemangioma, osteoporotic fracture, etc.) that predisposed them to complications with manipulation.
They found 46 pertinent studies:
- One randomized controlled trial
- Two case-control studies
- Six prospective studies
- Twelve surveys
- Three retrospective studies
- 115 case reports
They recognized that “the heterogeneity of the study designs did not allow conducting a formal meta-analysis.” But they did the best they could to make sense out of what they found.
One RCT
It is surprising that after over a century of chiropractic manipulation, only one randomized controlled trial has attempted to evaluate its safety. And that study was really designed to compare different chiropractic methods to each other: manipulation (high velocity low amplitude thrusts that cannot be resisted by the patient) vs mobilization (low velocity passive motion that can be stopped by the patient), with and without adjunctive measures of heat or electrical muscle stimulation. The study, published in 2005 by Hurwitz et al. in both a chiropractic journal and in Spine, was limited to patients with neck pain. Of 336 patients enrolled, 280 responded 2 weeks later to an adverse events questionnaire. 30% reported at least one adverse symptom, most frequently increased neck pain or stiffness. Adverse reactions were more frequent with manipulation than with mobilization, but the difference didn’t reach statistical significance. The study concluded
Given the possible higher risk of adverse reactions and lack of demonstrated effectiveness of manipulation over mobilization, chiropractors should consider a conservative approach for applying manipulation to their patients, especially those with severe neck pain.
2 Case Control Studies
A study in Canada, published in Stroke in 2001 matched 582 cases of vertebrobasilar accidents (stroke) with controls. In patients <45 years old, those with VBA were 5 times as likely as controls to have visited a chiropractor in the previous week, and 5 times more likely to have made more than 3 visits for cervical treatment in the preceding month.
A second study published in Neurology in 2003 used a nested case-control design and found that vertebral artery dissections were independently associated with spinal manipulative therapy in the previous 30 days, even after controlling for neck pain. The authors advised,
Patients undergoing SMT should be consented for risk of stroke or vascular injury from the procedure. A significant increase in neck pain following spinal manipulative therapy warrants immediate medical evaluation.
Prospective Cohorts
6 prospective studies [1] involved having patients, chiropractors, or physiotherapists fill out questionnaires on a predetermined number of consecutive patients (usually between 10 and 15).
1. 20 New Zealand physiotherapists were approached; only 9 returned the forms, and only 1 participated for 3 weeks. Questionnaires were completed by physiotherapists. There was only one report of increased neck pain. This study was inconsistent with all the rest. It raises the question of whether manipulation by physiotherapists might be safer than manipulation by chiropractors, and whether they are actually using the same techniques.
2. 10 Norwegian chiropractors reported side effects in 1/3 of patients. 23% had local or radiating symptoms: 90% moderate or slight, 87% commencing on the day of treatment and 83% disappearing in 24 hours. Questionnaires were completed by the chiropractor.
3. 86 Swedish chiropractors were approached and 66 participated; 27% of patients did not participate and 5% were lost to follow-up. 44% reported adverse reactions, mostly local discomfort in the area treated. Questionnaires were completed by the chiropractor.
4. 146 Norwegian chiropractors were approached; 102 participated. Adverse reactions were reported in 55% of patients, with 64% occurring within 4 hours of treatment and 74% disappearing by 24 hours. Questionnaires were completed by the chiropractor.
5. 11 British chiropractors were approached; 9 participated. 74% of patients responded of which only 63% of the forms were complete. 53% reported adverse reactions; 44% of these occurred within an hour of manipulation. Questionnaires were completed by patients.
6. 59 Belgian manipulative therapists; questionnaires filled out by patients. 60.9% reported adverse reactions, mainly headache, stiffness, and local discomfort, most appearing within 4 hours of treatment and resolving in 24 hours.
It is interesting that not one of these studies was from the US, where chiropractic originated and where it is most popular.
Retrospective Cohorts
12 retrospective surveys mainly involved asking chiropractors, neurologists, or other physicians to fill out questionnaires. A couple of studies were based on medical or insurance records. In all, 308 serious adverse effects were reported: 163 strokes, 26 myelopathies, 100 radiculopathies, 3 transient ischemic accidents, 1 acute subdural hematoma and 29 other cases not specified. Minor adverse reactions totaled 1337 cases, most of them vertigo (1218 cases) and diminished or lost consciousness. Most of these occurred within 24 hours of manipulation; 5 patients died and 80 were left with permanent neurologic deficits.
A retrospective study of medicolegal cases suggested that chiropractors may have failed to recognize a stroke in progress. “The sudden onset of acute and unusual neck and/or head pain may represent a dissection in progress and be the reason a patient seeks manipulative therapy that then serves as the final insult to the vessel leading to ischemia.” Strokes occurred at any point during the course of treatment and there was no dose-response relationship.
Case Reports
115 case reports included strokes (66), spinal fluid leak (5), spinal epidural hematoma (7), cauda equina syndrome (2), herniated disc (20), radiculopathy (7), myelopathy (3), diaphragmatic palsy (3) and pathologic fractures of vertebra (2).
Conclusions
The results of this new systematic review are consistent with previous reviews. Adverse reactions are common after spinal manipulation, but they are usually benign and transitory. The true risk of serious injury is not known. Estimates of the risk of stroke vary wildly from 1 in 20,000 manipulations to 1.46 in 10,000,000 manipulations. The authors point out that these numbers are speculative because they are based on assumptions about the total number of manipulations performed, and because the degree of underreporting is likely to be high. In one survey, 35 cases of neurologic complications were identified, none of which had been previously published. Another study [2] by the Stroke Council of the American Heart Association identified 360 unpublished case of arterial damage. Chiropractors and neurologists are likely to have different perceptions of the risk, because without systematic followup, chiropractors may not know when their patient has suffered a stroke, while neurologists see only patients with stroke. One interesting but not unexpected finding of this study was that questionnaires completed by patients reported a higher incidence of adverse reactions than questionnaires completed by chiropractors.
This study concluded that the “data are inconclusive in terms of incidence, but the risk of occurrence of serious adverse reactions should be assumed.” There is no way to know if one type of treatment is more dangerous than another because the studies almost never specify what chiropractic maneuver was performed. But there is a hint that mobilization might be safer than manipulation, and there is a plausible rationale.
Screening protocols have been developed that attempt to identify patients at higher risk of stroke, but they have not proven to be useful. Their sensitivity and specificity are low. An intriguing study using PET scans concluded that cerebellar hypoperfusion (decreased blood flow to the base of the brain) may occur after cervical spinal manipulation. This could explain reports of headache, dizziness, vertigo, nausea, blurred vision, etc. It also raises the possibility that some of the minor reactions were strokes that almost happened but didn’t.
One might ask, if half of patients have adverse effects, why do they keep coming back? There are plenty of psychological factors that could explain that. Many alternative providers tell patients that increased symptoms mean the treatment is working and they have to feel worse before they can get better. And one practice-building technique taught to chiropractors is not to ask whether the original symptom is better, but to ask “What’s better today?” If they can find anything positive, like sleeping better or improved appetite, they emphasize that improvement and distract the patient’s attention from the fact that their original complaint has not improved.
We simply don’t have enough good data to quantify the risks of chiropractic treatment. It’s hard to understand why we don’t have good data after all this time. It would seem to be in the best interests of chiropractors and their insurance companies to get the facts. Good data would be easy to obtain by establishing a database specifying the exact intervention and contacting patients a day or two later and also a month after the treatment to ask about adverse effects or subsequent diagnoses of stroke. It could be compiled electronically and data pooled for a large number of chiropractors. It would cost next to nothing and could be carried out by office assistants as part of their routine duties.
Patients have the right to know. Apart from the risk of stroke and other serious outcomes, if there is a 50% chance I will feel worse after a treatment, I would like to be warned.
And as the authors point out, the question of risk is all that more important because we don’t have a “robust demonstration” of the effectiveness of these treatments. Risk alone is meaningless: it must be balanced against benefits to make a risk/benefit assessment. They say “Although the list of indications for which chiropractic is recommended is enormous, there is insufficient published evidence to support or refuse the efficacy of this treatment modality.”
The bottom line: chiropractic manipulations, especially neck manipulations, carry a small risk of serious consequences, a large risk of minor adverse effects; and, depending on the indication, there is little or no evidence that they are effective.
———-
[1] Rivett DA, Milburn P. A prospective study of complications of cervical spine
manipulation. J Manipulative Physiol Ther 1996;4:166–70.
Senstad O, Leboeuf-Yde C, Borchgrevink CF. Side-effects of chiropractic
spinal manipulation: types, frequency, discomfort and course. Scand J Prim
Health Care 1996;14:50–53.
Leboeuf-Yde C, Hennius B, Rudberg E, et al. Side effects of chiropractic
treatment: a prospective study. J Manipulative Physiol Ther 1997;20:
511–15.
Senstad O, Leboeuf-Yde C, Borchgrevink CF. Frequency and characteristics
of side effects of spinal manipulative therapy. Spine 1997;22:435–41.
Barrett AJ, Breen AC. Adverse effects of spinal manipulation. J R Soc Med
2000;93:258–9.
Cagnie B, Vinck E, Beernaert A, et al. How common are side effects of spinal
manipulation and can these side effects be predicted? Man Ther 2004;9:
151–6.
[2] Robertson JT. Neck manipulations as a cause for stroke. Stroke 1981;12:1
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269 Responses to “Adverse Effects of Chiropractic”
“One might ask, if half of patients have adverse effects, why do they keep coming back? There are plenty of psychological factors that could explain that. ”
Yes, people are IDIOTS, MORONS, they have NO BRAINS. Everything people do is calculated to make themselves feel worse, not better. It’s a wonder that anyone is still alive. Except for the MDs, of course, who have learned critical thinking skills in medical school.
@ pec
FYI, chiropractors are known to tell patients who are experiencing a deterioration in their symptoms that they are ‘retracing’ and that it’s important that they continue with their (potentially life-threatening) manipulative treatments:
Quote
“Retracing is the re-experiencing or re-awakening of pain or other symptoms…
-snip-
Patients going though a particularly intense retracing pattern may feel as if they’ve had a serious relapse or are perhaps even getting worse. Although retracing experiences usually last a short time and often pass relatively quickly, patients have been known to terminate their care as a result of them. During this period it is especially important that the patient tell the doctor what is going on. Patients who terminate their care as a result of retracing symptoms will be cheating themselves of a healing experience.”
http://www.vaneverychiropractic.com/PDFs/brochures/KST_and_Healing.pdf
pec,
There’s no need to be jealous. It may take you a while but I’m sure you can learn them too. Those skills were learned not only in medical school but throughout residency too. So don’t feel too bad.
Can we please vote pec off the island at the next tribal council??
Nobody is calling chiropractic patients stupid but you, pec. People can be misinformed, or wrong as wrong can be, or even lied to by their chiropractors, without being the least bit stupid.
You did beat the crap out of that straw med school though. Well done!
[...] Hall at Science-Based Medicine has a good synopsis of the adverse effects of chiropractic treatments: The bottom line: chiropractic manipulations, especially neck manipulations, carry a small risk of [...]
The only time I ever ever heard of retracing was a PT doing deep tissue massage on a patient as a demonstration of the phenomenon. The treating doctor, an MD, was on the stage with them. Never heard about it in chiro school.
I had a patient doing some simple ROM stretches for her neck yesterday and she came in today hurting and sore. Just stretches mind you, performed by the patient herself. After todays session, the soreness was gone and her ROM was about 10% improved over yesterday. Tomorrow she will come in saying that she is sore but less so. I have seen it time and again.
There are very few physical medicine modalities that will not illicite some response such as soreness or some slight increase in discomfort, because physical medicine is re-introducing patients to activities which, as a normal, healthy, uninjured person they should, to some degree, be able to do, within reason.
As to manipulation, the usual response is “that was wonderful” or “that is much better”. Only occasionally does a patient have a negative complaint about manipulation. Of course some patients are not candidates for manipulation and thus I see very few complaints in that regard.
As to critical thinking being learned in the med schools, why is it that I get so many patients whose MD has told them they saw a pinched nerve on their x-rays? Why do so many patients come in from the hospital sporting a new prescription for hydrocodone when they are already taking Lortab given by their PCP for their ongoing “arthritic” condition, of which there is no evidence of what so ever? Why is it that so many of my patients have been diagnosed as having arthritis when they went for the back pain they got when they bent over to start their mower or some other such action?
I know, not related, ad hominem, tu quo que (or what ever), etc, etc. Maybe some intellectual want-to-be can correct me on that.
nwtk – it’s worse than just ad hominem. Your anecdotal experience is guaranteed to be misleading. You are probably seeing a self-selective subset that did not get a good result from their regular doctor. and you are relying on second hand patient reports of what their doctor said and thought.
If I judged other specialties and professionals (chiropractors, MDs, whatever) just on what disgruntled patients told me, I would be led to think that every practitioner in the world besides me is a complete moron.
P eeve – E xasperate – C hafe ! ! !
While I am certainly no advocate for chiropractors, I think it might be fair to say that any treatment modality that has the potential to do good, can also have the potential to do harm.
I’d be suprised if a client who had a joint that didn’t move much have no pain in it after having it forcefully moved through a range of movement in a rapid manner. The next day they might feel a lot better, but right after treatment when the initial endorphin release has gone, I’ll bet they are sore.
Interesting article which seems to say we need more information about manipulation.
Anecdote disclaimer. I have undergone physical therapy on two separate occasions for a ‘frozen shoulder’ ( the left ,then the right), and even though it was quite painful to have my shoulder manipulated during treatment, it always felt much better immediately afterward. I think that if I left there feeling worse each time, I probably would not have gone through it.
By the way, whenever I would explain to someone what was going on with my shoulder, I often would get a reply with something like ” Oh, have you seen a chiropractor for it. I go to this guy and he always fixes my (back/neck/shoulder/allergies etc.) here let me give you his card, I been going to him for years and years!” Hey if I had a car mechanic that had to fix my car over and over, I just might get a little suspicious . I know, I know , not the same thing.
Novella – “If I judged other specialties and professionals (chiropractors, MDs, whatever) just on what disgruntled patients told me, I would be led to think that every practitioner in the world besides me is a complete moron.”
Quite true and not related to this post but it is amazing how consistent the stories are over the years of having seen more than a few thousand patients. I’m just saying.
And tmac57, people go to the same practitioner over and over again for the same thing all the time; sinus infection, uper respiratory infection, allergies, etc. etc. Again not related to the poat but, I’m just saying. And they switch doctors all the time also.
As to the “problems’ associated with manipulation both just after and a while after, isn’t the data a bit subjective and anecdotal in and of itself when patients are asked to describe their experiences and complete surveys?
Harriet, I find your comment interesting – “Chiropractors and neurologists are likely to have different perceptions of the risk, because without systematic followup, chiropractors may not know when their patient has suffered a stroke, while neurologists see only patients with stroke.”
I would guess that if a patient was manipulated and never again seen by their chiro then the chiro might NOT know if the patient had suffered a stroke. But as is so often pointed out, the chiro’s see patients over and over again and it is likely that they would have followup. Or do you mean that chiro’s would not know if a stroke had occured because they would not recognise the signs and symptoms. If that is the case, what is it that a chiro would not notice that a neurologist would?
nwtk2007,
What I meant was chiropractor manipulates neck, patient later has a stroke, goes to the hospital, is seen by a neurologist, patient never returns to chiropractor. Or if he returns to the chiropractor at a later date, he might fail to make the connection between the neck manipulation and the stroke.
I read about one family where they kept going back to the same chiropractor until 3 family members had suffered strokes.
There are also plenty of examples of chiropractors not realizing their patients are having a stroke despite obvious symptoms. Sandra Nette’s is a case in point.
What happened to the recent Connecticut bill language that would require chiros to give informed consent?
The group pushing for this amendment puts up billboards around the country warning the public about the risk of stroke. http://www.chiropracticstroke.com
A host of influences ensure that medical practitioners consistently overestimate the beneficial activity of their treatments while underestimating poor outcomes. This is why quacks can be as sure in their belief as nwtk2007. It is the very reason for all those controlled clinical studies.
As Steve suggests, the patient unwittingly colludes in this, through their “answers of politeness” and their tendency to rate highly and respond positively to any kind of sympathetic medical attention.
They are also inclined to express adverse opinions with their feet rather than with their mouths. Annoyingly, they don’t report back when dead, or in intensive care.
pmoran – “This is why quacks can be as sure in their belief as nwtk2007. ”
Mr moran, I am sure you meant “that is why quacks can be as sure in their beliefs as other medical practitioners” as your previous reference indicated.
pmoran – “As Steve suggests, the patient unwittingly colludes in this, through their “answers of politeness” and their tendency to rate highly and respond positively to any kind of sympathetic medical attention.”
So, if the patient “colludes” with the chiropractors as a response to “sympathetic medical attention”, then what does it say about the medical profession itself when the patient does NOT collude with them, if, indeed they are “colluding” with chiropractors?
And when you say “answers of politeness” are you implying that they might actually be lying and responding untruthfully when rating chiropractors highly and positively? Therefore they must be answering truthfully when responding not so highly or positively to the attention they get from the medical profession.
Novella – “Your anecdotal experience is guaranteed to be misleading. You are probably seeing a self-selective subset that did not get a good result from their regular doctor. and you are relying on second hand patient reports of what their doctor said and thought.”
Really, how many hundreds of times do I have to hear something for it to rise above the level of anecdotal evidence? I personally see people who are injured and I get this information from the medical history I take, which is extensive. Ms Hall refers to the scant evidence of chiropractic induced stroke as a smoking gun. Does the hundreds of times I hear these same stories over and over again amount to at least that or is it still anecdotal?
Finally Mr moran – “They are also inclined to express adverse opinions with their feet rather than with their mouths. Annoyingly, they don’t report back when dead, or in intensive care.”
Patients who are injured I presume. I would say that neither do the many who die at the hands of the medical profession, by accident no less, which numbers in the thousands every single year. So sorry Mr moran, but you started that one.
Sir Peter Medawar the famous British Nobel laureate came up with this gem….
“Exaggerated claims for the efficacy of a medicament are very seldom the consequence of any intention to deceive; they are usually the outcome of a kindly conspiracy in which everybody has the very best intentions. The patient wants to get well, his physician wants to have made him better, and the pharmaceutical company would like to have put it into the physician’s power to have made him so. The controlled clinical trial is an attempt to avoid being taken in by this conspiracy of good will”.
I think it makes the exact point that people are thinking about this post..
It will never “rise above” anecdotal evidence.” Anecdotal is anecdotal. As is commonly repeated in skepticism: “a large amount of low quality evidence does not make high quality evidence.” A large amount of similar anecdotes can lead you to think that there might be something of interest there to study, but only good scientific tests can give good evidence that the effects are better than placebo.
The fact that chiropractic techniques, when rarely tested, fail to show this and many times seem to show negative effects makes all your anecdotes worthless unless you can produce good scientific evidence.
And by the waytnwtk, how dare you compare unfortunate deaths from medical mistakes to deaths from unneeded and unhelpful chiropractic “care.” Mistakes happen, but the difference is that medical techniques are proven to and do work, unlike most chiropractic techniques which have not been shown to work. A death from stroke due to neck manipulation is extra tragic considering that chiropractic neck manipulation has no proven effectiveness.
If you are upset SDR then I apologize, I wasn’t comparing the tragic-ness of the deaths, only the sheer numbers; several hundred per day versus what, one per year, if that?
As to the effectiveness of cervical manipulation, to deny that is to be obstinate at best.
What I mean is, I’m sorry, but does it make the medico’s here feel better about all those senseless deaths to once again bring an attack on chiropractic?
Chiropractic is much more than manipulation of the neck, no matter the “technique” being used or the modality being performed. If there are specific manipulation techniques or methods of manipulation that are specifically dangerous, then I would probably agree, but here there is no specificity about it, just that it is “chiropractic” manipulation. The broad brush doesn’t apply any more and criticisms should be more specific, if, given your knowledge base, you possibly can be.
Another excellent post, Harriet.
Anecdotally (sorry nwtk2007)…I’ve lost count of the number of patients I’ve seen come into the ER with back or neck pain that is worse after a chiropractic “adjustment”. I always wonder why they are waking me up at 0300 instead of the chiropractor, and many times I’ve been tempted to phone the chiro at home and let them know their patient has arrived, and go back to bed.
I recently received a “shared patient notification” from a local chiro about an 11 year old patient of mine she was treating for “various muskuloskeletal and other health issues”. This is a normal healthy kid with no medical problems…other than an overprotective, home schooling, homeopathy and acupuncture using, ear candling, hypochondriac of a mother. I responded that while adults may get temporary relief of mild musculoskeletal pain (though not for the reasons that chiropractors claim), there was no indication for it in children, and it is potentially harmful.
She wrote me back a letter saying she was reporting me to some Pediatric Chiropractic group, and very kindly sent me a copy of her book on “natural pregnancy”, and all the brochures from her clinic.
I think it will make a great addition to my “library of quackery”. She is right out of the DD Palmer tradition…and promises cures of ear infections, allergies, asthma and diabetes.
Are there any actual studies on pediatric chiropractic?
Harriet, most of your concerns about the chiropractic profession were delt with in the New Zealand Commission of Inquiry into Chiropractic, 1979. This commission heard evidence given under oath, and the results were in favour of Chiropractic. This report has yet to be superceded by anything of the same quality. I would suggest you read it, especially the section on Dr. Stephen Barrett and the Quackwatch group. They were totally discredited.
The dangers are not with “Chiropractic Care”, but with the procedure of “Spinal Manual Therapy” as performed by Chiropractors, Medical Practitioners, Osteopaths and Physiotherapists et al. No one practitioner can claim to be safer than the other. It is unfair to blame chiropractors for the strokes that have occurred with manipulation. Allan Terrett, in his book, Current Concepts in Vertibrobasilar Complications following Spinal Manipulation, did an indepth analysis of the mis-reporting of complications. For example, in 1999 Hufnagel et al published a paper, “Stroke Following Chiropractic Manipulation of the Cervical Spine”. In the Journal of Neurology (Aug);246 (8):683-8. The word “Chiropractic” was used 26 times, yet when the authors were questioned, it was revealed that the practitioners were 7 orthopaedists, one physiotherapist and two other healthcare providers (not specified). This is not fair or true reporting and could be termed “academic fraud”.
@Newcoaster, When dealing with chiropractors one must specifically ask for “reliable” evidence; otherwise, one gets referred to their fanzines. The title of the Pediatrics paper is self-explanatory. The Chiro and Osteo paper is odd in that it reviews 57 articles, yet doesn’t cite them. From the body of the text, one can see that experimental results for any condition (e.g., colic) are mixed- sometimes chiro seems to work, sometimes not. The authors conclude the most chiro treatments are supported, if at all, only by low-quality studies.
Adverse Events Associated With Pediatric Spinal Manipulation http://www.pediatrics.org/cgi/content/full/119/1/e275
Chiropractic manipulation in pediatric health conditions – an updated systematic review http://www.chiroandosteo.com/content/16/1/11
“there is little or no evidence that they are effective.”
This comment by you does not reflect the multi-disciplinary research done and published by the “Bone and Joint Decade”.
It found that spinal manual therapy was indicated in neck pain, more so that physiotherapy modalities such as heat, ultrsound, TENS etc. You overlook the dangers of medications in your articles. NSAIDS are not without risks. One just needs to look at the short history of Vioxx and the number of people who experienced severe complications from taking it. I would love to see you do an indepth analysis of this, with the same vigor that you criticise chiropractic.
Perhaps it would be an interesting exercise in statistics to compare the relative dangers of the two forms of care.
nwtk2007, I was trying to point out in a reasonably non-threatening manner something that applies to all kinds of medical practice whether science-based or not. This ruthless self-awareness is the main distinguishing feature of the mainstream and it was very painfully and slowly acquired through the numerous mistakes of *our own* members.
We can predict that you have the exaggerated impressions of effectiveness and safety that we are referring to, because *everyone* does.
It is juvenile to be justifying deaths with the “everyone does it” ploy. The reluctance of chiropractic to look at what it does in srict cost/risk/benefit terms is a symptom of its immaturity as a profession. I can say that while allowing that the mainstream still has a way to go in this regard at this stage of its evolution, but it is gradually doing better and can be predicted to do better still. Can we yet say that about your profession?
ntwk,
I just had a patient die of metastatic prostate carcinoma. He had been on hospice care for the past 3 months or so. Are you saying that he died at my hands? Do I need to amend his death certificate?
By the reasoning that allows CAMsters to rely on anecdotal evidence (post hoc ergo propter hoc), sure.
weing,
I am impressed that you have patients who die of conditions such as cancer. Your statement has carried it’s message and was well heard by all those you wished to impress with it.
However, I am also sure that you are clearly aware that I was referring to those patients who have died as a result of mistakes made in the medical arena by medical practitioners. Certainly it is clear the difference between mistakes and the end results of terminal illnesses.
I can only assume that is what you meant by your statement, otherwise it is utterly meaningless in the context of this post and the responses therein.
Newcoaster,
Where is this place where one would lose count of the number of people coming to you, the ER I mean, because of neck pain after manipulation by a DC? I know several MD’s who work in local ER’s who can say that they have seen none such as you describe. They can, however, relate quite a few cases of patients coming to them after receiving no benefit from their PCP for quite a number of conditions. I must say, I don’t think I believe you on this one. Sorry.
moran,
There is no attempt at justification through the “everyone” has done it argument, just a comparison of the dangers and I clearly pointed that out.
pmoran
“As Steve suggests, the patient unwittingly colludes in this, through their “answers of politeness” and their tendency to rate highly and respond positively to any kind of sympathetic medical attention.”
In general, people tend to be polite and non-confrontational with people who are trying to help them or just be friendly to them.
I recall a story on NPR a few years ago, where subjects went through some sort of interactive program on a computer, and when finished, took a survey where the computer asked questions in the first person like “how did I do?”. The subjects then went to a different computer and took the same survey regarding the performance of the first computer, asking essentially the same questions, but in the third person, “how did computer a do?”. People tended to give significantly better ratings on the first survey that they did on the second survey. It turned out that even though they knew it was a computer, people were following their natural tenancies and were being polite to the first computer and trying not say anything negative to it, but were more honest in their appraisals when given to a third party.
@ Fred Dagg on 03 Jun 2009 at 1:22 am wrote “there is little or no evidence that they are effective.” This comment by you does not reflect the multi-disciplinary research done and published by the “Bone and Joint Decade”.
If memory serves, both articles I cited were published in 2007 (thus, covering most of the Decade) and the conclusion about inferior studies was drawn by chiropractors. Look at those papers. The chiro lit. abounds with tiny, un-controlled and un-blinded “studies” that are little more than anecdotes.
Also see:
“A systematic review of systematic reviews of spinal manipulation” http://www.jrsm.org/cgi/content/full/99/4/192 “Conclusions: Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.”
“Chiropractic: A Critical Evaluation” Journal of Pain and Symptom Management Volume 35, Issue 5, May 2008, Pages 544-562 “Manipulation is associated with frequent mild adverse effects and with serious complications of unknown incidence. Its cost-effectiveness has not been demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.”
Fred Dagg on 03 Jun 2009 at 12:36 am wrote “… The dangers are not with “Chiropractic Care”, but with the procedure of “Spinal Manual Therapy” as performed by Chiropractors, Medical Practitioners, Osteopaths and Physiotherapists et al. No one practitioner can claim to be safer than the other.”
Wrong: “Manipulation of the Cervical Spine: Risks and Benefits” http://www.ptjournal.org/cgi/content/full/79/1/50 shows that chiropractors are implicated in the vast majority of cases of stroke after cervical manipulation.
“I am impressed that you have patients who die of conditions such as cancer. Your statement has carried it’s message and was well heard by all those you wished to impress with it.”
Jaw-dropping, nwtk2007. Kind of makes anything else you have to say irrelevant.
Joe,
nice try in quoting
http://www.ptjournal.org/cgi/content/full/79/1/50
In order to put the risk of cervical manipulation in perspective, some authors have compared the estimated rate of occurrence of manipulation-induced injury to other treatments for cervical impairments. Dabbs and Lauretti170 suggested that the risk of complications (eg, gastrointestinal ulcers, hemorrhage) or death from the use of nonsteroidal anti-inflammatory drugs (NSAIDs) is 100 to 400 times greater than for the use of cervical manipulation. Hurwitz et al44 reported that the incidence of a “serious gastrointestinal event”associated with NSAID use was 1 in 1,000 patients compared with 5 to 10 cases of complication per 10 million cervical manipulations. Cervical spine surgery, by comparison, had 15.6 cases of complication per 1,000 surgeries.44
In the whole article, this is the decisive quote.
Joe,
Allan Terrett’s book, Current Concepts in Vertibrobasilar Complications following Spinal Manipulation, that I mentioned above went through all those references. It was published in 2001, 2 years after the article you cited. So your comments are null and void.
The issue is not “Chiropractic Manipulation”, as you continually refer to, but “Spinal Manual Therapy”, as performed by Chiropractors, Osteopaths, Physiotherapists and Medical Practitioners. All professionals who do SMT are aware of the dangers of their care.
The Bone and Joint Decade analysis of Neck Pain is now considered to be the gold standard for the treatment of neck pain. It was a multi-disciplinary analysis of the treatment of neck pain. It is actually a better review than the ones you quote.
Fred Dagg,
“Perhaps it would be an interesting exercise in statistics to compare the relative dangers of the two forms of care.”
No one can (or should) ignore the risks of any mode of treatment, however just comparing risks of different treatments has little meaning. Benefits also have to be figured into the math.
In medicine we talk about risk/benefit ratio. This, of course, an oversimplification, since both risk and benefit range in frequency and magnitude.
If a treatment has a low, but finite risk of a deadly complication, and no benefit, the risk is unjustified.
@Fred Dagg on 03 Jun 2009 at 12:58 pm wrote “Joe,
nice try in quoting”
Typical try in distorting. When a treatment offers no benefit over safer methods, no risk is acceptable. The chiro neck-snap is unproven as therapy and certainly causes discomfort and, sometimes, serious death.
Don’t stop now, show us the definitive literature that supports the neck-snap as safe and effective.
@Fred Dagg on 03 Jun 2009 at 1:09 pm wrote “… The Bone and Joint Decade analysis of Neck Pain is now considered to be the gold standard for the treatment of neck pain.”
Only by chiros who have everything to lose if it is not. Take the papers I cited and tell me how they are wrong.
nwtk2007 said:
“Really, how many hundreds of times do I have to hear something for it to rise above the level of anecdotal evidence?”
This is a really important point.
Its like the manufacturer who loses money on every widget he makes. Increasing his volume will only put him deeper in the hole.
Anecdotal evidence is known to be based and misleading. Repeated anecdotal evidence only reinforces the bias. If the data are biased, you can’t make it up on volume.
nwtk2007 asks:
At least one more time, as always.
The danger in anecdotal “evidence” is that it is unverified and essentially unquantified. Anecdotal “evidence” was/is very solidly behind such “modern” treatments as homeopathy and acupuncture, not to mention more archaic treatments like bleeding, purging and moxibustion.
To pick an obviously bad treatment, bleeding was widely held to be beneficial in a variety of conditions through the end of the 19th century on the basis of anecdotal “evidence”. However, when the results of bleeding were compared to no treatment at all (not exactly a placebo-controlled trial), “no treatment” had slightly better outcomes.
If you go to the average chiropractor, they will tell you that almost all of their patients get better in a relatively short time. And how do they know this? Because they stop coming back for treatment!
Of course, there are alternative explanations for that “data”. The patients who didn’t come back might have gone home and decided that the “cure” was worse than the ailment, or they might have gone to a different chiropractor, or they might have gone to a real doctor, or they might have gone to the Emergency Department for treatment or they might have had a stroke.
Even if we have “testimonials” about how chiropractic “cured” a number of people, we still don’t know the denominator – how many people were treated to get that number of “cures”.
Finally, we have no way of gauging how many of those chiropractic “cures” would have occurred without spinal manipulation. Maybe all they needed was a little neck rubbing and some gentle encouragement.
Fred Dagg comments:
I’d be interested in knowing how many of these practitioners – apart from chiropractors – perform “spinal manual therapy”. I know that DO’s used to (and may still) be taught spinal manipulation, but not very many of them in my area advertise it or even do it. None of the MD’s I’ve known did “spinal manual therapy” and the few physiotherapists I’ve encountered were generally opposed to it.
Additionally, while DO’s, MD’s physiotherapists and “medical practitioners” may perform “spinal manual therapy”, it is only a part – a small – part of what they can do for a patient. For the chiropractor, it is all they can do.
The chiropractor, then, is like the fabled man whose only tool is a hammer: every problem looks like a nail.
Prometheus
Joe,
when someone resorts to sarcasm and rudeness, as you have in your last two posts, it is a clear indication that that person has lost the argument. The “neck-snap” wording by you shows that you have no clear understanding of the issues. It is not “Chiropractic manipulation” that is the issue. It is “Spinal Manual Therapy”, performed by a number of different practitioners.
Bone and Joint Decade is the best citation. You have been unable to better it.
Wholly Father, I do not disagree with you over the cost-benefit ratios. It is not “medicine” that has the hold on that issue. You will find many healthcare providers echo your desires.
Prometheus
your comments on who does SMT reflect the area in which you live in, probably the U.S.A. However the rest of the world is not like the U.S., so your comments are only valid in regard to the U.S. The rest of the world is a bit different from the U.S. For example, Biederman, a German orthopaedic surgeon has written a very interesting book on the treatment of children using Spinal Manual Therapy. A significant proportion of this book is spent discussing the spinal causes and treatment of behavioral conditions such as autism and organic conditions such as colic.
Your comment
“The chiropractor, then, is like the fabled man whose only tool is a hammer: every problem looks like a nail.
could just as easily apply to surgeons who only cut, medical practitioners who only prescribe and dentists who only drill teeth.
You tend to rely upon gross generalisations to validate your arguments. Not good.
Dagg-
You keep referring to SMT, what do you think this entails? High Velocity Low Amplitude, Muscle Energy, Myofascial Release? Please describe the techniques you are talking about.
@Fred Dagg on 03 Jun 2009 at 1:56 pm wrote “Joe, when someone resorts to sarcasm and rudeness, as you have in your last two posts, it is a clear indication that that person has lost the argument.”
Being wounded by “sarcasm and rudeness” is the last refuge of a scoundrel; and I take it that you cannot refute the articles I cited.
Don’t be shy, tell us what conclusively has come out of your Decade. Pick one article that you think exemplifies the therapeutic value of your industry. Note: I will spot you low-back pain which is equally effectively treated by other methods, including the manipulation that chiro adopted from true, health-care providers.
@Dr. Skeptizmo on 03 Jun 2009 at 2:20 pm wrote “You keep referring to SMT, what do you think this entails?”
That is a problem, chiros have more than 100 unvalidated techniques. “Advances in Chiro” V. 2 DJ Lawrence Ed. (Mosby, 1996); TF Bergman, former Editor of “Chiropractic Technique.”
Dr. Skeptizmo,
there is a presumption that I am a chiropractor.
In regard to SMT, it is a difficult question to answer. If one was to look at the books or articles produced by Grieve (British Physiotherapist), Stoddard (British Osteopath), Maigne (French Medical Practitioner, I think), Biederman (German orthopaedic surgeon), Gorman (Australian Opthalmologist) or Beck (Canadian Chiropractor) one would see that there are some remarkable similarities beteween treatment methods. Terrett, in his book on strokes talked about inconsequential actions such as minor getting ones haircut, or a massage as a cause of a stroke. It is not the practitioner type that is the total concern. One must also take into account type of treatment and also pre-existing factors e.g. arterial thinning and medication that may also exist. High Velocity Thrusts have been implicated, but strokes can occur with any action and that is a tradegy, not only for the patient, but also for the practitioner involved.
Joe, Bone and Joint Decade does refute your citiations.
@Fred Dagg on 03 Jun 2009 at 3:04 pm wrote “there is a presumption that I am a chiropractor.”
Which you are, apparently, embarrassed to defend. How sad is that?
@Fred Daggon 03 Jun 2009 at 3:04 pm wrote “Joe, Bone and Joint Decade does refute your citiations.”
Which evidence you are embarrassed to cite and defend. How sad is that?
You still have the opportunity to cite your best evidence in favor of chiropracty.
Joe,
this blog is entitled “Adverse Effects of Chiropractic”.
I have endevoured to point out to all the incorrect nature of the title, using peer review literature and valid referencing. I have not resorted to sarcasm, snide remarks or falsities. I have used no innuendo or smear tactics. I have, I believe pointed out that it is not “Chiropractic” that is in question, but “Spinal Manual Therapy”, as performed by a number of practitioner groups, that is of issue. This is a multi-disciplinary issue. I am not defending Chiropractic, I am pointing out the inconsistencies in your argument. The following is a link to BJD, if you have a problem with their findings you should consult them. The other interesting avenue you should pursue are the NICE recommendations for the British NHS. It does specifically mention Chiropractic, Osteopathy (British kind, not U.S., there is a difference) and acupuncture. This is for the treatment of low back pain and the results do favour Chiropractic, Osteopathy and Acupuncture.
Haldeman SDC, Carroll L, Cassidy DJ, et al. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: Executive summary. Spine. 2008;33(4S):S5-S7.
Harriet,
you forgot to put this conlusion from the article you quoted.
CONCLUSION: There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue.
You selectively took out the juicy bits to suit your argument. That is not good science. Allan Terretts’ book that I mentioned in an earlier post, deals with probably all complications prior to 2001. A significant proportion of them were due to mis-reporting, and I gave you an example of this.
Further investigations are needed into the prevalence of complications as a result of Spinal Manual Therapy as a form of treatment. Chiropractic is a subset of this, as is Physiotherapy, Medical manipulation (I wonder what the risk factors are for manipulation done under anaesthetic by orthopaedic surgeons??) and Osteopaths.
Come on now people! Why cant we play nice!
I said this before and i will gladly say it again. Until you can
outlaw CAM practice, then everyone has the right to choose
where and how the get treatment!
My back hurts from working out to hard, so im gonna go
see my acupressure guy!
Helps every time!
Mr. Dagg,
The executive summary for the special issue of Spine (2008) that collects the unsubstantiated opinions of chiros is not compelling evidence. I have cited three articles in better-reviewed journals, and one in Chiro and Osteo by two chiros, and you have not addressed them. Nor have you cited reliable literature to support subluxations, which are central to chiro. “Manipulation” is performed by health professionals, and chiros like to claim that they do it as well. The PT article I cited, which you tried to distort, shows that chiros performing cervical manipulation are less competent.
Hi Joe,
who mentioned subluxations? I did not. Who said I was a chiropractor, I did not. The discussion is on the dangers of Spinal manual Therapy.
The conclusions of the Bone and Joint Decade into the treatment of Neck Pain are a far more reliable source of information than you have cited. I did not try to distort anything.
Keep to the topic please.
Fred Dagg wrote –
“…..multi-disciplinary research done and published by the “Bone and Joint Decade”.
It found that spinal manual therapy was indicated in neck pain, more so that physiotherapy modalities such as heat, ultrsound, TENS etc.”
I find it exceedingly odd “bone and joint decade” chose “physiotherapy modalities” that Physiotherapists no longer, or very rarely use.
We are fully aware that ultrasound has insufficient evidence to continue it’s use, and passive modalities in general are losing favour in the face of the evidence supporting more active input.
So – to prove the superiority of an approach they compared it with out of date physio modalities that we know had bollock all evidence.
Ultrasound is very good example of how a profession striving for an evidence based approach operates. Anecdotally we believed ultrasound worked – we believed we had helped, our patients believed we had helped, our patients got better. Trouble was, when compared with natural history (ie control) in RCTs, it made no difference. Ultrasound has been abandoned to the point that Robin McKenzie has called for the last remaining U/S stalwarts to be drummed out of the profession.
This strikes me as a fundamental difference between conventional medicine and CAM. A profession with conventional roots changes with what the evidence tells us, rather than ignoring research in favour of anecdotes
Hello PTsickofBS
I absolutely agree with you over the use of ultrasound. In regard to low back pain, you could also include in that list of unproven treatments TENS, Ice, interferential, exercises, (Not advice to keep active, that is good), shortwave diathermy, corsets, biofeedback, manipulation under anaesthetic.
Gordon Waddell, The Back Pain Revolution. The problem as I see it, is that in some countries and professions there is a strong desire for Evidence Based care, and in others there is not. You will still find ultrasound used in other countries, by Physiotherapists. It is still taught in Physiotherapy schools.
The argument still revolves around the inappropriate blame the Chiropractic profession is recieving for accidents that have occurred, with SMT, by non-chiropractors.
Robin MacKenzie had some really good ideas, what is really interesting is the number of physios who ignore his intuative and well researched writings.
I have never meet him, but have heard him talk at meetings. I have heard that he is not well at present.
Fred Dagg on 03 Jun 2009 at 7:56 pm wrote “Hi Joe,
who mentioned subluxations? … Keep to the topic please.”
Certainly, the topic is “Adverse effects of chiro” and subluxations are central to chiro, according to the Association of Chiropractic Colleges. The problems, then, revolve around reasons to resort to chiro (is it effective for anything?) versus counterbalancing adverse effects.
I have offered evidence that its effectiveness remains unproven (after 114 years) and it is harmful, you reply that chiros disagree according to a sub-par publication.
@Fred Dagg on 03 Jun 2009 at 8:28 pm “The argument still revolves around the inappropriate blame the Chiropractic profession is recieving for accidents that have occurred, with SMT, by non-chiropractors.”
Oh great, I suppose you can support that claim …
This is a time and again argument here and used to be interesting but is now rather dull.
Joe previously admitted to not reading articles in “sub-par” publications and even commented incorrectly on publications that he later admitted to NOT reading. Waste of time.
The biases of many of the commenter’s here has also been pointed out and demonstrated with clarity to the point of them simply admitting that the evidence for chiro stroke is slim but you can’t deny the “smoking gun”.
Now we are back to the effectiveness of manipulation and other modalities employed by chiro’s and PT’s world wide and very effectively so.
Always back to lack of studies and when presented, sluffed off for various reasons by the anti-chiro biased, but supported by the objective reasoned responses by guys like Mr Dagg.
Apparently everything I see in terms of patient improvement is anecdotal even though I do initial assessments, interim assessments, and final assessments with documented improvement and much of the time FCE’s showing the improvements, all of which are performed by certified PT’s in CARF certified facilities. Well not all, some are performed by the PT’s boss, a licensed DC. The ortho’s agree, the neurosurgeons agree and yet according to these guys here, it is anecdotal.
Many of the commentors here remind me of the hired “medical professionals” who will do retrospective reviews of patient care, assessment and improvement, then claim that it was all not medically necessary, just as their bosses at the insurance companies want them to say. True, corrupt bias in action.
In reality, all they need to do is state “denied for lack of medical necessity” because I(they) think so, sign it and move on because that is about the extent of their logic and reasoning.
Why bother with all the circular arguments, references only to studies that support “their” position, referral to “guidelines” put together by insurance companies (not to mention totally anal rigidity with respect to these guidelines which are pre-stated not to be “anally” subscribed to), illogical inferences that everyone will need only a certain amount of treatment, etc, etc.
Not to mention the inuendo underlying implied insults.
Yawn.
Joe (Yawn),
I did support the claim in an earlier post, by referencing you to the book by Prof. Allan Terrett, Current Concepts in Vertebrobasilar Complications following spinal manipulation. It was written in 2001 and does a detailed analysis of the causes of VBI’s. It also lists all recorded incidents of VBI’s since 1966, including listing the practitioner types and types of occurences. Allan Terrett also contacted the authors of many of the articles to find out who performed the treatment. Many of the treatments were described as “Chiropractic manipulations”, yet performed by a PT, Orthopaedic Surgeon and others. My argument is, repeatedly, these accidents and incidents do occur. They should be well documented and studied. Not to lay blame, but so those who practice SMT can learn from it, and reduce the incidents of them. They are tradgic events for all concerned.
You seem to bring up the “Chiropractic is ineffective argument” (Yawn). That is not what we are discussing. We are concerned about safety.
For some anecdotal information, I have seen cervical spine manipultions done by Orthopaedic Surgeons (under anaesthetic), Physiotherapists, Medical Practitioners, Osteopaths, Chiropractors and Opthalmologists, just to name a few off the top off my head. Unless I knew beforehand the profession of the person doing the manipluations, I would be unable to tell you the difference between them all. They all had the same risk profile for causing a VBI.
Finally, have yet bothered to look at the results of the Bone and Joint Decade synopsis on Neck Pain. It out-cites you.
nwtk2007 ; “Always back to lack of studies and when presented, sluffed off for various reasons by the anti-chiro biased, but supported by the objective reasoned responses by guys like Mr Dagg.”
I just checked the Cochrane database, which contains extremely comprehensive literature reviews, and it has several concluding that SMT has no unique effects upon low back pain and various other conditions when compared to other commonly used modalities.
The Cochrane researchers found 39 studies to include in its review of SMT for low back pain. Which studies did that review overlook?
Medical science is often a bit fuzzy, allowing for a range of possibilities while also usually placing limits upon what is possible. For example, I am prepared to accept, partly on the basis of the anecdotal material, that SMT may help a very small subgroup of patients with LBP or neck pain, but not enough to show up distinctly in studies of the usual size and subject diversity.
But we have to be consistent. You can’t use your own anecdotal experiences to make causal deductions of a “post hoc ergo propter hoc” type in relation to the apparent benefits of SMT and then ignore the collection of very strong anecdotal material showing patients regularly experiencing strokes after, or during, SMT..
If you wish to find fault with the systematic studies that support such a causal association then you must allow others the same prerogative in relation to any studies you may wish to produce.
In the end, a judgment is called for as to what is best for the patient. There is no question in my mind that neck manipulation should not be being employed as the first line of treatment for any condition. There are many safer options to try first. It will expose most subjects to unnecessary risk
nwtk2007 ; “Always back to lack of studies and when presented, sluffed off for various reasons by the anti-chiro biased, but supported by the objective reasoned responses by guys like Mr Dagg.”
I just checked the Cochrane database, which contains extremely comprehensive literature reviews, and it has several concluding that SMT has no unique effects upon low back pain and various other conditions when compared to other commonly used modalities.
The Cochrane researchers found 39 studies to include in its review of SMT for low back pain. Which studies did that review overlook?
Medical science is often a bit fuzzy, allowing for a range of possibilities while also usually placing limits upon what is possible. For example, I am prepared to accept, partly on the basis of the anecdotal material, that SMT may help a very small subgroup of patients with LBP or neck pain, but not enough to show up distinctly in studies of the usual size and subject diversity.
But we have to be consistent. You can’t use your own anecdotal experiences to make causal deductions of a “post hoc ergo propter hoc” type in relation to the apparent benefits of SMT and then ignore the collection of very strong anecdotal material showing patients regularly experiencing strokes after, or during, SMT..
If you wish to find fault with the systematic studies that support such a causal association then you must allow others the same prerogative in relation to any studies you may wish to produce.
In the end, a judgment is called for as to what is best for the patient. There is no question in my mind that neck manipulation should not be being employed as the first line of treatment for any condition. There are many safer options to try first. It will expose most subjects to unnecessary risk
nwtk2007 ; “Always back to lack of studies and when presented, sluffed off for various reasons by the anti-chiro biased, but supported by the objective reasoned responses by guys like Mr Dagg.”
I just checked the Cochrane database, which contains extremely comprehensive literature reviews, and it has several concluding that SMT has no unique effects upon low back pain and various other conditions when compared to other commonly used modalities.
The Cochrane researchers found 39 studies to include in its review of SMT for low back pain. Which studies did that review overlook?
Medical science is often a bit fuzzy, allowing for a range of possibilities while also usually placing limits upon what is possible. For example, I am prepared to accept, partly on the basis of the anecdotal material, that SMT may help a very small subgroup of patients with LBP or neck pain, but not enough to show up distinctly in studies of the usual size and subject diversity.
But we have to be consistent. You can’t use your own anecdotal experiences to make causal deductions of a “post hoc ergo propter hoc” type in relation to the apparent benefits of SMT and then ignore the collection of very strong anecdotal material showing patients regularly experiencing strokes after, or during, SMT..
If you wish to find fault with the systematic studies that support such a causal association then you must allow others the same prerogative in relation to any studies you may wish to produce.
In the end, a judgment is called for as to what is best for the patient. There is no question in my mind that neck manipulation should not be being employed as the first line of treatment for any condition. There are many safer options to try first. It will expose most subjects to unnecessary risk
nwtk2007 ; “Always back to lack of studies and when presented, sluffed off for various reasons by the anti-chiro biased, but supported by the objective reasoned responses by guys like Mr Dagg.”
I just checked the Cochrane database, which contains extremely comprehensive literature reviews, and it has several concluding that SMT has no unique effects upon low back pain and various other conditions when compared to other commonly used modalities.
The Cochrane researchers found 39 studies to include in its review of SMT for low back pain. Which studies did that review overlook?
Medical science is often a bit fuzzy, allowing for a range of possibilities while also usually placing limits upon what is possible. For example, I am prepared to accept, partly on the basis of the anecdotal material, that SMT may help a very small subgroup of patients with LBP or neck pain, but not enough to show up distinctly in studies of the usual size and subject diversity.
But we have to be consistent. You can’t use your own anecdotal experiences to make causal deductions of a “post hoc ergo propter hoc” type in relation to the apparent benefits of SMT and then ignore the collection of very strong anecdotal material showing patients regularly experiencing strokes after, or during, SMT..
If you wish to find fault with the systematic studies that support such a causal association then you must allow others the same prerogative in relation to any studies you may wish to produce.
In the end, a judgment is called for as to what is best for the patient. There is no question in my mind that neck manipulation should not be being employed as the first line of treatment for any condition. There are many safer options to try first. It will expose most subjects to unnecessary risk
“– SMT may help a very small subgroup of patients –” By that I mean in a way beyond placebo or other common treatments such as massage or physiotherapy. Trying to be precise.
Bone and Joint Decade did a more comprehensive review than the Cochrane data base, and is the citation to quote. The NICE study in Britiain for the treatment of low back pain is also more relaible than the Cochrane data base.
Fred Dagg wrote on 04 Jun 2009 at 1:14 am: “The NICE study in Britain for the treatment of low back pain is also more reliable than the Cochrane data base.”
Clearly you’re not up to speed on the NICE fiasco…
http://www.dcscience.net/?p=1542
Not a fiasco, just sour grapes. If you follow the clinical practice guidelines and are aware of the evidence based research into low back pain, then there are no problems. Look at the book by The British orthopaedic surgeon, Gordon Waddell. The NICE study mirrors many of the recommendations in his book, The Back Pain Revolution. Any practitioner of SMT would agree with the outcomes of the NICE recommendations, irrespective of profession. Sour Grapes.
@ Fred Dagg
How is it possible for one British orthopaedic surgeon and a small British back pain guideline development group, which included at least 3 pro-manipulation participants (two of which had *very* strong vested interests), to be more impartial than the global Cochrane review group?
Also, bearing in mind that (1) it is not uncommon for chiropractors to manipulate the cervical spine even when a patient’s problem is confined to the lower back,
Quote:
“Some subluxation-based chiropractors believe that most ailments, including low-back pain, are related to misaligned vertebrae in the neck. These “upper cervical specialists” always adjust the neck, usually the top two vertebrae at the base of the skull. This can be dangerous, since excessive rotation of the head and upper cervical spine places a strain on the vertebral arteries and can result in vascular injury or stroke.” http://www.quackwatch.com/01QuackeryRelatedTopics/chiroeval.html
and that (2) a recent survey of the scope of practice of UK chiropractors revealed that traditional chiropractic beliefs (chiropractic philosophy) were deemed important by 76% of the respondents, with a further 63% considering the imaginary “subluxation” to be central to chiropractic intervention (http://tinyurl.com/599vfs), it would be interesting to hear your views on what can be done to protect patients from the ‘bait and switch’ of unscientific medicine:
http://www.sciencebasedmedicine.org/?p=156
@ Fred Dagg
How is it possible for one British orthopaedic surgeon and a small British back pain guideline development group, which included at least 3 pro-manipulation participants ( two of which had *very* strong vested interests), to be more impartial than the global Cochrane review group?
Also, bearing in mind that; (1) it’s not uncommon for chiropractors to manipulate the cervical spine even when a patient’s problem is confined to the lower back:
Quote:
“Some subluxation-based chiropractors believe that most ailments, including low-back pain, are related to misaligned vertebrae in the neck. These “upper cervical specialists” always adjust the neck, usually the top two vertebrae at the base of the skull. This can be dangerous, since excessive rotation of the head and upper cervical spine places a strain on the vertebral arteries and can result in vascular injury or stroke.” http://www.quackwatch.com/01QuackeryRelatedTopics/chiroeval.html
and that; (2) a recent survey of the scope of practice of UK chiropractors revealed that traditional chiropractic beliefs (chiropractic philosophy) were deemed important by 76% of the respondents, with a further 63% considering the imaginary “subluxation” to be central to chiropractic intervention (http://tinyurl.com/599vfs), it would be interesting to hear your views on what can be done to protect patients from the ‘bait and switch’ of unscientific medicine:
http://www.sciencebasedmedicine.org/?p=156
Hi Blue Wode,
You asked the following of me,
“How is it possible for one British orthopaedic surgeon and a small British back pain guideline development group, which included at least 3 pro-manipulation participants ( two of which had *very* strong vested interests), to be more impartial than the global Cochrane review group?”
I am sorry, I do not know the answer. It is something you should take up with the authorities in the U.K. rather than discussing it on blogsites such as this.
It is interesting that you should quote “Quackwatch”. In 1979, a Royal Commission of Inquiry into Chiropractic said the following about Dr. Stephen Barrett and Quackwatch.
“We have considered material published over Barrett’s name. The chapter on chiropractic in The Health Robbers (entitled “The Spine Salesmen”) was written by him. It is plainly propaganda. What we have seen of the rest of his writings on chiropractic has the same tone. Nothing he has written on chiropractic that we have considered can be relied on as balanced.”
“It is clear that the enthusiasm of the Lehigh Valley Committee Against Health Fraud (Quackwatch) is greater than its respect for accuracy, at least in regards to facts concerning chiropractic. We are not prepared to place any reliance on material emanating from the Lehigh Valley Committee.”
The British Commonwealth is very keen on Common Law, and in it is the law of precedence. Thus, unless Barrett can prove in peer review journals and books of his honesty and integrity, then precedence says that the words of the Royal Commission still stand and are correct.
However to get back to the main argument here, it is the inappropriate use of the term “Chiropractic Manipulation” when describing accidents that may have occurred with SMT, irrespective of the practitioner.
@ Fred Dagg
You wrote on 04 Jun 2009 at 1:14 am: “ The NICE study in Britiain for the treatment of low back pain is also more relaible than the Cochrane data base.”
Bearing in mind that the NICE back pain guideline development group was small and included at least 3 pro-manipulation participants (two of which had very strong vested interests), what criteria are *you* using to support *your* assertion that the NICE study is “more reliable than the Cochrane data base”?
As regards subluxation-based chiropractors who believe that most ailments, including low-back pain, are related to misaligned vertebrae in the neck and always adjust the neck (e.g. NUCCA chiropractors), we already know that it was that procedure which preceded the catastrophic injury sustained by former Canadian chiropractic patient, Sandra Nette:
http://www.casewatch.org/mal/nette/claim.pdf
Indeed, at the time of her injury Ms Nette had been in good health and was, apparently, having her neck manipulated as part of a chiropractic “maintenance care” regimen. In view of that, and the UK survey which I cited in my last post, what, in your view, can be done to protect patients from the ‘bait and switch’ of unscientific medicine?
http://www.sciencebasedmedicine.org/?p=156
“These “upper cervical specialists” always adjust the neck, usually the top two vertebrae at the base of the skull. This can be dangerous, since excessive rotation of the head and upper cervical spine places a strain on the vertebral arteries and can result in vascular injury or stroke.” http://www.quackwatch.com/01QuackeryRelatedTopics/chiroeval.html”
I don’t think the upper cervical technique NUCCA involves rotation. I also don’t think the manipulation in Ms Nette’s case was NUCCA either.
@Fred Dagg on 04 Jun 2009 at 5:35 am wrote “However to get back to the main argument here, it is the inappropriate use of the term “Chiropractic Manipulation” when describing accidents that may have occurred with SMT, irrespective of the practitioner.”
You have been shown strong, contradictory evidence. Where is your proof?
Fred Dagg on 04 Jun 2009 at 5:35 am also mentioned The 1979 New Zealan commission report. http://www.chirobase.org/05RB/NZ/nzjarvis.html That was a farce that consisted of an inexpert panel (a barrister, a chemistry professor, and a retired headmistress of a girls secondary school) that tried to determine which expert witnesses were more credible. That is no way to decide technical issues.
Joe – “strong, contradictory evidence”?
Of what? What were those studies again that were contradictory?
Strong?
@ nwtk2007 on 04 Jun 2009 at 11:10 am wrote Joe – ““strong, contradictory evidence”?
Of what? What were those studies again that were contradictory?”
I have posted them. Look them up for yourself.
Hi Joe,
the commissioners took the evidence of Dr. Stephen Barrett and Dr. Murray Katz to be unreliable and innacurate. It was not a technical decision, it was one based around honesty and integrity. Follow this link and you will get an idea of what was said, under oath, and how these witnesses were found to be not telling the truth. “Propaganda” was the term used.
http://www.chiro.org/LINKS/New_Zealand_Report.shtml
I have in previous posts given you references that out-cite you for the inaccurate labelling out accidents that occur with Spinal Manual Therapy.
These incidents should be investiated further, for patient safety, irrespective of the profession the treatment provider is.
I have a qualification in Health Science.
OK Joe, one paper is a review of reviews and the other is a discussion or as it puts it “a critical evaluation”.
Neither one is a study at all and neither constitute “evidence”.
Are you still reading summaries and abstracts only?
Did you pay the $31 to see the article by Ernst or are you a member? Either way I would assume that you have the full article and could therefore E-mail it to me at nwtk2007@yahoo.com so I too could read it through and through as I am sure you will say you have, which, indeed, you might have. If so then I appologize for the sarcasm.
In fact, if you could send me both, that would be greatly appreciated. If there is a difficulty, just copy and paste the articles to a notepad document and attach it to my E-mail.
Thanks in advance for your help.
Fred Dagg “The NICE study in Britain for the treatment of low back pain is also more reliable than the Cochrane data base.””
You joke, surely. That group looked at only seven selected studies. Only one of these suggested “small to moderate” benefits. Four showed no benefits from SMT, and in two the results are not very clear from the information supplied, but apparently somewhat underwhelming.
Their overall conclusions are, appropriately, well short of a ringing endorsement:
” Manual therapies (including SMT –PM) have a modest effect and are *at least equivalent to usual care*” (my emphasis)
– and —
” The GDG felt that from the evidence presented it was not appropriate to rule out either treatment option.” (referring to SMT and exercise — PM).
This last comment supports something I suspected when I first heard that this group was endorsing SMT and acupuncture — it is asking itself a slightly different question to that usually asked by Cochrane (and the medical skeptic).
Cochrane asks, basically, “do these methods have worthwhile intrinsic effectiveness over placebo and other non-specific benefits of medical attentions?”.
The GDG group is asking something like this: “when nothing we do makes a whole lot of difference, what the hell can we offer patients when they are not getting better as quickly as usual?”.
Theirs may yet prove to be a reasonably valid, pragmatic approach to some aspects of medical practice, taking into account more of the human side to medicine.
@ Fred Dagg:
Only interpretation of the law is precedent (not “precedence”). Findings of fact, including the credibility of witnesses, is never precedental. I have not read the 30-year-old NZ report, but it appears that this was some sort of commission which made findings. That would never constitute prececent under British or American law. Only appellate courts create precedent and only on interpretations of law.
I am thumbing through my copy of the Bone and Joint Decade “Best Evidence Synthesis on Neck Pain” and not seeing the degree of support you apparently found for use of spinal manipulation for neck pain; in fact the report clearly concludes there is no good evidence for its use in treating whiplash associated neck pain, as I read it. It is never superior to other forms of treatment, even by their analysis. In fact, for all five categories of neck pain listed, it was listed as “likely helpful(worth considering)” for only one: Grade I or II neck pain not associated with whiplash.
It appears that you view spinal manipulation as a treatment for musculoskeletal symptoms only, and that you do not believe the chiropractic subluxation exists, correct?
Hi Versus,
Thanks for the comments on precedent. I am not a lawyer, so I appreciate your advice. However, if one was to look at the Commission report in its entirity, it is still a very good analysis of the Chiropractic Profession. It also is extremely critical of the integrity of the medical witnesses. These people, Dr. Murray Katz from Canada and Peter Modde, as well as Dr. Stephen Barrett (Quackwatch) were found to be unreliable.
Considering the finding against Barrett et al. it astounds me that he and Quackwatch are given any serious credence in “Science Based Community”. The commissioners had evidence presented to them under oath by the Chiropractors, Physiotherapists, Medical Association plus other parties. If the evidence did not support the arguments, then the commissioners ruled that way. It was worse that some information given under oath, was found to be incorrect.
http://www.chiro.org/LINKS/New_Zealand_Report.shtml
I am not qualified to comment on the subluxation theories, so prefer not to. That is not the issue here.
The initial discussion was on the innappropriate use of the term “Chiropractic” when an accident has occurred using SMT.
@ nwtk2007 on 04 Jun 2009 at 4:24 pm “one paper is a review of reviews and the other is a discussion or as it puts it “a critical evaluation”.
Neither one is a study at all and neither constitute “evidence”.
… I would assume that you have the full article and could therefore E-mail it to me at {snip} so I too could read it through and through ”
You obviously still don’t understand what you are talking about; e.g., what constitutes “a study” or “evidence” in science. Sorry, I won’t send the articles because I don’t give out me e-mail address.
Mr. Dagg, if you are not qualified to comment on “subluxation” then you are not qualified to discuss this topic, at all. Subluxation is the core of chiro http://www.chirocolleges.org/paradigm_scopet.html whereas the cognoscenti know it is a fairy tale. If you don’t know these things, you don’t know the basics of the topic you are arguing. Of course, not knowing what Cochrane reviews are, and overstating the meaning of the “New Zealand,” “NICE” and “Decade” reports already told us that; but that ignorance is commonplace for chiropractors (who believe in subluxations).
What is your purpose here?
Joe,
you miss the point. I am pointing out your huge inconsistencies with your and Harriett Halls’ statements. The original article was on adverse effects to Chiropractic. I have pointed out to you that this is an incorrect statement. We are not arguing about the issue of chiropractic causing these accidents, but any practitioner of SMT. I have said that multi-diciplinary studies need to be done between the 4 main practitioner groups who practice SMT. This is responsible and ethical. If you disagree with this approach, please let me and all the readers know. Then we will understand your motives.
You seem to be obsessed with an argument over chiropractic etc and subluxations. Neither issue is relevant here and my main reason for bring up items such as New Zealand, NICE etc is to show how narrow your view of this issue is.
One does not have to be a chiropractor, physiotherapist, orthopaedic surgeon, osteopath or even a rocket scientist to see that you miss the point. That is my issue, but you seem intent on diverting it, you are also resorting to sarcasm and derision. Shame.
Fred,
Ok. I think I see your point. If a kid points a gun at someone and pulls the trigger the other person is shot. If a policeman, criminal, husband, wife does it, you get the same result. Now you want multi-disciplinary studies to be done among these groups as that would be responsible and ethical?
Weing
How about this analogy?
A Medical Doctor, Chiropractor, Osteopath, Physiotherapist and Orthopaedic Surgeon all perform spinal manual therapy.
All do it for the right reasons and all perform a really good work-up to determine if there are any contraindications to care.
They do this for many years, and it comes to their attention that occassionally there is a bad reaction to the care the give to patients. No one practitioner group is immune from this happening, and the treatments given appear remarkably similar.
They decide to form a working group to investigate how and why patients have these reactions. The practitioners decide that instead of pointing the finger to one another saying that it was the other persons fault, they recognise that for the safety of patients, it would be best to discover why these things happen.
They get on really well, have some long and frank discussions and there is some occassional acrimony. They organise some research and have a very professional and collegial discussion to remedy this issue. Their goal is to find a solution, Their goal is to maintain patient safety.
That ladies and gentlemen is what needs to be done. Anyone disagree????????????????
Fred Dagg “I have said that multi-diciplinary studies need to be done between the 4 main practitioner groups who practice SMT. ”
“That ladies and gentlemen is what needs to be done. Anyone disagree????”
Yes, me. If neck manipulation was a necessary treatment for any potentially fatal or seriously disabling condition we would probably accept the risk of a rare fatality or serious stroke, just as we have to accept that NSAIDs may cause serious gastrointestinal bleeding.
As it is, neck manipulation has not been shown to be a necessary treatment for anything. It is therefore already unethical to be continuing to expose hundreds of thousands of people to even the *potential* risk, especially in clinical trials that are going to measure the number of strokes produced to no real purpose.
Here is a true analogy. If neck manipulation was a drug suspected of causing stroke, and other drugs were just as effective without causing stroke, there is no question that it would have be taken off the market well before now. At minimum there would already be in place strict guidelines as to its use.
No, neck manipulation is not the same thing as “chiropractic”, but it is chiropractic that makes this a difficult issue. Few chiropractors seem to be able to think in risk/benefit terms, and too much of their income is tied up in manipulation.
@Fred Dagg on 04 Jun 2009 at 8:26 pm wrote “… We are not arguing about the issue of chiropractic causing these accidents, but any practitioner of SMT.”
I have twice asked for evidence to support your contention, and I provided the link to an extensive review of the literature that shows you are wrong. Here it is again http://www.ptjournal.org/cgi/content/full/79/1/50
Show us the literature.
Then again, since you don’t know what Cochrane reviews are, and you cannot evaluate the NICE and New Zealand reports, and you don’t know what a chiropractic subluxation is- why are you even posting here? Methinks I smell a troll.
Hi Joe and pmoran
all the references and answers to your questions are in previous posts. have a look, especially the Terrett book.
here are some more.
http://books.google.com/books?id=SwhoZYtgVd8C&pg=PA304&lpg=PA304&dq=headaches+jull&source=bl&ots=7sFslNpRf0&sig=yDt6FjqMh1yK7TheC4kpEKhcCm8&hl=en&ei=vcEoSuLDMpqutAOlmKmyCw&sa=X&oi=book_result&ct=result&resnum=1#PPA304,M1
Have a look at the qualifications of this very well known and eminent Australian Physiotherapist. Look at the organizations she belongs to.
http://uq.edu.au/ccre-spine/gwen-jull
http://uq.edu.au/ccre-spine/gwen-jull
In fact Gwen Jull has done some extensive research into manual therapy and the treatment of headaches and whiplash disorders. Follow her links.
More from Jull
http://www.cam.org.nz/Treatment%20Methods/Other/Physical%20therapies%20for%20chronic%20headache%20Evidence%20review%20-%20%2008%20Aug%2006.htm
More physiotherapy citations
http://www.physiosouth.co.nz/files/the_evidence_01_web.q.pdf
Bogduk N. Cervical causes of headache and dizziness.,In: Grieve GP. Modern Manual Therapy. Churchill Livingstone; 1994: 317-331.
Jull G. Headaches associated with the cervical spine – a clinical review. In: Grieve GP. Modern Manual Therapy of the Vertebral Column. Churchill Livingstone; 1986: 322-329.
The list is endless. Jull has done extensive research into the complications from SMT.
Harriet, in the original post, said this was about “Adverse effects of chiropractic”.
This was based on a survey, whose authors were unequivocal in its abstract: “CONCLUSION: There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue.”
However, Harriet concluded, from this same study, that “chiropractic manipulations, especially neck manipulations, carry a small risk of serious consequences, a large risk of minor adverse effects”.
OK, difference of interpretation perhaps.
But she also stated “There is a very good chance that you will feel worse after seeing a chiropractor.” No evidence was provided for this — none of the studies cited investigated whether patients “felt worse”. For example, I have had many medical treatments with side effects, some quite bad, but with most I still “felt better”.
It unhelpful to muddy the waters like this.
Adverse effects of chiropractic do occur – some very serious. It is not at all clear whether similar manipulations done by non-chiropractic practitioners have similar risks; nor whether it is particular kinds of chiropractic treatment that are risky; nor whether the risk profile is better or worse than non-chiropractic treatments for the same conditions; nor whether the risks are greater than background life risks. But chiropractic manipulation is very common, and other kinds much less so, so if there is a risk, that is where our attention should focus.
The standard to which all treatments should be held to is that the risk of harm should be proportionate to the likelihood of improvement. But no such risk-benefit analysis can be done without information on both risks and benefits. Where we do not know the risk, or do not know the likelihood of improvement, we have to tread cautiously — and we know that sometimes medical practice shows insufficient caution. Likely benefit, and likely risk, must be estimated from evidence we already have about the body; and effects must be monitored as trials progress.
However, no such caution is shown by most chiropractors, nor most professional associations of chiropractors.
The balance of evidence is extremely strongly against subluxation theory, and there is no mechanism proposed for it that fits with what we have evidence for about the body. There is no evidence that chiropractic manipulation works for most of the things which many chiropractors claim.
However, even if subluxation theory is wrong, there seems to be some beneficial effect from the treatment for some conditions — eg lower back. Until we know how it works, it will be difficult to assess risks except by inference from similar treatments, and tracking of adverse effects.
Research should focus on the areas with most promise for spinal manipulation, and seek understanding of what is going on, together with tracking of adverse events and assessment of risks.
Chiropractic, in all its forms, is struggling to find provable usefulness as medicine progresses; and if this continues, it should die out; just as blood-letting did before it. Almost certainly, its core theory is wrong; all that remains is to determine if some of its practices can be useful.
But overstating our level of certainty about the risks, and conflating “adverse effects” with “feeling worse” is not going to help unseat it.
For reasons known only to chiropractic leaders, there seems to be a fair bit of research testing subluxation theory and finding it lacking, but no good research about its risks, precious little about where it actually works, and almost none about how it actually works. That is the real story, in my mind: how can a medical practice, with many active practitioners, be in such a position after all these years? Why have they not done the research? Why should patients go them, if they do not do the research?
Joe – “Sorry, I won’t send the articles because I don’t give out me e-mail address.”
What a joke. You mean to tell me you don’t have some nondescript E-mail address like Joe@yahoo.com you could use?
I think you are lying now Joe. I think you don’t have the articles you cited and that means you have not read them either.
Prove me wrong Joe. My E-mail is nwtk2007@yahoo.com.
To continue to site articles and studies that you have not read is dishonest at best and kills your credibility.
@Fred Dagg on 05 Jun 2009 at 2:18 am
The items you offer are not sufficient. And G. Jull is a PT. I never understood why chiros claim to be better than PT; but then want to cite PTs as evidence in favor of chiropracty.
nwtk2007 on 05 Jun 2009 at 6:48 am …
The first article is free On-Line, how much simpler does life get?
http://www.jrsm.org/cgi/content/full/99/4/192
I guess I failed to mention that I have that one, “A review of reviews”. Nothing new there by the way.
And what is “chiropracty”. The same as chiorpractic or choirpracty?
And chiropractors don’t compare themselves to PT’s, we merely point out that we are not the only ones who do manipulation. I had a patient some weeks ago went to her DO for a sinus problem, was given antibiotics and a cervical manipulation which she compared to mine as being identical.
There really is no comparison of chiro’s to PT’s really. I work with one now, I have worked with others and can confirm this thru my own experience. I will say this, no one can “stroll” through their day like a PT and no one can delegate more to an unlicensed aid than a PT. Oh yeah, and everything they see in a musculoskeletal problem is myositis. Everything. And they will always prescribe home esercises if there is no specific “machine” regime they can place them on. And they just don’t seem to want to “see” patients. And ….
@nwtk2007 on 05 Jun 2009 at 8:24 am “I guess I failed to mention that I have that one, “A review of reviews”. Nothing new there by the way.”
Exactly- “Conclusions: Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.” Nothing new there.
@nwtk2007 “I had a patient some weeks ago went to her DO for a sinus problem, was given antibiotics and a cervical manipulation which she compared to mine as being identical.”
Identical as in being useless, or, can you provide high-quality, definitive reports of it being effective for sinus problems?
The DO obviously thought it would help. The patient said it helped clear her head and got rid of the sinus HA she had at the time. According to the patient, the decongestants were no longer needed and the antibiotic cleared up heer infection within a few days, although she continued to take the antibiotics as her doctor ahd recommended until they were gone.
Maybe the DO has some studies we are unaware of.
nwtk2007,
I, being a PT, am not surprised by your experience with PTs. My experience with my colleagues who work in chiropractor’s offices is similar to what you describe.
When one considers what most of these PTs are OK with in regards to what the chiropractors tend to call “physical therapy” it is not surprising. I constantly encounter chiropractors who advertise that they provide physical therapy (without one on site), or some derivative of the words like “physiotherapuetic modalities” when in fact they provide e-stim, or ultrasound, or have an exercise ball, or employ a personal trainer. Or they’ll call me and say “I want to have you do the physical therapy on this patient of mine because I just don’t have the time to do it myself.” What an insult. This would be like a PT saying that they provide “chiropracticals” if they perform spinal manipulation. Insulting and misleading right?
I’ve had experiences with chiros that diverge from this, but they are the exception.
So, I’m not surprised that your experience with PTs working in chiro settings are providing care of the quality that you describe. They obviously have a different idea of what physical therapy is as compared to most of the rest of us and are, as you say, just strolling through their days.
And if you encounter PTs who delegate innapropriately to aides and just walk their patients through machine regimes all day long or continue to waste time on ultrasound or the other useless modalities (and I know that this lack of quality of care is out there), sounds like its time you refer elsewhere. I certainly wouldn’t continue to send my patients to such an “insurotherapy” provider.
@nwtk2007 on 05 Jun 2009 at 12:23 pm “The DO obviously thought it would help.”
Years ago, doctors thought bleeding, scalding, purging and leeches helped. You don’t understand the difference between anecdote and evidence.
There is no good evidence that neck manipulation helps sinus problems- cite definitive evidence that shows I am wrong.
I said the DO abviously thought it would help, not “I” thought it would help. And the patient thought it “did” help.
And I heard bleeding is on it’s way back! Getting my leeches ready to go.
As to the PT’s, the ones I see at work and in the clinics we occasionally refer to are running work hardening programs. During a day of work hardening, the patients will interact with the aid almost all day while the actual PT sit’s at a desk. The most they do is perform FCE’s or eval’s, most of which translate into a home exercise program or a referral to the work hardening program where the patient works very closely with the aid in doing a range of exercises, stretching, cardiovascular exercises, or the once a week visit with the psychologist for his “here’s how you avoid eating to much” or “here’s some things to avoid or do” speeches, or his “stay away from alcohol and caffeine” talks. Almost NO actual PT where the PT is actually working with a patient.
The PT feels put upon if she/he has to do more than two evals in a day.
I know quite a few chiro’s who are getting the referral for post op therapy as the PT’s do next to nothing in the clinics around town.
There is a lot of PT talk about rules and regulations regarding some very anal issues which amount to next to nothing, and they seem to be very paranoid about locking doors to storage closets, bathrooms, and kitchens, not to mention the rather vocal need to maintain separate restroom facilities from the patients.
How are you different, Mr Blick, from the PT’s I have observed?
nwtk2007 on 05 Jun 2009 at 2:28 pm “I said the DO abviously thought it would help, not “I” thought it would help. And the patient thought it “did” help.”
Can you say back-pedaling? I thought you could.
What does it matter that your customer thought it was helpful? People used to think that “purging” helped them. Would you pass that along without reflective comment? Does nothing embarrass you?
Why would I be embarrassed to have listened to my patient?
I am not saying that I really and truly think the manipulation helped her to be able to stop taking decongestants, I simply report what she said.
The first and number one thing to do to be able to help a patient is to listen to them and at least note in your mind what they said; in otherwords LISTEN.
Step number one to treatment is to listen to your patient. Maybe there would be a lot less malpractice and a lot fewer deaths due to error and mistakes if listening occured … at all.
You ask, “What does it matter what my “customer” thinks?”
That has got to be one of the most idiotic comments I have ever heard from anyone regarding a doctor patient relationship/interaction or what ever YOU might call it. Believe me, it IS part of the doctor/patient relationship to LISTEN to the patient.
You’re worried that I might be embarrassed? Look in the mirror.
Do you actually work with patients in any form what so ever or do you just do it in your mind?
“What does it matter that your customer thought it was helpful?” ……..WOW………Customer? ……
Fred, the Cochrane database cannot be freely accessed unless you live in a country that subscribes to it, as I do. So I am unable to show you how their exhaustive and relatively unbiased reviews of the clinical studies (they have produced ones favouring acupuncture and even fairly neutral ones on homeopathy) contain far more reliable judgments regarding the efficacy of treatments than the material that you want us to be reading.
But keep on thinking critically about it all, and in the meantime be very careful with those necks.
nwtk2007,
Work hardening is totally overutilized in my estimation. It has its place in a narrow population of chronic pain (not that his population is narrow, but hardening is often used for every worker whose been off work for any period of time). If these are the only clinics in your area and all they are doing is work hardening, you’ve not got a good representation of what PT typically consists of. Most PTs who do any kind of manual therapy would not likely stay long in a clinic such as this, as it tends to be entirely hands off, and so would give a poor sampling of PT in general. Thus your view that PTs don’t like to actually see patients. Likely the same if your only experience is with PTs who work in a chiropractic clinic as I said before, IMO.
In my practice, we see every patient one on one, no support staff doing any patient care. Only one restroom.
[...] reader perversely determined to distract me from the writing of my book put this worm on a hook and cast it my [...]
Looking at the best evidence available, there is good research supporting the use of SMT for mechanical neck pain. Fred Dagg is indeed correct that this document, the BJD Neck Pain Task Force is the GOLD Standard with respect to the best evidence in neck pain management. It was published in 2008 and it was a multi-disciplinary document consisting of DCs, MDs, OTs, PTs, PhDs, etc. Clearly there is a definitive benefit (in comparison to risk) otherwise it wouldn’t have been recommended.
Nevertheless, there is much confabulation going on here with SMT=chiropractic care. In fact, there are numerous instances where a non-chiropractor performed a cervical manipulative procedure which resulted in a serious adverse event only to be published as a “chiropractic”manipulation.
Yet, there is research that is SPECIFIC to chiropractic manipulation which involves manipulation done by chiropractors which involved looking at a) adverse events and b) risk/benefit.
Dr. Rubenstein, DC, PhD recently published his thesis (2008) which specifically looked at adverse reactions in cervical manipulation done by chiropractors and identifying predictors to those events.
Predictors of adverse events following chiropractic care for patients with neck pain.
Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW.
CONCLUSIONS: Of the 60 independent variables examined, only 4 were found to be predictive of adverse events after chiropractic treatment for neck pain, one of which was found to be protective. The chiropractic practitioner can identify 3 of these variables before initiating treatment.
Next article for consideration:
Benign adverse events following chiropractic care for neck pain are associated with worse short-term outcomes but not worse outcomes at three months.
Rubinstein SM, Knol DL, Leboeuf-Yde C, van Tulder MW.
CONCLUSION: Self-reported benign adverse events after chiropractic care for neck pain are associated with worse short-term outcomes. Intense adverse events are associated with more neck disability and clinically relevant differences at the short-term only. However, there is no association between adverse events and worse outcomes at 3 months.
However, the smoking gun which specifically looked at risk/benefit appears here
Adverse events following chiropractic care for subjects with neck or low-back pain: do the benefits outweigh the risks?
Rubinstein SM.
Quote
“The incidence of severe complications following chiropractic care and manipulation is extremely low. The best evidence suggests that chiropractic care is a useful therapy for subjects with neck or low-back pain for which the risks of serious adverse events should be considered negligible.”
All articles from 2008, all published in respect biomedical journals, all specific to chiropractic care.
To the dogmatic skeptics out there, the research suggests that a) SMT for mechanical neck pain Grades 1,2 is effective (moreso when combined with exercise) that it relatively safe (benign, minor side effects) and most importantly, the benefits outweigh the risks.
Please refrain from ad hominems and logical fallacies and stick to the research which is what I am basing my argument on.
Thank you,
NMS
Oh, thank goodness there is someone else out there who has looked at the peer review research!!!!!!!!!!!!!!!!!!!!!
@NMS-DC on 08 Jun 2009 at 8:27 pm.
Rubinstein’s articles are mostly in JMPT, which is written by and for chiropractors and known for its low quality.
Mr. Dagg, JMPT is for quacks, and the peer-review is by quacks. So, yes it is peer-reviewed; but it is unreliable. People who do good research do aspire to publish there; it is only for shoddy work.
“People who do good research do aspire to ” should say “People who do good research do not aspire to ” publish in JMPT.
Hi Joe
sounds to me like you have a really bad case of sour grapes.
Anecdotes and unsubstantiated opinion like yours have only a limited role in a site like this
Have a nice day.
Fred
Fred,
Joe has already more than once in past comments admitted that he has not read the studies he has commented on. At most he will look at an abstract, but more often than not, he won’t even look at that.
My favorite of Joe’s responses are the ones where he comments with mistakes which make it readily apparent that he has NOT read the studies cited.
Sour grapes indeed.
Reminds me of Wisdom who comments against chiropractic on the Topix forums.
I had asked that he actually E-mail me a study he cited in this thread that he claimed to have read on a Web journal that costs 31$ to read the entire article but Joe says he won’t do it for fear of giving out his E-mail as if he couldn’t have a non-descript one like Joe@yahoo.com. Too paranoid. Thinks someone might track him down or something I guess.
@ nwtk2007 on 10 Jun 2009 at 7:09 am
I do not comment on things I don’t see (except to cite other, informed opinion), that is disturbed thinking on your part. What I have said is that I have quit looking at quack publications because it is a waste of time since they are so amateurish.
Often, an abstract is sufficient to know that a study is not definitive. Let me help you out- if the study involves 30 subjects, is not blinded and is not controlled and is based on subjective measures- it is about as useful as an anecdote.
As for the Spine article I won’t send you, a health professional would know how to get it at no cost, just as I did. Why scrimp, it is your business- don’t you want to know the current thinking about it? Considering that “Spine” publishes a lot of articles concerning chiro, why don’t you subscribe?
@ nwtk2007 on 10 Jun 2009 at 7:09 am
What is one to think of a “professional” who does not subscribe to the relevant literature?
NMS-DC is indeed correct when he posts:
“Nevertheless, there is much confabulation going on here with SMT=chiropractic care. In fact, there are numerous instances where a non-chiropractor performed a cervical manipulative procedure which resulted in a serious adverse event only to be published as a “chiropractic”manipulation.”
–which leads to flawed “bottom lines” such as:
HH—The bottom line: “chiropractic manipulations, especially neck manipulations, carry a small risk of serious consequences, a large risk of minor adverse effects; and, depending on the indication,
there is little or no evidence that they are effective.”
To de-construct the confabulation, let’s take a look at a few papers which address this very issue:
http://www.chiroandosteo.com/content/14/1/16
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer-reviewed biomedical literature
Conclusion:
The results of this year-long prospective review suggests that the words ‘chiropractor’ and ‘chiropractic manipulation’ are often used inappropriately by European biomedical researchers when
reporting apparent associations between cervical spine manipulation and symptoms suggestive of traumatic injury. Furthermore, in those cases reported here, the spurious use of terminology seems to have passed through the peer-review process without correction. Additionally, these findings provide
further preliminary evidence, beyond that already provided by Terrett, that the inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ may be a significant source of over-reporting of the link between the care provided by chiropractors and injury. Finally, editors of peer-reviewed journals were amenable to publishing ‘letters to editors’, and to a lesser extent ‘corrections’, when authors had inappropriately used the title ‘chiropractor’ and/or term ‘chiropractic manipulation’.
AND
http://www.ncbi.nlm.nih.gov/pubmed/7636409?dopt=Abstract&holding=f1000,f1000m,isrctn
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Misuse of the literature by medical authors in discussing spinal manipulative therapy injury.
CONCLUSION: The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical
organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a nonchiropractor. The true incidence of such reporting
cannot be determined. Such reporting adversely affects the reader’s opinion of chiropractic and chiropractors.
One recent example:
http://www.ncbi.nlm.nih.gov/pubmed/16511634?dopt=Abstract
Vertebral Artery Dissections After Chiropractic Neck Manipulation in Germany Over Three Years
J Neurol 2006 (Mar 6); [Epub ahead of print]
Reuter U, Hamling M, Kavuk I, Einhaupl KM, Schielke E
Charite-Universitatsmedizin Berlin, Dept. of Neurology, Schumannstr. 20-21, 10098, Berlin, Germany,
uwe.reuter@charite.de
Abstract:
Vertebral artery dissection (VAD) has been observed in association with chirotherapy of the neck.
However, most publications describe only single case reports or a small number of cases. We analyzed data from neurological departments at university hospitals in Germany over a three year period of time of subjects with vertebral artery dissections associated with chiropractic neck manipulation. We conducted a countrywide survey at neurological departments of all medical schools to identify patients with VAD after chirotherapy followed by a standardized questionnaire for each patient. 36 patients (mean age 40 + 11 years) with VAD were identified in 13 neurological departments. Clinical symptoms consistent with VAD started in 55% of patients within 12 hours after neck manipulation.
Diagnosis of VAD was established in most cases using digital subtraction angiography (DSA), magnetic resonance angiography (MRA) or duplex sonography. 90% of patients admitted to hospital showed focal neurological deficits and among these 11 % had a reduced level of consciousness. 50% of subjects were
discharged after 20 +/- 14 hospital days with focal neurological deficits, 1 patient died and 1 was
in a persistent vegetative state. Risk factors associated with artery dissections (e. g. fibromuscular dysplasia) were present in only 25% of subjects. In summary, we describe the clinical pattern of 36 patients with vertebral artery dissections and prior chiropractic neck manipulation.
Key words chiropractic – neck manipulation – artery dissection – disability
~~~~~~~~~~~~~~
This abstract blatantly conceals the facts stated in the body of the paper when it states that “we describe 36 patients with vertebral artery dissections and prior chiropractic neck manipulation”.
Of the 36 “patients”, –18—yup!-50%! were treated by orthopedic surgeons! 2(6%)- by a GP, 1(3%)- by a neurologist, 5(14%)- by physiotherapists, 1(3%) Homeopath, 3(9%) Unknown.
The factual “bottom line” here is —-89% of the cites were NOT treated by a DC!
The shoddy, even perhaps biased, construction of the abstract and poor choice of keywords confabulates the contents of the paper. Thusly, misleading all who are searching those terms and keywords. And therby directly contributing to flawed “bottom line” conclusions.
There is a very interesting report
http://www.quackometer.net/blog/2009/06/chiropractors-told-to-take-down-their.html
This may have significant implications.
Joe, based upon your recent post I just called five MD’s at random in the Dallas FtWorth area. Not one subscribed to any medical journal at all. They claim to keep up with relevant research through continuing ed seminars and licensing course work as well as through the internet services.
No doctor subscribes to ALL of the relevant literature. Sorry for this misconception you have about health care providers.
The real worry are the ones who don’t read it when it is readily available or claim to have read it but haven’t. To limit your reading only to studies of double blinded nature with huge numbers of subjects is a bit silly at best.
As to the letter from the McTimoney Chiropractic Association, they do mention “advertising for treatments not supported by Chiropractic research”. If you don’t recognize chiropractic research publication as valid then you would have a point to make, but since much of chiropractic is supported by “chiropractic” research then then I suppose you don’t.
And besides, Joe’s says it doesn’t matter what the “customer” thinks helps so what is the point of research or treatment? If we don’t care what they think helps then all we need do is tell them that they are OK and move on. Thus 500 deaths per day from medical mistakes and errors, I guess of caring or not caring (not sure which) what the “customer” thinks.
@ nwtk2007 on 10 Jun 2009 at 3:57 pm “Joe, based upon your recent post I just called five MD’s at random in the Dallas FtWorth area. Not one subscribed to any medical journal at all.”
I believe you, and I believe in the tooth fairy since I used to get a nickel every time I lost a tooth. I am not surprised that you, and your imaginary friends, don’t try to keep up with the literature.
@ nwtk2007 on 10 Jun 2009 at 3:57 pm “As to the letter from the McTimoney Chiropractic Association, they do mention “advertising for treatments not supported by Chiropractic research”. If you don’t recognize chiropractic research publication as valid then you would have a point to make, but since much of chiropractic is supported by “chiropractic” research then then I suppose you don’t.”
Hoist by your own petard. “Chiropractic research” does not support the claims they were making. It is not that such “research” is amateurish, it goes to professional evaluation.
Health professionals have “patients,” lawyers and accountants have “clients,” merchants (such as yourself) have “customers.” Deal with it.
Dang, formatting problems. The bottom line “chiropractic” research does not support its practices.
NMS-DC “Looking at the best evidence available, there is good research supporting the use of SMT for mechanical neck pain. Fred Dagg is indeed correct that this document, the BJD Neck Pain Task Force is the GOLD Standard with respect to the best evidence in neck pain management. It was published in 2008 and it was a multi-disciplinary document consisting of DCs, MDs, OTs, PTs, PhDs, etc. Clearly there is a definitive benefit (in comparison to risk) otherwise it wouldn’t have been recommended. ”
The executive summary of this document makes NO specific recommendation of neck manipulation. It mentions neck manipulation as one of eight treatments “worth considering”.
The reviewers also seem to have given undue weight to a single seriously flawed study on the risk of stroke from spinal manipulation, the one claiming that that there were no more strokes after visits to chiropractors than visits to medical practitioners.
This, together with an emphasis upon its supposed rarety, suggests a bias on these reviewers towards chiropractors, because no other group could completely ignore the implications of the available evidence on stroke. Any other group would see the desirability of discouraging its use as the first line of treatment for conditions that can nearly always be adequately managed without it.
Joe, old confuscious saying, applies to you.
“There are none so blind, as those who will not see”.
I am sure you will want the last reply to this post, with your normal sarcasm, snide and unsubstantiated remarks. So help yourself.
However, despite what you think, responsible health care is multi-disciplinary. No one has all the answers and even Evidence Based Medicine contradicts itself.
You just need to look at the conflicting rates of low back surgery in the U.S.A. in comparrison to the United Kingdom. (Five times the rate).
I would really like someone to tell me why? Because the cynical and sceptical side of me tells me that there now are some very wealthy orthopaedic surgeons in the U.S.
Perhaps a brave member of the EBM panel could write a critical analysis of this. I will not hold my breath, as I do not believe people like Harriett Hall have the desire to look in the mirror of medicine as it exists in the U.S.A.
Evidence Based is looking at all the evidence, and not dismissing it because of the publication it was in.
Evidence Base is realising there is more than one correct answer and that knowledge is in a continual state of flux. It changes.
Have a nice day, Joe.
Poor Joe,
You just can’t hide that bias of yours. Were you unsuccessful in your attempt to be a chiro yourself? Did you fail at something that was indirectly attributable to a chiro influence? Do you take orders from chiro’s? Are you just a PT and not a doctor?
When I see my patients everyday I often think of you. When I take their medical history, review their complaints, perform examinations, order x-rays, other imaging if needed, formulate treatment plans, coordinate their care with other physicians, chart their progress, modify their treatment plan accordingly, etc, etc, yes, I often think of you.
When my patients thank me for their help and their care, I really appreciate the comments like yours, calling me a merchant and my patients customers. I’m sure they would appreciate it also.
We all understand the immaturity behind your bias and the overwhelming desire to get revenge on our profession for some past hurt you must have endured at the hands of the profession as a whole.
Thank you for your bias, it undermines any logical argument you might have against chiropractic and lifts us above the rest, so to speak.
Thanks Joe.
Dr. Moran,
“The executive summary of this document makes NO specific recommendation of neck manipulation. It mentions neck manipulation as one of eight treatments “worth considering”.
1) Your personal opinion aside, this Task Force was comprised of individuals representing the medical, chiropractic, physical therapy, occupational therapy professions and PhDs. To suggest that DCs somehow convinced all these other clinician-scientists to display bias TOWARDS spinal manipulation is absurd.
2) The document does indeed recommend spinal manipulative therapy for uncomplicated (Gr 1,2) mechanical neck pain along with other conservative therapies commonly practiced by doctors of chiropractic such as soft tissue therapy (massage), exercise rehabilitation, education/counseling, etc.
3) The best evidence suggests that serious, adverse events following neck manipulation (in particular upper cervical) manipulation are extremely rare and negligible.
It is rather distressing to see some posters here who claim to be “evidence-based” and on the “side of science” arbitrarily ignore the literature that refutes their claims which seem to be based more on personal philosophy and dogma than the most current literature.
NMS
Joe,
Is Dr. Ernst a quack? He is a peer reviewer of JMPT.
Unfortunately, you and many others here will have to learn to accept (or grow accustomed) to evidence-based chiropractors who are informed, knowledgeable and are the experts are manual medicine which is a very legitimate and increasingly popular form of therapy for many neuromusculoskeletal conditions.
First a general question: is the practice of chiropractic medicine appropriate for neuromusculoskeletal conditions? Your answer will determine whether or not you are rational skeptic or merely dogmatic, idealistic one.
Remember, this is a science-based blog. Stick to the science. And, if you have questions regarding common chiropractic practice/theory, feel free to ask. I’m here to help, clarify and educate.
NMS
NMS-DC: “The document does indeed recommend spinal manipulative therapy for uncomplicated (Gr 1,2) mechanical neck pain along with other conservative therapies commonly practiced ”
I don’t have to accept such a statement. I would like to know precisely what this paper says about the efficacy of spinal manipulation, and why it would differ from ether that differs materially from that of an at least equally comprehensive review of the 37 available studies of spinal manipulation for neck pain, which found no significant difference from sham treatment and other commonly used treatments when used alone.
I am not saying spinal manipulation NEVER works. I am saying it is not obviously superior to other methods and that its risks can be justified only under certain circumstances and with a high standard of informed consent.
The theory that the vertebral artery dissection precedes the manipulation may explain an occasional case, but it is grasping at straws. It cannot explain all the cases, such as the fatal stroke that occurred after the 11th cervical manipulation for tension headaches and those cases where the patient had no symptoms, or different ones prior to the manipulation. Then there are the cases where the patient collapses or is paralyzed immediately, or that have bilateral VAD coincidentally with NM.
“is the practice of chiropractic medicine appropriate for neuromusculoskeletal conditions?”
That depends on what you mean by “chiropractic medicine.” If you mean finding and correcting subluxations, no it isn’t appropriate, because chiropractic subluxations are mythical. If you mean “whatever a chiropractor does” then the answer is yes, but only if the chiropractor uses spinal manipulation therapy for appropriate indications and/or uses exercise, heat, massage, lifestyle advice, etc. appropriately and avoids inappropriate treatments like neck adjustments for low back pain.
Edzard Ernst said that “Chiropractors… might compete with physiotherapists in terms of treating some back problems, but all their other claims are beyond belief and can carry a range of significant risks.”
Is spinal manipulation therapy appropriate for neuromusculoskeletal conditions? Yes, for certain limited ones. But it is not superior to other treatments. And it carries risks. And it can be done by physical therapists.
In essence, the only “appropriate” things “chiropractic medicine” offers are the same things physical therapists can offer. One might question whether it is “appropriate” to seek those services from a chiropractor whose education was based on a myth and on pseudoscience.
Hello Harriett
as you do not reference any of your comments, so they will be treated as anecdotal or opinion.
Your desire that chiropractors use methods e.g. heat and massage, that are essentially un-substantiated by peer review literature is interesting. Please provide me with the references that cite physical therapy modalities such as heat, massage and ultra-sound are effective and for that matter ethical. Cerival mobilization, a treatment used by all practitioners of Spinal Manual Therapy is not without its risks. Please tell me that the manipulative treatment styles are different? I do not know and I have witnessed examples of all the styles, as I have pointed out to you in the past.
You quote Edzard Ernst. Well done, but we have shown you time and time again that those comment from him about the dangers and risks relate to “Spinal Manual Therapy”as opposed to chiropractic care. Ernst is wrong to say those things, as has been proven to you in previous posts by me and several other contributors to this site. In fact, because he is so “anti-chiropractic”, it makes his comments irrelevant. He would be considered a hostile witness in a court of law. This has been pointed out to you as well.
You compare chiropractic treatment to that of physical therapy. Great!!!!!!!!!!!! The dangers are still the same, irrespective of the practitioner. I have pointed this out to you as well. Now we need to see from you as a contributor to “Evidence Based Medicine” is a report to show that a physical therapist, osteopath or medical practitioner is more effective in the treatment they provide.
“Please provide me with the references that cite physical therapy modalities such as heat, massage and ultra-sound are effective and for that matter ethical.”
I don’t think Harriet mentioned ultrasound, but the paper that NMS-DC suggested should be regarded as the “Gold Standard” on neck pain lists massage as among the treatments apparently equally “worth trying”. I am sure heat would produce temporary ease. Here is their list.
Education
Exercise
Mobilization
Manipulation
Acupuncture
Analgesics
Massage
Low level laser therapy
http://www.wfc.org/Website/wfc/Graphics.nsf/Graphics/Neck Pain Task Force Key Findings/$file/NPTF Key Findings.doc
More of their comments –
Pain relief is often modest and short-lived.
Be cautious of treatments that make “big” claims for relief of neck pain.
Short episodes of care may be helpful: lengthy treatment is not associated with greater improvements.
As with low back pain, it is possible that no treatment actually terminates the condition and that most act mainly via placebo influences.
The link above does not work-”no website found”
Please repost?
Harriett,
Thank you for responding. I’ll take time to address your points in 2 separate posts, first with the comparison of physical therapy.
It seems as of late, PTs are doing their very best to become full fledged clinicians (in the US at least) as they move towards a full Doctor of Physical Therapy (DPT) program. More than ever, they are including SMT in the core curriculum as they attempt to replace DCs are the expert in manipulative therapy. Physical therapists are well needed and definitely have a role in MSK arena, but they do not duplicate the services or expertise offered by chiropractors.
Unfortunately, the comparison between DCs and PTs does not do chiropractors justice for many reasons. First, PTs have no formal training in diagnostic imaging, either in taking radiographs or interpreting them. Nor do they have the training to order and interpret laboratory diagnostic tests like blood and urine work. These are in the undergraduate component of the chiropractic programme as well. Also, the majority of chiropractic schools offer differential diagnosis in ORGANIC/VISCERAL conditions in addition to neuromusculoskeletal. I don’t suggest my diagnostic skill set in organic pathology is as polished as an MD, but I can at least provide reasonable differentials and perform basic exams in EENT, abdomen, thorax/lungs and know when to refer when the condition falls outside my scope of practice.
Lastly, to those who are concerned about the safety of SMT, then it is dubious to suggest that PTs are better equipped to perform this psychomotor skill since they rarely a) use it clinical practice and b) devote little time to learning adjusting techniques. Proper delivery of SMT requires time, experience and skill. Letting other professions perform manipulation without the recommended training as per the WHO is compromising patient safety.
Hence, while it may seem to be appropriate to compare DCs to PTs and see a redundancy, chiropractors are establishing the cultural authority in manipulative medicine and in becoming the spinal health care experts.
I will address your comment regarding the chiropractic subluxation in a subsequent post.
NMS
Nobs, if you mean the Executive summary of the BJD Neck Pain Task Force that I was quoting from, this tinyurl may help.
http://tinyurl.com/mddqqu
Just a word on the PT’s here in Texas NMS:
Every legislative term the PT’s try to pass laws allowing them to perform SMT. They can already do joint mobilization but they want to “pop” necks and backs because patients almost always say it is extremely helpful for their pain and function.
The ones I have observed really, really, really want to be doctors and to be free of the doctor referral they need to see patients.
The ones I have observed do very little, however, and tend to talk down to patients as well as doctors; MD’s, DO’s and DC’s alike.
They are extremely territorial and extremely anal about trivial things.
Most of the PT’s I have worked with, not all mind you, think they know everything; more than any doctor could.
I will say, however, the hospital PT’s I know are very good people, very gracious and very helpful. I really like to refer to them when the opportunity arises. This statement alludes to tone made by coryblick a few comments back. I think that might be where they do their best work and should probably stay there. It’s just my experience with them and so, I am just saying.
On a different note, why is it that the anti-chiro, anti-SMT folks always so venomous in their resistance when there is so much to clean up in the medical profession in general? It is as if they have some personal vendetta against chiropractors and try to lump them up into one package: subluxation practioners.
Why is it that guys like Joe won’t even read the works he cites as evidence of his position? How is it that chiro’s and anti-chiro’s or anti-SMT’s read the same thing and both come to such a different conclusion? It reminds me of democrats vs republicans. But if “everyone” is “independent” as they say, then why do only the democrats or the republicans get elected?
Digression but analogous.
pmoran:
Nobs, if you mean the Executive summary of the BJD Neck Pain Task Force that I was quoting from, this tinyurl may help.
http://tinyurl.com/mddqqu
~~~~~~~~~~~~~~~~~~~
I don’t think that is a link to site you posted above as:
http://www.wfc.org/Website/wfc/Graphics.nsf/Graphics/Neck
This(above) is the errant link I was referring to.
Thank-you
Harriett,
In my follow I want to address the “mythical” chiropractic subluxation. I also want to state emphatically that I support the physical therapy profession and they are skilled at what they do. But DCs fulfill a very important niche as well, one they they are experts at: manual therapy and, in particular spinal manipulation.
That brings me to my next point. What exactly are ANY manipulative practitioners manipulating/adjusting? What is there purpose and what is their target if any? Specificity, like coryblick alluded to is a different ballgame (although there are many valid arguments that moving cephalad it is far easier to palpate joint dysfunction and to target a specific spinal motion segment than it is in the lumbar spine.
So, let’s get back to it. Subluxation. It would help to dissociate subluxation PHILOSOPHY (in particular straight chiropractic philosophy) which essentially in 1895 suggested that vertebral joint dysfunction caused a disruption in innate/energy which was responsible for disease. Like the water/hose analogy. It doesn’t take a genius to know this is absurd. This was a turn of the century idea.
However, skeptics seem to think that time has stood still and that chiropractic medicine has failed to evolve or to provide plausible models for subluxation. Subluxation is known in osteopathic medicine as somatic lesion, and is synonymous with segmental dysfunction, joint restriction/fixation/dysfunction, etc. The mortise joint in the ankle, could be subluxated (chiropractically speaking). So, it’s important for the medical community to realize first and foremost the main component of the chiropractic subluxation: abnormal BIOMECHANICS. The joint is not moving correctly in some way shape or form.
I graduated from CMCC where the term subluxation isn’t used and we basically just called it joint fixation/restriction and to be honest I don’t like the term subluxation because its baggage and the fact it has such a negative connotation outside (and inside) the profession.
But, nonetheless, the concept of structure affecting function, i.e. improper joint mechanics affecting at the very least neuromusculoskeletal function is valid.
Next, I shall present some of the more recent research on chiropractic subluxation/joint dysfunction and help present the contemporary view so that, at the very least, the critics can attack the research and stop spewing nonsense from 1895 that is neither valid nor reliable in 2009.
First, the subluxation is essentially a biomechanical lesion in the spine. Dr. James DeVocht, DC, PhD has a good paper that provides an updated model on subluxation: a manipulable lesion. Providers of SMT are manipulating SOMETHING that doesn’t feel quite right (to them and the patient).
Clin Orthop Relat Res. 2006 Mar;444:243-9.
History and overview of theories and methods of chiropractic: a counterpoint.
There is also some good research lately on animal models of the consequences of joint fixation/subluxation from a biomechanical perspective:
Introducing the external link model for studying spine fixation and misalignment: current procedures, costs, and failure rates.
Henderson CN, Cramer GD, Zhang Q, DeVocht JW, Sozio RS, Fournier JT.
J Manipulative Physiol Ther. 2009 May;32(4):294-302.
PMID: 19447266 [PubMed - in process]
Introducing the external link model for studying spine fixation and misalignment: part 2, Biomechanical features.
Henderson CN, Cramer GD, Zhang Q, DeVocht JW, Fournier JT.
J Manipulative Physiol Ther. 2007 May;30(4):279-94.
PMID: 17509437 [PubMed - indexed for MEDLINE]
Introducing the external link model for studying spine fixation and misalignment: part 1–need, rationale, and applications.
Henderson CN, Cramer GD, Zhang Q, DeVocht JW, Fournier JT.
J Manipulative Physiol Ther. 2007 Mar-Apr;30(3):239-45. Review.
PMID: 17416279 [PubMed - indexed for MEDLINE]
There is also some good, nascent research on the effects of SMT on neuroimmunological function:
Enhancement of in vitro interleukin-2 production in normal subjects following a single spinal manipulative treatment.
Teodorczyk-Injeyan JA, Injeyan HS, McGregor M, Harris GM, Ruegg
Chiropr Osteopat. 2008 May 28;16:5.
Spinal manipulative therapy reduces inflammatory cytokines but not substance P production in normal subjects.
Teodorczyk-Injeyan JA, Injeyan HS, Ruegg R.
J Manipulative Physiol Ther. 2006 Jan;29(1):14-21.
The least understood component of spinal manipulation is its effects on the autonomic nervous system and its role in somato-visceral responses. Nonetheless, there is likely a subgroup of indivuals who do respond to SMT for certain organic conditions and the research, over time will bear this out. But, let’s stick to the science when we’re debating here and avoid logical fallacies and ad hominems.
NMS
Nobs, its the same document.
Well, based on review of the majority of the posts here we can summarize the evidence such as
1) there is good evidence for the use of manual therapy, including spinal manipulation for uncomplicated mechanical neck pain grades 1,2
2) the best evidence that looks specifically at chiropractic care and cervical manipulation, as performed by Dr. Rubinstein suggests the serious adverse reactions are negligble and that the benefits outweigh the risks
3) there are numerous documented instances where medical journals have published case studies detailing a serious adverse event following a “chiropractic” neck manipulation only to see that in some instances, 89% where not done by a DC which is misleading the public and health professionals
4) Claims that PTs should become the default providers of SMTs proves that some posters here are more anti-chiropractic than SMT and would prefer that less adequately trained professionals provide a mode of therapy that is “potentially fatal”
5) the majority of skeptics rely on the “evidence” presented by Dr. Ernst who can now surely be called a anti-chiropractic extremist who attempts to denigrate and distort ANY possible good coming from the profession. Based on his stance which now borders on zealotry RATIONAL skeptics should seek to produce ORIGINAL high quality practice-based clinical trials that refute the evidence that has steadily accrued the past 2 decades in support SMT.
Moreover, Ernst’s “evidence’ (an army one 1) is being soundly refuted by multi-disciplinary panels of musculoskeletal medicine experts in Europe and North America whose papers carry more weight academically than the “systematic reviews of systematic reviews” of Dr. Ernst.
6) No one has even mentioned the blossoming specialization of animal/veterinary chiropractic (here comes Dr. Ramey!) which is increasingly becoming popular with pet owners, DCs, and DVMs as animals can benefit from manual therapy to increase their function and quality of life. Note to PTs out there who claim SMT is THEIR expertise: It’s called animal chiropractic, not animal orthopaedic manual physical therapy
NMS
” the best evidence that looks specifically at chiropractic care and cervical manipulation, as performed by Dr. Rubinstein suggests the serious adverse reactions are negligble and that the benefits outweigh the risks”
What “best evidence”? And death is a negligible risk for a treatment that some chiropractors dish out for almost anything?
Anyway I am glad that you are now acknowledging the risks.
Since your own “Gold Standard” paper sees other methods as having equal efficiacy to neck manipulation for neck pain but without the risks (e.g. acupuncture), what do you now see as the proper place of SMT in the treatment of neck pain?
While you are here, comment upon neck manipulation’s widespread use by chiropractors for headache, certain childhood complaints, and general “wellness”.
nwtk07,
I’m not sure what your hospital statement alludes to from my post. `Wanna hear about my experiences with chiros and some generalizations based upon them? Would that be a sensible argument of the state of your profession?
The PTs in Texas want the right to manipulate because it is within their skill set and expertise and this has the support of the evidence.
NMS-DC said:
“Claims that PTs should become the default providers of SMTs proves that some posters here are more anti-chiropractic than SMT and would prefer that less adequately trained professionals provide a mode of therapy that is “potentially fatal”’
Save the fear mongering for the statehouse. In order for chiropractors to keep SMT firmly in their legislative grasp they have to continue to show that 1) PT are inadequately trained- a fallacy 2) Patients are therefore less safe in their hands- a fallacy 3) chiro’s are more effective- a fallacy.
Evidently, to be “adequately trained” you must have spent years and thousands on learning to feel movements with a specificity and apply movements with a specificity which have been shown to be bogus perceptual fantasy. I’d say that’s worse than inadequate, that’s a waste! However, the more you spend on a ship the more likely you are to grasp to it tightly as it sinks.
Truth is that SMT is enty level education for PTs at this point. Student PTs are “adequately trained” and this has published research behind it. Also problematic for the chiros, I’d guess, is that the evidence continues to narrow the populations of patients for whom SMT is appropriate and likely to be pain reducing.
What the hell is your point on the animal chiro thing? I don’t know a single PT who would claim to provide any kind of chiropractic. We’re not chiropractors. That would be like a chiropractor claiming to perform physiother……oh wait.
(1) A Cochrane review found HVLA neck manipulation no better than mobilization, and neither worked alone; they had to be combined with exercise programs.
(2) The benefits may outweigh the risks for appropriate manipulations below the neck, but I’m not convinced that they do for neck manipulation. Manipulators and nonmanipulators draw different conclusions from the same evidence. Obviously those who use manipulation routinely or who use it exclusively are going to be biased.
(3) It’s pointless to quibble about who did the manipulation. We’re not trying to fix blame, but to establish the risk of the procedure, whoever performs it. Of course it gets associated in our minds with chiropractors because SMT is their main claim to fame.
(4) I don’t remember ever suggesting that PTs be the default providers of SMT. What I did was question whether chiropractic offers anything a well-trained PT couldn’t offer. Why is chiropractic special?
(5) Ernst is not a zealot. He is a professor of complementary medicine who leads a team that has researched the literature for something like 14 years now, who used to support alternative medicine and has gradually been forced to change his mind because he has recognized that the evidence just isn’t there. His opinion is supported by evidence, for instance by the independent Cochrane review showing manipulation for low back pain was no more or less effective than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner. Your poor opinion of Ernst does not change the evidence he and others have found.
(6) “animals can benefit from manual therapy to increase their function and quality of life.” Oh really? Where is the evidence? I hope our resident veterinarian will comment.
For the nth time, I have no vendetta against chiropractors. I would be delighted if they would reject the subluxation myth and provide appropriate short-term care of musculoskeletal problems without any of the quackery like applied kinesiology that so many of them have fallen for. I recognize that some chiropractors have become very skilled at SMT and that some of them have good diagnostic skills and can recognize red flags and refer appropriately. I would support any chiropractor who practiced science-based medicine.
Harriet Hall – “A Cochrane review found HVLA neck manipulation no better than mobilization, and neither worked alone; they had to be combined with exercise programs.”
These reviews are weak at best but I would agree with their findings. In my experience, it seems that combining any form of physical medicine with exercise definitely shortens the treatment time for many, if not most, patients. I sometimes wonder if it is just their lack of desire to perform exercises that shortens their treatment time. I would also say that a huge contributing factor to many musculoskeletal problems is lack of exercise. I still find that most patients, 80 to 90%, are in piss poor condition and it is no wonder that they are so easily injured.
Harriet Hall – “Manipulators and nonmanipulators draw different conclusions from the same evidence. Obviously those who use manipulation routinely or who use it exclusively are going to be biased.”
The reverse can also be said about the bias view of evidence. There is plenty of “evidence” of it seen by the comments of “some” of the folks who comment here regularly.
Harriet – “It’s pointless to quibble about who did the manipulation. We’re not trying to fix blame, but to establish the risk of the procedure, whoever performs it. Of course it gets associated in our minds with chiropractors because SMT is their main claim to fame.”
Isn’t that an admission of bias, albeit a logical statement of the cause of the bias? Just asking.
Harriet – “I don’t remember ever suggesting that PTs be the default providers of SMT. What I did was question whether chiropractic offers anything a well-trained PT couldn’t offer. Why is chiropractic special?
I don’t think it was you, Dr Hall, that suggested it. As to what makes chiro’s special as compared to PT’s: not much except for the training in examination and diagnosis for conditions which a PT might not recognize based upon lack of training. Treatment wise, chiropractors are, to me, just glorified PT’s. They can offer little more than PT’s in actual treatments, but can manage care thru referral and coordination with other health care providers.
Harriet – “Ernst is not a zealot. ”
Isn’t he the guy who claimed to be some sort of consultant for some Canadian health agency’s but wasn’t? Back in the 70’s?
Harriet – “I would be delighted if they would reject the subluxation myth and provide appropriate short-term care of musculoskeletal problems without any of the quackery like applied kinesiology that so many of them have fallen for”
Me too. The subluxation myth is a thorn in our sides to be sure. The word needs to be wiped from the earth as does the belief that it’s removal can cure all ills.
@nwtk2007:
Do you have any evidence to back up this suggestion?
I’ve not heard of it, and given the CAM industry’s repeated efforts to discredit Ernst, it seems unlikely that they wouldn’t have cottoned onto such an allegation.
coryblick
That’s great that you have strong research to support your claims, and I know that Childs, Cleland and other good researchers have done some OK work.
So, if you could provide the hours spent on learning SMT in a typical DPT curriculum so we can compare the two professions. Also, given the fact that the majority of experienced manipulators say that it takes years of practice to truly master (see Byfield, Chiropractic Manipulative Skills) and the fact that I’m still refining and learning my techniques on a daily basis your claims somehow ring shallow.
Lastly techniques used by PTs, such as the ones described in your research by Childs et. al are not only far less likely to be specific, but they are, in a biomechanical sense, far more dangerous even in the lumbar region since the published “PT” techniques (which are really adopted osteopathic ones) use long levers which produces more torque and overall force and has less specificity than a short lever technique which is biomechanically more efficient and safer as forces are more controlled.
That’s OK though, you can continue to believe that less training on SMT in biomechanics and actual lab hours results in safer, better manipulators, because that just makes common sense. Lastly, does the DPT programs that teach SMT skill acquisition meet the minimum guidelines suggested by the WHO in terms of total hours spent?
I’d appreciate some fresh research in your reply coryblick, since I’m aware of the one’s you cited and I would call it preliminary at the very best.
Cheers
NMS
http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53681
After saying that “education” in manipulation consists main of practicing on fellow students, this Chiro wrote:
“…As a greenhorn DC, I clearly recollect the first patient who told me, straight out, that he needed a “good cracking.” … “Just roll my hips”, he offered, “and that should do it. And don’t be afraid to give ‘er all ya got!” Since I was just out of school and without any meaningful experience, this seemed perfectly reasonable.” [italics added]
That does not sound like you really learn much in school.
As a consumer (and purchaser of insurance plans for a large groups of employees), I have a bone to pick with DCs, especially in the United States. They frequently misrepresent their training, capability and divert people from care which would be efficacious.
Individuals who seem to most benefit from visiting a DC would be better served by a PT and some lifestyle counseling. They must reimburse them out of pocket (although most plans I buy include some chiro reimbursement, along with massage and health club membership).
I would like to see a fundamental statement of the efficacy of therapies whcih can be offered by a chiro. For example, a general dentist will offer prophylactic care, prenentative dentistry and some minor repair of caries – but maxillofacial surgery would not likely be in their repetoire.
The argument over the SMT issue is interesting, but it belies the more sinister and dangerous aspect of chiropractic, delay of effective treatment and a financial drain on the medical system.
Sorry Mojo, the doctor I was thinking of ws Dr Katz.
NMS,
As I stated before, wasting time learning various forms of perceptual fantasy, regardless of how long it takes, is a waste. Chiros spend much more time with SMT, the question is why?
You cite a book written by a chiropractor as evidence that years are required for mastery? Years may be required to learn elaborate schemes of patient encounter which impact patient expectation. Just look at accupuncture. This has nothing to do wtih the skill necessary to manipulate.
In fact, the research shows that it is not the skill nor the specificity of application that predicts outcome, but the person it is being performed on (Flynn, Childs) and thier expectation (Steven George).
You state that PT techniques are less specific. Even if there was such a thing as “the PT technique” it wouldn’t matter if its less specific and this is supported. Specificity of application does not lead to improved outcome and in fact the evidence demonstrates that thinking you can even be specific is a fallacy, as I stated above it is perceptual fantasy. You also state that “the PT technique” is less safe. PT application of manipulation being less safe is not supported.
Have you even read this WHO document that is posted all over the place as being proof chiros are the only ones adequately trained to perform SMT? The 2200 course hour and 1000 hour of clinical focus is the WHO recommendation to become a chiropractor, not to perform SMT.
Cory
Thanks for your reply cory.
As DCs are the experts in manipulation, and since skeptics have a doubt regarding it’s safety, don’t you feel that more training in the biomechanics and psychomotor skill development would be essential?
Wasting time according you you, and perceptual fantasy talk leads me to believe you’ve been spending too much time hanging out with Diane Jacobs and Barrett Dorko.
Technique is important from a mechanical perspective one because you want to minimize unnecessary torque and excessive force on structures. Hence, long lever techniques, as demonstrated by Childs, Flynn etc. are mechanically less desirable. Short lever technique are preferred, from a mechanical standpoint.
And you have failed to address my point is that respected clinician scientists such as Dr. Byfield and Dr. Breen as well as the experience of thousands of DCs support the inherent truth that the ART of spinal manipulation takes time to develop. Also, certain patients have better responses to certain manual manipulative techniques, which is the now the focus on ongoing research.
You also failed to address my point regarding the DPT curriculum and training in SMT. How much time is spent learning and practicing SMT in the average DPT program?
To answer your question, DCs spent more time with SMT because it is their expertise. Only recently have research funds been available to study mechanisms of action (which have validated that it definitely acts on the nervous system) and any research of SMT that looks at neurological outcomes or changes (fMRI for example) is really investigating “chiropractic”. Ironic since some PTs are eager to demonstrate the neurological link between SMT which is simply validating part of the chiropractic hypothesis.
I’m not sure if you are naiive about the subject or inexperienced in the application of spinal manipulative therapy but I find it somewhat disconcerning that you’re lecturing me about acquiring mastery in the art of spinal manipulation.
Don’t forget to bring some evidence of the DPT curriculum regarding SMT lecture/practice hours. I’m curious.
NMS
Citizen Deux
Demonstrating clinical effectiveness and therapy dosage is essential. I definitely agree there is a segment of straight/subluxation-based chiropractic that promotes overtreatment and makes claims that are unsupported by the literature. Yet, it is a segment, and this segment is a minority in the profession in North America and especially so in Europe and world-wide.
People need to be informed and make the best decision based on the best evidence. In that regard, the chiropractic profession as developed clinical practice guidelines regarding management of low back disorders. It’s an evidence-based guideline and it talks about appropriate dosage (treatment) of SMT in particular, for back pain.
It can be found here
http://www.jmptonline.org/article/S0161-4754(08)00277-7/abstract
http://www.jmptonline.org/article/S0161-4754(08)00276-5/abstract
The best advice I can give to you, is find a good chiropractor that uses multi-modal manual therapies (soft tissue, mobs/manips) exercises/stretches, self care, education etc.
There is an interesting article about what to look for in a “good” chiropractor (one that deals primarily with MSK complaints) I believe the article is free of charge to the public.
http://www.chiroandosteo.com/content/17/1/3
PTs have their expertise and time and place (for example I could not be bothered with rehabing a post-surgical ACL repair) but I don’t doubt my ability to complement a PTs work after the fact by ensuring proper biomechanical joint function as well as optimal myofascial healing. This area is new in the research, but fascia is a whole new ball game in understanding MSK and, in some cases, internal disorders.
NSM-DC, your articles (unaccessible via link) are very narrow and address only the simple aspects of chiropractic. The ACA – a leading advocacy group for your profession – provides the following;
Wow! Psychological! Environmental! Vascular! All that’s missing is endocrinology.
Whoops, here it is.
Why on earth would DCs be engaged in food allergy testing – and why would a governing body see fit to disavow its use – despite the fact that it is still in use by many DCs?
Here is the bottom line – DCs have a narrow, easily substituted area of clinical effectiveness. It is an area easily supported by existing medical professionals (MDs, NPs, DOs, PAs, PTs and other scientifically trained and licensed practioners – even LMTs).
They have sought to expand their role via fraudulent claims of efficacy for “adjunct” therapies. This despite statements of adherence by the ACA to evidence based medicine, opposition to fraud and quackery and other unsupported practices.
The DC is NOT a general practioner. They lack sufficient medical training, skills and licensing. Depsite the appearance of adhering to “EBM” and professional standards – a straightforward reading of the ACA Master Plan would reveal a number of dangerous contradictions and questionable definitions.
If you are a DC, do you consider yourself a specialist or a GP? If you are a DC do you engage in activities which may be considered contrary to your governing body’s (recognizing that there are at least 3 bodies for DCs) recommendations?
The danger is not in the manipulations, or the lack of evidence the danger is in the fraud of chiropractic itself.
And finally, the final course in the un-scientific category, the ACA’s stand on vaccines;
Seems to be at odds with the rest of the scientific community.
And lastly, since you referenced this journal – what is your position on this article?
How can chiropractic become a respected mainstream profession? The example of podiatry
The assertion, rightly, is that chiropiractic remains outside respected, mainstream professions.
My apologies for the combative nature. These are very important questions which should be examined and answered.
NMS-DC on 12 Jun 2009 at 12:07 pm “As DCs are the experts in manipulation, and since skeptics have a doubt regarding it’s safety, don’t you feel that more training in the biomechanics and psychomotor skill development would be essential?”
http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53681
After saying that “education” in manipulation consists main of practicing on fellow students, this Chiro wrote:
“… As a greenhorn DC, I clearly recollect the first patient who told me, straight out, that he needed a “good cracking.” … “Just roll my hips”, he offered, “and that should do it. And don’t be afraid to give ‘er all ya got!” Since I was just out of school and without any meaningful experience, this seemed perfectly reasonable.” [italics added]
It does not sound like chiros are experts in manipulation. In fact, http://www.ptjournal.org/cgi/content/full/79/1/50 this article shows you are bad at it; at least, when it comes to serious adverse consequences.
“And you have failed to address my point is that respected clinician scientists such as Dr. Byfield and Dr. Breen as well as the experience of thousands of DCs support the inherent truth that the ART of spinal manipulation takes time to develop. ”
That’s odd. My understanding is that within chiropractic there are numerous very different styles fo manipulation, all strongly supported by their adherents, but that it has not been possible to clearly demonstrate superiority of one over the other.
And simple mobilisation works as well in the studies. All this suggests that they all “work” about the same and for the same reasons and that it is the practitioner’s ability to evoke placebo responses or patient subordination that improves with time.
NMS,
you said:
“As DCs are the experts in manipulation, and since skeptics have a doubt regarding it’s safety, don’t you feel that more training in the biomechanics and psychomotor skill development would be essential?”
I’d say that determining risk to benefit is essential. The risk involved with manipulation of the upper cervical spine despite the biomechanical load placed is unnacceptable and undefensible in my view. There is no delineation between a safe and unsafe amount of manip force in the cervical spine. In the lumbar and thoracic spine the risk is much lower and I’ve no knowledge of evidence of reduced risk with psychomotor skill development beyond that of the entry level clinician in terms of manip. Personally, while manipulation is sufficient to reduce pain in certain populations, I feel that the evidence points to it not being necessary. So, for me, even in the lumbar/thoracic spine the risk is not acceptable although it is much more defensible. In my view, manipulation risk is best reduced by limiting its usage. As the research continues to identify more and more narrow populations of potential responders, this should be exactly what happens for manual therapists who are following the research.
While I don’t speak for Diane or Barrett, my guess is that they’d likely agree with me. Was I supposed to be embarrassed in regards to my knowing them? Quite the contrary.
“the inherent truth that the ART of spinal manipulation takes time to develop. ”
The skill of spinal manipulation can be learned relatively quickly. The non-descript ART that you speak of describes the patient/clinician interaction. I agree that takes time. Especially when the interaction is built upon complicated models of joint symetry/mobility/alignment/balance/etc that are unnecessary and unsupported. Also, this interaction is not specific to manipulation.
I didn’t ignore your request regarding the DPT curriculum. I acknowledged that chiros get lots more. Lets say its 30 times as much (not sure. You can look it up yourself if you want a number.). But, to what gain? What is supported is that PT students are able to identify potential responders and apply the intervention with adequate expertise.
“and any research of SMT that looks at neurological outcomes or changes (fMRI for example) is really investigating “chiropractic”. ”
It is? Chiropractic holds the patent on neurologic outcomes does it? This is a strange argument.
I’m not lecturing you about anything regarding your “ART mastery.” But I’m not about to sit here and listen to spouting of the typical gibberish that may work in the statehouses but has no authority over science.
“This area is new in the research, but fascia is a whole new ball game in understanding MSK and, in some cases, internal disorders.”
Oh, don’t even get me started on fascia! You want to talk pseudoscience. Whoa nellie!
Cory,
Despite your knowledge of the pain sciences, it’s clear that you do not truly understand the science of spinal manipulation or the purpose of manipulative medicine in general.
The risk to benefit has ALREADY been established as the cited paper by Rubinstein (2008) demonstrated. The Neck Pain Task Force also addressed the validity of manual therapy, including SMT.
You write
“Personally, while manipulation is sufficient to reduce pain in certain populations, I feel that the evidence points to it not being necessary.”
Manipulation is proven to be just as, if not more effective for mechanical spinal pain syndromes. There is strong evidence for manipulative therapy in every area of the spine as demonstrated by the clinical chiropractic guidelines which is provided a literature synthesis to produce evidence-based guidelines.
http://www.ccgpp.org/
You claim to be scientific yet you ignore the basic science on effectiveness of manipulative therapies while arguing PTs should provide manipulations.
Much like Diane and Barrett you let your personal philosophy get in the way of accepting the science and value of manipulation. On one hand you criticize chiropractors for using manipulation as a means of therapy in spinal pain, and yet advocate a method, Simple Contact which is based on the ideomotion whose literature base is quite frankly non-existent compared to PROVEN methods of care.
Quote
“Chiropractic holds the patent on neurologic outcomes does it? This is a strange argument.”
It’s not strange, and if you’re up on the neurosciences (which you should be at SomaS) you know that there the effects of manipulation are primarily neurological than biomechanical. It is a mechanical stimulus, that, by process of mechanotransduction, results in reflex neuromodulation of the neuromusculoskeltal
system, but in particular the brain and its effects at the sensorimotor cortex. Chiropractic has ALWAYS been about the fundamental relationship between joint manipulation and neurological function. So, no, chiropractic doesn’t hold the patent on neurological outcomes, but when we are discussing MANUAL THERAPY and neurological outcomes you are talking about the principle of chiropractic medicine.
Regarding fascia, I think I’m going to go with the findings and work of the of the scientific committee of the fascia congress than listen to your claims of pseudoscience….
http://www.fasciacongress.org/2009/committees.htm
It’s amazing how people’s personal philosophy blinds them from the truth. There is obviously SOMETHING valuably inherent in fascia; it serves an amazing important purpose. Yet you discard it as if it was clinically irrelevant in physical function.
Anyways, we are far off track, but I’m not advocating any gibberish and your arguments on the safety and efficacy of SMT for spinal pain far exceeds the evidence of the ideomotor response in treating spinal pain. Just sayin’.
NMS
Cory
1) risk to benefit has been determined and we cited the paper, Rubinstein 2008 as well as the Neck Pain Task Force
“Personally, while manipulation is sufficient to reduce pain in certain populations, I feel that the evidence points to it not being necessary”
2) The evidence suggests that it is effective in treating all mechanical spinal pain (www.ccgpp.org)
3) While you may feel fascia is pseudoscience, I think that I’ll side with the scientifc panel of the Fascia congress
http://www.fasciacongress.org/2009/committees.htm
I use the best available evidence to help my patients function. You use ideomotion which has far, far, far less evidence and could easily be construed as quackery by members here. Manipulation science far exceeds in depth and breadth that a Tx method you advocate.
Lastly, the principle of chiropractic medicine is about the improvement of neurological outcomes through manual therapy. If you know your neurosciences and research, you’d see that the SMT primarily works on the nervous system via mechanotransduction. While chiropractic doesn’t “hold the patent on neurologic outcomes” the relationship between manual therapy and neurological function is what defines the chiropractic profession.
Citizen Deux
The cited material in your posts are so old and irrelevant, they are a red herring that requires no rebuttal. The ACAs stance is not chiropractic’s stance and evidence-based DCs support vaccination as does many national chiropractic association such as Canada’s. Chiropractic medicine has a place in public health and contemporary chiropractors can play an important role. There is research to support this as well.
Your view of contemporary chiropractors is distorted at best, deliberately ignorant at worst. I do not consider myself a general physician, but I do consider myself a chiropractic doctor who is primarily a neuromusculoskeletal specialist whose expertise is in manual medicine. My training, and many other DCs who have trained in university-based programmes are legitimate health care providers who serve an important niche and it’s time for skeptics to accept that chiropractic doctors are valid as neuromusculoskeletal specialists.
test
pmoran inquires:
>>”Since your own “Gold Standard” paper sees other methods as having equal efficiacy to neck manipulation for neck pain but without the risks (e.g. acupuncture), what do you now see as the proper place of SMT in the treatment of neck pain?
While you are here, comment upon neck manipulation’s widespread use by chiropractors for headache, certain childhood complaints, and general “wellness”.”<>”For the nth time, I have no vendetta against chiropractors.”<<
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Really? Your claim rings very disengenuous. I remain skeptical and unconvinced.
If your claim, was indeed genuine, your op/ed piece would have been titled: “Adverse of Effects Manual Medicine”(or something similar).
Does it search better with “chiropractic”? Get cited more with “chiropractic”? Provoke more attention/comments with “chiropractic”? I highly suspect the answer is “YES” to all.
Truthful? Resoundingly “NO”
Please review:
http://www.ncbi.nlm.nih.gov/pubmed/7636409?dopt=Abstract&holding=f1000,f1000m,isrctn
Misuse of the literature by medical authors in discussing spinal manipulative therapy injury.
AND
http://www.chiroandosteo.com/content/14/1/16
Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer-reviewed biomedical literature
My Last post got goofed- I will repost it here:
pmoran inquires:
>>”Since your own “Gold Standard” paper sees other methods as having equal efficiacy to neck manipulation for neck pain but without the risks (e.g. acupuncture), what do you now see as the proper place of SMT in the treatment of neck pain?
While you are here, comment upon neck manipulation’s widespread use by chiropractors for headache, certain childhood complaints, and general “wellness”.”<<
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Allow me to direct you to the sites below that address your query:
Council on Chiropractic Guidlines and Practice Parameters
http://www.ccgpp.org/articles.htm
This link from that site, is for the document on neck pain
http://www.ccgpp.org/neck_related_disorders.pdf
It is important to keep in mind, that irrespective of the provider, a universal truth is that: a “best practice” health care model includes not only research/evidence, but also clinical decision-making and patient values/preferences.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
And here:
Harriets posts:
>>”For the nth time, I have no vendetta against chiropractors.”<<
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Really? Your claim rings very disengenuous. I remain skeptical and unconvinced.
If your claim, was indeed genuine, your op/ed piece would have been titled: “Adverse of Effects Manual Medicine”(or something similar).
Does it search better with “chiropractic”? Get cited more with “chiropractic”? Provoke more attention/comments with “chiropractic”?
I highly suspect the answer is “YES”. Is it truthful? Resoundingly “NO”.
Please review:
http://www.ncbi.nlm.nih.gov/pubmed/7636409?dopt=Abstract&holding=f1000,f1000m,isrctn
Misuse of the literature by medical authors in discussing spinal manipulative therapy injury.
AND
http://www.chiroandosteo.com/content/14/1/16
Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer-reviewed biomedical literature
The issue of the poor reporting of accidents to SMT being attributed to “Chiropractors” was pointed out to Harriett very early on in the post. She has yet to acknowledge she erred on this topic, despite all the citations provided. Shame.
Alright, NMS, let’s take your comments at face value;
If you dissociate yourself with the ACA, then which association speaks for you?
What place does chiro have in public health (I would support the view of the Osteo magazine which is a podiatry model).
What do you consider the base accredidation for DC education?
I hardly think these views are out of date and the VAST majority of DCs in the US offer therapies for which they are neither adequately trained, educated or supported by science.
And finally, if the ACA is irrelevant – which is a specious argument, then explain their masthead statement.
Fred Dagg,
“The issue of the poor reporting of accidents to SMT being attributed to “Chiropractors” was pointed out to Harriett very early on in the post. She has yet to acknowledge she erred on this topic”
I didn’t err. This article was written to explain the findings of a new systematic review that was titled “Safety of CHIROPRACTIC interventions: a systematic review.” and the great majority of the studies it reviewed specifically involved CHIROPRACTORS. It specifically showed that a large percentage of patients who visited a CHIROPRACTOR had short-term adverse effects, and most of the studies didn’t even specify what treatment was given. There are several studies BY CHIROPRACTORS themselves identifying short-term side effects from what they themselves call CHIRORACTIC TREATMENT or CHIROPRACTIC SMT.
I have already acknowledged that it is the procedure we are concerned with, not who does it., and that the risk of stroke is with SMT, whoever provides it. Chiropractors have claimed SMT for their own, and their practice is based on it. They are the ones who are known for doing SMT, even though a minority of manipulations are done by others. . YOU are the ones who have identified SMT with chiropractic. I’ve never seen a chiropractic ad or website stressing that they offered SMT to treat musculoskeletal problems. Instead they claim to be practicing chiropractic” and treating subluxations. You guys are hoist on your own petard; I didn’t do it.
Just curious: why do you use the word “accidents” rather than side effects? I doubt if you would call adverse effects of NSAIDS “accidents.”
By the way, I noticed that Dagg has two G’s. You didn’t notice that Harriet has only one T. If you read that carelessly, it makes me wonder if you read the scientific studies carelessly too. If your error is due to a neurologic deficit like dyslexia, I apologize for bringing it up; I wouldn’t want to insult the handicapped.
NMS,
“Despite your knowledge of the pain sciences, it’s clear that you do not truly understand the science of spinal manipulation or the purpose of manipulative medicine in general.”
Really? Are you saying the purpose of manpulative medicine and the science behind it something other than resolution of pain?
You missed my whole point on effectiveness. I agree its been shown to be effective in certain populations. I also acknowledge that risk/benefit ratios have been established. My point is that even though manip is sufficient it is not necessary to relieve pain. When that is the case the tolerance to risk becomes zero, at least as a first line treatment. Thanks for continuing to call me naive and ignorant though. Great argument!
To this point, I think if you read through my posts above you’ll see that I’m not advocating that PTs be providing manipulation. Only that they are more than adequately trained and that any claims of pts being endangered by seeing a PT vs. a chiro are pure propaganda.
I notice that your argument has shifted from the propaganda onto me myself. Nice argument tactics. I’m curious to know what my personal philosophy is exactly, since you seem to know, and how it is important to the points being made? While simple contact has nothing to do with this argument, I feel complelled to provide a brief defense now that you’ve put it in a context with quackery. It simply states that people will seek an end state of comfort if not compelled to do otherwise (a documented phenomenon called the end state comfort effect), that the mechanism of action is ideomotor movement (again documented), that a non-threatening context is necessary for expression toward this end state (consistent with placebo research for example), and that manual contact is one method (but not the only way) of communicating this context. It is hypothesized that this method may be effective at relieving mechanical pain only. This is testable and has preliminary evidence warranting further study. Rampant quackery, eh?
You’re arguing that neuroscience equals chiropractic when it comes to manipulation as the item of investigation. This is strange. Here I thought it remained neuroscience. The chiropractic “theory” of nerve pathways is not supported. Mechanotransduction may be the mechanical mechanism by which the applied force becomes a nerve impulse, but the recent evidence by Steven George (a PT) indicates temporal summation through descending inhibition to be the mechanism of action, at least in the scenario he studied. Thanks for the condescension though. I thought I, being a PT, was supposed to be the expert at that? Right nwtk07?
Fascial therapies typically quickly leave the realm of science and enter the realm of microtubules and quantum physics and quantum consciousness, and a whole bunch of other BS. What brand of fascial therapy are you NMS? Pray tell, what kinds of NMSk and visceral conditions are fascial in origin?
Cory
Nobs, Why can I not get direct answers to simple questions? Here they are again. You wasted my time by referring me to sites that contribute nothing new and nothing of relevance.
Here are the questions again.
>>”Since your own “Gold Standard” paper sees other methods as having equal efficiacy to neck manipulation for neck pain but without the risks (e.g. acupuncture), what do you now see as the proper place of SMT in the treatment of neck pain?
While you are here, comment upon neck manipulation’s widespread use by chiropractors for headache, certain childhood complaints, and general “wellness”.”<<
Hello Harriet,
my apologies for the incorrect spelling of your name.
In regard to the use of the word “accident” rather than “side effect”. In the context of this discussion, the alternate use is irrelevant. We could argue semantics until the cows come home, but I am sure we all know what each other means.
I would call any adverse effect to care provided by a registered health care professional, practicing responsibly, within his scope of practice, where the intent is to provide good and ethical care, an “accident” or “side effect”.
You have avoided the issue, (Oh crap, she has done it again), that a significant proportion of strokes have been attributed to chiropractors”, when in fact, it was not Chiropractors that provided the treatment.
I cannot comment on your viewing of websites and chiropractors. Perhaps that is more of a problem you have, rather than the sites themselves.
“You have avoided the issue, (Oh crap, she has done it again), that a significant proportion of strokes have been attributed to chiropractors, when in fact, it was not Chiropractors that provided the treatment.”
That is so obvious to anyone following the literature on this matter, as have Harriet and I, and others, as to be not worth the mention.
It is even possible that some non-chiropractors, such as GPs who may occasionally dabble in it, are a greater risk to the public. They may be less aware of the potential for stroke than chiropractors, who will more certainly have learnt about it during their training (even if adopting a “what, us cause stroke?” stance later). In fact I believe most currently practicing chiropractors will have been taught certain now discredited manoeuvres that were supposed to detect patients at risk of stroke.
So this is not something recently cooked up by medicos, with which to persecute chiropractors. It is a real problem that should be generally impacting upon the use of neck manipulation, reserving it for use as a relatively late resort in a limited number of conditions when other methods have not helped.
To my knowledge, I have never attributed a stroke to a chiropractor if it was caused by a non-chiropractor. I have attributed them to SMT. There are plenty of documented cases directly attributed to chiropractors. We don’t have good data, but two studies have indicated that around 60% of manipulation-induced strokes were due to chiropractors and the rest to a combination of other practitioners. If chiropractic and SMT are conflated in the public mind, the chiropractors themselves are to blame.
I don’t know of any reliable statistics to show the relative or absolute risk of SMT as performed by chiropractors, physical therapists, osteopaths and other providers. It doesn’t matter. Even if we haven’t quantified it accurately, we have good reason to believe the procedure is risky, no matter who performs it.
I do know that chiropractors offer SMT for conditions where it is not indicated, such as neck manipulation for low back pain and for routine “health maintenance.” I have seen studies showing that at least some chiropractors offer neck manipulation to a very large percentage of their patients, surely a larger percentage than other providers do. Because of those factors, I suspect the risk of seeing a chiropractor is greater; but there are no data to prove it.
There are clear data in the systematic analysis to indicate that a large percentage of patients who visit a chiropractor have short-term side effects (accidents?). So my title was correct, even though there are also data showing side effects after SMT by other providers.
Would you have been happier if my title had been “Adverse Effects of Visiting a Chiropractor or of Visiting Other Providers Who Do What Chiropractors Do?
It sound like you’re trying to defend chiropractic by saying that chiropractors aren’t the only ones who hurt people. That’s a tu quoque argument. How about taking full responsibility for the strokes caused by chiropractors and warning about strokes caused by anyone else who does SMT?
How about “Adverse Effects to Spinal Manual Therapy”.
Precise, simple and honest.
Then perhaps a short introductory paragraph on who provides spinal manual therapy throughout the world, not just the U.S.A. and even a short paragraph on how these tragedies are mis-reported within literature.
Nothing too controversial there, but then that depends on the spin you may want to put on.
You could even, if you were brave, write something about the intent of the authors in doing the research.
A comparative analysis would be on the relative dangers of other forms of care for spinal pain of bio-mechanical origin e.g. NSAIDS, surgery, etc. Quoting Bone and Joint Decade results as one source of your information.
Despite what you claim, your Barrett inspired, Quackwatch, anti-chiropractic propagandist agenda has come through.
You have ended up in becoming sarcastic and aggressive, when if you had written the article properly it would have been a really good learning experience, for all practitioners of SMT and for all readers of EBM.
“How about “Adverse Effects to Spinal Manual Therapy”.
Precise, simple and honest.”
But not the title of the study I was describing.
A comparative analysis was not part of the study I was reporting.
You keep criticizing me for what I DIDN’T write. Perhaps you would comment on the actual results of the study. And perhaps you would answer Peter Moran’s question: what do you now see as the proper place of SMT in the treatment of neck pain?
Well, Harriet (one t, not two), see Bone and Joint Decade results for the inclusion of SMT in the treatment of neck pain. It includes SMT in the treatment profiles for Neck Pain. As valid as anything else.
This is Evidence Based Medicine, how about taking a “global” look at the issue of adverse effects, rather than “cherry picking”.
Fred, this is Science Based Medicine not Evidence Based Medicine. The two are quite distinct and the differences are well described by Kimball Atwood and others.
This was the blog post that caused the scales to fall from my eyes so that I could see the difference between EBM and SBM.
http://www.sciencebasedmedicine.org/?p=48
Fred Dagg on 13 Jun 2009 at 2:36 pm posts:
>>”The issue of the poor reporting of accidents to SMT being attributed to “Chiropractors” was pointed out to Harriett very early on in the post. She has yet to acknowledge she erred on this topic, despite all the citations provided. Shame.”<>”I didn’t err. This article was written to explain the findings of a new systematic review that was titled “Safety of CHIROPRACTIC interventions: a systematic review.” and the great majority of the studies it reviewed specifically involved CHIROPRACTORS.It specifically showed that a large percentage of patients who visited a CHIROPRACTOR had short-term adverse effects, and most of the studies didn’t even specify what treatment was given. There are several studies BY CHIROPRACTORS themselves identifying short-term side effects from what they themselves call CHIRORACTIC TREATMENT or CHIROPRACTIC SMT”<>”This is the paper that appeared in Spine and which claimed to be a
systematic review of adverse events following chiropractic
manipulation. It put all RCTs, prospective and retrospective studies,
case studies, and surveys under one roof and, although claiming that
hard conclusions were impossible due to the heterogeneity of the
studies, still managed to give them equal weight. This, in my opinion,
leads to disaster.
What amazed me, for instance, was how the authors in one breath could
claim that the “frequency of adverse events varied between 5 strokes/
100,000 manipulations to 1.46 serious adverse events/10M
manipulations.” Notwithstanding the fact that both these figures were
drawn from mere surveys [one, by Carlinni, was thoroughly discredited
by Scott Haldeman and others], you’re looking at a 100-fold variation
of incidence–assuming that a stroke is indeed a “serious adverse
event.” Somehow, it just impresses me that without a review of the
validity of the studies, themselves, that poor data such as that
brought forward by Carlinni is given another breath of life when in
fact it deserves just the opposite–as argued over 14 years ago by Lou
Sportelli.
Frequencies of complications, large and small, were reported to range
from 33%-60.9%. Yet not a single reference seems to have been made to
studies which report lower rates of, or no, significant problems–such
as by Haymo Thiel or Jaskoviak. I found the summary statement at the
conclusion of the article to the effect that “complications associated
with chiropractic procedures are frequent” to be unfounded.
Finally, I was bothered by a reference to something I had published in
Spine, attributing my work to documenting intracranial hypotension. In
truth, it was precisely the opposite. It was a Letter to the Editor
which questioned the validity of the original study which had
attempted to attribute this condition to spinal manipulation. The
original study, it turns out, appears NOT to have been cited in the
paper in Spine. Another reference by the authors to a paper that I had
published with Joe Morley attacking Edzard Ernst for improperly
presenting evidence had nothing to do with claiming that “there were
few properly designed randomized trials, such that the results were
frequently inconclusive.” Yet this was plainly suggested by the
authors of this so-called systematic review. Is this scholarship? One
has to wonder whether this paper has, in fact, made a substantial
contribution to the literature at all.
Am I missing something? Other than serving as a repository of data
concerning adverse outcomes, I am not certain that this particular
publication has helped advance our knowledge base. In at least a few
instances, it has presented corrupted information instead.
Gouveia LO, Catanho P, Ferreira JJ. Safety of chiropractic
interventions: A systematic review. Spine 34(11): E405-E413.
Anthony L. Rosner, Ph.D., LL.D.[Hon.]”
~~~~~~~~~~~~~~~~~~~~~~~~~~
HH->>”I have already acknowledged that it is the procedure we are concerned with, not who does it., and that the risk of stroke is with SMT, whoever provides it.”<>”Chiropractors have claimed SMT for their own, and their practice is based on it. They are the ones who are known for doing SMT, even though a minority of manipulations are done by others.”<>” YOU are the ones who have identified SMT with chiropractic. I’ve never seen a chiropractic ad or website stressing that they offered SMT to treat musculoskeletal problems. Instead they claim to be practicing chiropractic” and treating subluxations.”<>”By the way, I noticed that Dagg has two G’s. You didn’t notice that Harriet has only one T. If you read that carelessly, it makes me wonder if you read the scientific studies carelessly too. If your error is due to a neurologic deficit like dyslexia, I apologize for
bringing it up; I wouldn’t want to insult the handicapped.”<<
THIS ad hom is an extremely disappointing, childish cheapshot. No further comment necessary.
This site has some strange formatting going on(also noted by others). It looked just fine before I hit submit. I am reposting the above.
Fred Dagg on 13 Jun 2009 at 2:36 pm posts:
>>”The issue of the poor reporting of accidents to SMT being attributed to “Chiropractors”
was pointed out to Harriett very early on in the post. She has yet to acknowledge she erred
on this topic, despite all the citations provided. Shame.”<>”I didn’t err. This article was written to explain the findings of a new systematic
review that was titled “Safety of CHIROPRACTIC interventions: a systematic review.” and the
great majority of the studies it reviewed specifically involved CHIROPRACTORS. It
specifically showed that a large percentage of patients who visited a CHIROPRACTOR had
short-term adverse effects, and most of the studies didn’t even specify what treatment was
given. There are several studies BY CHIROPRACTORS themselves identifying short-term side
effects from what they themselves call CHIRORACTIC TREATMENT or CHIROPRACTIC SMT”<>”I have already acknowledged that it is the procedure we are concerned with, not who
does it., and that the risk of stroke is with SMT, whoever provides it.”<>”Chiropractors have claimed SMT for their own, and their practice is based on it.
They are the ones who are known for doing SMT, even though a minority of manipulations are
done by others.”<>” YOU are the ones who have identified SMT with chiropractic. I’ve never seen a
chiropractic ad or website stressing that they offered SMT to treat musculoskeletal
problems. Instead they claim to be practicing chiropractic” and treating subluxations.”<>”By the way, I noticed that Dagg has two G’s. You didn’t notice that Harriet has only one T. If you read that carelessly, it makes me wonder if you read the scientific studies
carelessly too. If your error is due to a neurologic deficit like dyslexia, I apologize for
bringing it up; I wouldn’t want to insult the handicapped.”<<
THIS ad hom is an extremely disappointing, childish cheapshot. No further comment necessary.
Please ignore my above posts. Sorry. I don’t have any more time right now to try and figure out what the problem is, but I will re-attempt later. If they can be taken off- that would be great. Thank-you
OK- My third attempt. Thank-you in advance for your patience.
Fred Dagg on 13 Jun 2009 at 2:36 pm posts:
>>”The issue of the poor reporting of accidents to SMT being attributed to “Chiropractors” was pointed out to Harriett very early on in the post. She has yet to acknowledge she erred on this topic, despite all the citations provided. Shame.”<>”I didn’t err. This article was written to explain the findings of a new systematic review that was titled “Safety of CHIROPRACTIC interventions: a systematic review.” and the great majority of the studies it reviewed specifically involved CHIROPRACTORS. It specifically showed that a large percentage of patients who visited a CHIROPRACTOR had short-term adverse effects, and most of the studies didn’t even specify what treatment was given. There are several studies BY CHIROPRACTORS themselves identifying short-term side effects from what they themselves call CHIRORACTIC TREATMENT or CHIROPRACTIC SMT”<<
That statement rings to me as a biased excuse, not a valid reason. The title of the paper you are claiming to ahem-”explain” is “SAFETY OF CHIROPRACTIC INTERVENTIONS”. From that, you choose to title your ahem-”explanation”/op/ed piece “ADVERSE EFFECTS OF CHIROPRACTIC”? You are right- that does explain…a.lot!
The “review” you are claiming to “explain”, is constructed from flawed studies, ambiguous nomenclature, and corrupt data. Your “explanation” fails to address this. AND- The study is so invalid, I am questioning why you bothered to “explain” it at all. It appears that when it comes to a chiropractic paper or issue, you need to “boil it down”, or “explain”. Why not call it what it really is?—–your personal comments/opinion.
OK-Back to the study that started all this…….
It’s amazing what happens when a study such as this begins to unravel.
Here is another, academically sound, “explanation” of the same study:
“This is the paper that appeared in Spine and which claimed to be a
systematic review of adverse events following chiropractic
manipulation. It put all RCTs, prospective and retrospective studies,
case studies, and surveys under one roof and, although claiming that
hard conclusions were impossible due to the heterogeneity of the
studies, still managed to give them equal weight. This, in my opinion,
leads to disaster.
What amazed me, for instance, was how the authors in one breath could
claim that the “frequency of adverse events varied between 5 strokes/
100,000 manipulations to 1.46 serious adverse events/10M
manipulations.” Notwithstanding the fact that both these figures were
drawn from mere surveys [one, by Carlinni, was thoroughly discredited
by Scott Haldeman and others], you’re looking at a 100-fold variation
of incidence–assuming that a stroke is indeed a “serious adverse
event.” Somehow, it just impresses me that without a review of the
validity of the studies, themselves, that poor data such as that
brought forward by Carlinni is given another breath of life when in
fact it deserves just the opposite–as argued over 14 years ago by Lou
Sportelli.
Frequencies of complications, large and small, were reported to range
from 33%-60.9%. Yet not a single reference seems to have been made to
studies which report lower rates of, or no, significant problems–such
as by Haymo Thiel or Jaskoviak. I found the summary statement at the
conclusion of the article to the effect that “complications associated
with chiropractic procedures are frequent” to be unfounded.
Finally, I was bothered by a reference to something I had published in
Spine, attributing my work to documenting intracranial hypotension. In
truth, it was precisely the opposite. It was a Letter to the Editor
which questioned the validity of the original study which had
attempted to attribute this condition to spinal manipulation. The
original study, it turns out, appears NOT to have been cited in the
paper in Spine. Another reference by the authors to a paper that I had
published with Joe Morley attacking Edzard Ernst for improperly
presenting evidence had nothing to do with claiming that “there were
few properly designed randomized trials, such that the results were
frequently inconclusive.” Yet this was plainly suggested by the
authors of this so-called systematic review. Is this scholarship? One
has to wonder whether this paper has, in fact, made a substantial
contribution to the literature at all.
Am I missing something? Other than serving as a repository of data
concerning adverse outcomes, I am not certain that this particular
publication has helped advance our knowledge base. In at least a few
instances, it has presented corrupted information instead.
Gouveia LO, Catanho P, Ferreira JJ. Safety of chiropractic
interventions: A systematic review. Spine 34(11): E405-E413.
Anthony L. Rosner, Ph.D., LL.D.[Hon.]“
“THIS ad hom is an extremely disappointing, childish cheapshot”
You are right. I apologize.
“not a single reference seems to have been made to
studies which report lower rates of, or no, significant problems–such as by Haymo Thiel or Jaskoviak”
I couldn’t find Haymo or jaskoviak, but the abstract of the Thiel study seems to support the findings of the systematic review:
“This translates to an estimated risk of a serious adverse event of, at worse approximately 1 per 10,000 treatment consultations immediately after cervical spine manipulation, approximately 2 per 10,000 treatment consultations up to 7 days after treatment and approximately 6 per 100,000 cervical spine manipulations. Minor side effects with a possible neurologic involvement were more common. The highest risk immediately after treatment was fainting/dizziness/light-headedness in, at worse approximately 16 per 1000 treatment consultations. Up to 7 days after treatment, these risks were headache in, at worse approximately 4 per 100, numbness/tingling in upper limbs in, at worse approximately 15 per 1000 and fainting/dizziness/light-headedness in, at worse approximately 13 per 1000 treatment consultations. CONCLUSION: Although minor side effects following cervical spine manipulation were relatively common, the risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low.”
It sounds from the abstract like they recorded spontaneous complaints by patients but did not survey the non-complainers in a systematic way, as most of the studies in the systematic review did. The reported neurologic side effects are very worrisome, as they could represent a stroke that almost happened but didn’t.
Every study has essentially reported frequent minor side effects and rare serious ones. We are only quibbling about the numbers. and the data aren’t good enough to resolve the debate.
HH->>”I have already acknowledged that it is the procedure we are concerned with, not who does it., and that the risk of stroke is with SMT, whoever provides it.”<>”Chiropractors have claimed SMT for their own, and their practice is based on it. They are the ones who are known for doing SMT, even though a minority of manipulations are done by others.”<>” YOU are the ones who have identified SMT with chiropractic. I’ve never seen a chiropractic ad or website stressing that they offered SMT to treat musculoskeletal problems. Instead they claim to be practicing chiropractic” and treating subluxations.”<>”By the way, I noticed that Dagg has two G’s. You didn’t notice that Harriet has only one T. If you read that carelessly, it makes me wonder if you read the scientific studies carelessly too. If your error is due to a neurologic deficit like dyslexia, I apologize for bringing it up; I wouldn’t want to insult the handicapped.”<<
THIS ad hom is an extremely disappointing, childish cheapshot. No further comment necessary.
HH->>”I have already acknowledged that it is the procedure we are concerned with, not who does it., and that the risk of stroke is with SMT, whoever provides it.”
Harriet please- “Not who does it”"?? Really?? I am unconvinced. Here are a few reasons why:
- Changing “SAFETY OF…” to “ADVERSE OF….”
- Refusal to acknowledge the inapproprite, misuse of “chiropractic” in the studies cited.
- failure to correct your “explanation” when this was brought to your attention.
- failure to take to task, the significant percentage of non-DC providers involved with serious adverse events(one study I provided to you showed 50% were orthopedic surgeons/89% non-DCs).
It appears to me, that when it comes to chiropractic, you somehow feel it necessary to “boil it down” or “explain”. Why not just call it what it is….Your personal opinion/comments?
(btw- Please direct me to any pieces you have authored on SMT and providers of SMT, other than DCs).
HH- >>”Chiropractors have claimed SMT for their own, and their practice is based on it. They are the ones who are known for doing SMT, even though a minority of manipulations are done by others.”
Yes- We are definately associated with SMT. Not because it is the ONLY option of treatment we are professionally trained to offer, ….BUT because, we are the only providers that are professionally masters of SMT. There are others may dabble in it, watch a video, maybe even take a weekend course. This creates, shall we say, “piano-players”. While DCs are “pianists”.
Which would you choose for a bypass, appendectomy, hip replacement, even a dermatology consult…… a piano-player, or a pianst? Honestly.
Since “a minority of manipulations are done by others”, this statisticly bodes very well for DCs- the majority of adverse
events occur with non-DC manipulations. Perhaps a valid safety reason for keeping manipulation out of “others” practice scope?
HH->>” YOU are the ones who have identified SMT with chiropractic. I’ve never seen a chiropractic ad or website stressing that they offered SMT to treat musculoskeletal problems. Instead they claim to be practicing chiropractic” and treating subluxations.”
C’mon……Really?? You claim you have seen NO DC ads or websites offering treatment for low back pain, hip pain, sciatica, neck pain…………? C’mon. I just can’t buy that.
Be honest.
“you have seen NO DC ads or websites offering treatment for low back pain, hip pain, sciatica, neck pain”
That’s not what I said. They offer “chiropractic treatment.”
“the majority of adverse events occur with non-DC manipulations.”
Really? See figure 2 at http://www.ptjournal.org/cgi/content/full/79/1/50 It indicates just the opposite.
What percentage of your patients with neck pain do you treat with SMT? How do you decide which ones to treat? Do you use HVLA or mobilization? Why? And please comment upon neck manipulation’s widespread use by chiropractors for headache, certain childhood complaints, and general “wellness”.
“Which would you choose for a bypass, appendectomy, hip replacement, even a dermatology consult…… a piano-player, or a pianst?”
I agree that chiropractors are more skilled at providing SMT. But I question whether they are skilled at deciding which patients to treat. Especially the ones who offer neck manipulations to the great majority of their patients, even those who are well and only seeking “health maintenance.” I would choose an experienced surgeon to do my appendectomy, but first I would want to make sure that I really had appendicitis.
Yes, Harriet, this is evolving exactly as have most other discussions of adverse events with chiropractors. How to get chiropractors to think of neck manipulation in risk/benefit terms ? Many have tried.
And how precious it is for chiropractors to be affronted at being a primary target in such debates!
No other component of medicine has members who subject patients to unnecessarily prolonged, even life-long programs of neck manipulation. No other branch accepts, though professional neglectfulness and ill-discipline, the use of neck manipulation for innumerable dubious reasons.
Sadly for chiropractors, also, no other profession has such an investment in neck manipulation as to have great difficulty in substituting equally effective, but safer treatments.
If these perceptions regarding the current state of chiropractic are wrong, I deeply apologize, but the reluctance of the present crop of chiropractic contributors to answer simple questions as to how they shape their current practices says much.
Sorry pmoran, I just don’t see it that way. Chiro’s understand the risk to benefit concept, it is the medical community that doesn’t.
The anti-chiro bias you possess is why you see such great risk in chiropractic but not in even simple meds like ibuprofen. I see the evidence against CMT as sketchy, unsubstantiated and weak at best.
Your view of chiropractors is purely biased and thus totally subjective. I have in the past pointed out your inability to apply the same standards to medical science: thus the “smoking gun theory” as I have heard so many times here.
I, however, have a great deal of experience in all fields of science and have had incredible experience in working with and dealing with all medical professionals. Some are good and some suck, just as some chiro’s are good and some suck. It is a pity that the medical profession does not really deeply consider the risk to benefit ratio with their standard treatment, that being drugs. It is also a pity that they do not get the idea of preventive medicine and the concept of in-depth doctor/patient relationship that would allow for true preventive medicine to occur.
Funny how the chiro’s seem to be able to gain such a trust of patients that the “placebo” effect you say they utilize is so effective. Why is that pmoran?
If you say the same lies over and over, that doesn’t make them true.
The medical community DOES understand the risk/benefit concept – in fact, I think if you go back in history you will find that it was the medical community that developed that concept.
We most certainly DO recognize the risks of ibuprofen. There are far more medical references for NSAID risks than chiropractic references for the risks of neck manipulation.
It is a false dichotomy to think ibuprofen and neck manipulation are the only two options.
I have never said there is “great risk” in chiropractic. I have said that studies have shown a significant rate of reported benign side effects and a small risk of serious complications.
We ARE applying the same standards to chiropractic as we do to other treatments. If chiropractic were a new drug, it would not have been approved based on the kind of evidence you have provided.
We ARE biased – but only against treatments based on a myth and treatments that have not been shown to offer a significant benefit.
The medical profession absolutely DOES get the idea of preventive medicine. And the concept of the in-depth doctor/patient relationship. It was a doctor, Francis Peabody, who said in 1925 “… the secret of the care of the patient is in caring for the patient.”
It’s easy to accuse me of bias and subjectivity, but it’s far more difficult to provide objective evidence supporting HVLA neck manipulation.
And now you comment on how chiropractors elicit the placebo response. Yes, I think that is a large part of what they do. We know many of the factors that enhance the placebo response. There is a great body of literature about that. There is also the effect of keeping patients occupied until the natural course of disease relieves the symptoms.Effective treatments also elicit the placebo response; why not use an effective treatment with a good risk/benefit ratio. There is no need to fool patients about bones out of place and imaginary subluxations.
Harriet – “There is no need to fool patients about bones out of place and imaginary subluxations.”
You know good and well from my previous posts that I don’t treat “bones out of place and subluxations” so don’t go getting all personal just as my previous comment was not directed at you personally.
Harriet – “If chiropractic were a new drug, it would not have been approved based on the kind of evidence you have provided. ”
So referring to JUST ibuprofen, given the risks that are well published, how did it get OTC status? and why is it so widely prescribed in huge quantities to patients every single day at amounts double that of the OTC strength. (3300 deaths per year and the number two cause of peptic ulcer.) And this is just ibuprofen.
Don’t tell me or any other chiro that the medical profession applies the same standard to drugs that this blog applies to chiropractic or CMT.
This is a TRUE bias. No doubt about it!
Harriet – “It is a false dichotomy to think ibuprofen and neck manipulation are the only two options.”
Well of course doctor! Once again you think that all chiropractors do is CMT. Bias once again.
I have explained the reasons for what you like to call “anti-chiro bias”? Do you wish to challenge any of those? I’m listening.
Based upon the executive summary of YOUR own stated “golf standard” of evidence (BJD), I have suggested that the only place for neck manipulation within medicine is as a relatively late resort for some patients with musculoskeletal neck pain that has not responded to simpler measures including massage and, possibly, gentle mobilisiation.
Over to you. What are YOUR indications, and why the reluctance to tell us?
Oh Harriet (one t, not two)
It is not only HVLA manipulations that are the cause is these incidents (I use the word “incident”, so as we do not spend hours arguing over semantics and the use of words and phrases such as “accidents” or “adverse effects”). You are, I believe, trying to divert the discussion away from the issue that it is SMT, irrespective of the type and practitioner, that is the cooncern. So is going to the hairdresser, yoga or just putting ones neck into a position that may occlude of disrupt the arteries in the neck. So when I read your comment……….
“It’s easy to accuse me of bias and subjectivity, but it’s far more difficult to provide objective evidence supporting HVLA neck manipulation.”
I actually wonder why on earth this debate is continuing. You are trying to hide behind semantics to justify what was, I believe, a poorly written article. One, which I believe, had it been on the topic of “Adverse Effects of (a certain aspect of medical care)” you would not have written.
SMT is used in the world, not just in the U.S.A. by a number of different practitioner groups. All of them are cognisant to the dangers of its use.
Why was ibuprofen approved? Because first it was clearly shown to be EFFECTIVE. Then the side effects were taken into account and it was determined that the benefits outweighed the risks in general. We can identify some patients who are at higher risk, and any good clinician takes risk into account and prescribes ibuprofen selectively. The risk/benefit ratio was so good that it was even approved as an OTC drug. The package insert (and any good clinician) advises patients about the risks.
Fredd Dag (just kidding)
says everyone who uses SMT is aware of its dangers. Maybe, but they’re not telling all their patients. Sandra Nette and others who had strokes were never warned of any risk. There is a movement to require any provider who performs neck manipulation to practice informed consent. See http://www.courant.com/news/local/columnists/hc-chiropractor-informed-consent-rgmar17-column,0,2557162.column
This article indicates that some chiropractors think manipulation is “the safest” form of treatment and some still deny that there is a risk. The chiropractors say this still singles them out. It seems they have the same chip on their shoulder?
“The chiropractors are all over this. It’s a lot of pressure,” Fasano said. “Legislators are getting called left and right. They are very vocal. They are saying things that are not quite accurate, like we are singling out chiropractors and there is no such thing as a stroke” caused by cervical manipulation.”
The sad thing is that some chiropractors are using “informed consent” forms that unfairly minimize the risks, don’t provide good evidence for benefits, and amount to blatant propaganda for chiropractic treatment.
If someone wrote an systematic review about side effects of treatment by a dermatologist, I hope they wouldn’t complain it was unfair because family physicians, pediatricians, and internists also provided the same treatments. I hope they would incorporate the information into their practice and expect the other specialities to follow suit.
Hello Harriet,
I do not have any complaints about your comments about informed consent being a requirement. I suppose I was talking about providers of SMT in my country. What amazes me, is that it is not used more often here, by other members of the health care fraternity.
Several dentists I know of do not use it and I believe that there is a presumption by some Healthcare Providers that patients know and accept the risk, despite it not being made aware of the (the “Doctor knows best” mentality). I am sure you and I as well as other members of this site can think of many proceedures in healthcare, that if the patient was made aware of the risk, they would not participate in it.
I suppose the main problem I see in continuing this discussion is that there are geographical differences. What is acceptable and unacceptable care differs in whatever country one practices in. I pointed that out to you, when one looks at the use of spinal surgery rates in the U.S. when compared to the U.K. Who is right? I am not sure. I hope that the intent of the surgeons is to get a good result.
In regard to your comment about treatment by dermatologists, I agree with you, however what would be criticised would be the treatment, rather than the fact that it was more dangerous provided by one group rather than the other. As an analogy, is Isotretien more dangerous when provided by a dermatologist or G.P.? The danger is in the medication, not the practitioner who responsibly prescribed it. In this case you singled out Chiropractors rather than Spinal Manual Therapy and that is where I have a problem.
Who is right? The difference in surgery rates has been a frequent topic of discussion in the medical literature. It seems that spinal surgery only improves short term response but has no long-term advantages over nonsurgical treatment. Is there a longer waiting list in Britain? Are patients in the US more demanding about wanting relief NOW? Do Americans have a different perspective about surgery? I don’t know, but these are questions that doctors themselves are trying to answer. The same questions are constantly being asked about the optimum rate of c-sections and other procedures.
If you think patients in the US are not made aware of risks, just plow through a few medication package inserts and read some of the informed consents we have to sign for even minor procedures like mole excisions. We used to joke about what a TRULY informed consent would be: “Your surgeon might have a heart attack and fall on you during the procedure. An earthquake might shake you off the table….” We carefully document in the medical record that we have obtained informed consent after the risks and benefits of the procedure were fully explained and the patient had the chance to ask questions and indicated that he understood.
Your implied criticisms of mainstream medicine say nothing about the risk/benefit ratio of neck manipulation. The questions you raise are appropriate for discussion elsewhere, but they are irrelevant to the topic of this post. the fact that you bring them up suggests an attempt to distract us from the real question, and is smacks of the tu quoque fallacy.
Please tell us what the indications for neck manipulation are in the US and in your country. The science should be the same everywhere, even though customs and decisions may differ.
You seem to have a problem with my choice of words; I have a problem with your lack of evidence and your evasion of simple questions.
Hello Harriet (one T, not two)
I feel I have answered all of your questions. Maybe this is the adversarial way in the U.S. where there is a competition to “out-cite” each other. The desire to be seen to be right, without realizing that in the process, the casualties will exist.
However, the Bone and Joint Decade results do give a good indication that SMT for neck pain is indicated, in Grades 1 and 2. (It does not specify the provider). It out-cites the Cochrane review.
I am sure I did not infer that patients in the U.S. are not made aware of informed consent. If that is your impression, then that is not what I intended.
One would hope that the science is the same, but it is not. The science of “medicine or healthcare” is not the same, between countries and between generations. Examples of this can be seen with the use of anti-depressants in Germany as opposed to the U.S.A. Less dependence on Prozac type medications and better use of psychological counseling and St. Johns Wort in Germany. In fact it has been proven that anti-depressants for mild and moderate depression are no better than placebos.
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050045
Yet the dollars that are wasted in the use of these antidepressants and the potential side effects must be horrendous. Does it ever worry you?
Generational differences can be seen by reviewing the historical state of “United States medicine” pre and post the Flexner Report of the early 20th Century.
So where does the science apply to this issue?. Is it “Clinical Science”, “Physiological Science” or even “”Pharmaceutical Science”. I would hope that common sense has a bit of influence here.
What worries me is that treatments, like chiropractic, which are narrowly efficacious are continued throughout the world. Other treatments, when subjected to any sort of scientific rigor – are discarded.
FD, as you clearly practice in another country (Canada?) – I am interested as to what association guides your standards of care. Do you offer – in your practice – therapies other than “traditional chiropractic”?
Within an open, scientific field – the desire is to be accurate. Thus providing the best options for practioners and patients. There is no relativism in science.
Please tell us what the indications for neck manipulation are in the US and in your country. The science should be the same everywhere, even though customs and decisions may differ.
# pmoranon 13 Jun 2009 at 5:21 pm
Nobs, Why can I not get direct answers to simple questions? Here they are again. You wasted my time by referring me to sites that contribute nothing new and nothing of relevance.
Here are the questions again.
>>”Since your own “Gold Standard” paper sees other methods as having equal efficiacy to neck manipulation for neck pain but without the risks (e.g. acupuncture), what do you now see as the proper place of SMT in the treatment of neck pain?
—————————-
I DID answer your “questions”. -AND-, may I add, supplied you with linked sources supporting my answers.
Since you refer to my documented/referenced/linked answers to your “questions” as: “wasted my time” and “nothing of relevance” …..It is, in fact, ME that wasted my time, reponding to your disengenuous questions. You are entitled to your dogmatic bias. I politely request that you don’t waste any more of my time with your feigned “questions”.
“the majority of adverse events occur with non-DC manipulations.”
HH- >>”Really? See figure 2 at http://www.ptjournal.org/cgi/content/full/79/1/50 It indicates just the opposite.”
Really? See: http://www.ncbi.nlm.nih.gov/pubmed/16511634?dopt=Abstract IT indicates just the opposite. 89% cases were non-DC, 14% being Physical Therapists.
HH->>”I couldn’t find Haymo or jaskoviak,…..
The Jaskoviak study reported that not a single case of vertebral artery stroke occurred in approximately five million cervical manipulations at the National College of Chiropractic Clinic from 1965 to 1980.
nobs,
Re strokes caused by non-chiropractors: The article you cited says “We analyzed data from neurological departments at university hospitals in Germany over a three year period of time of subjects with vertebral artery dissections associated with chiropractic neck manipulation.” The abstract says “chiropractic” and it doesn’t mention other providers. That article was included in the systematic review, by the way.
The Jaskoviak study makes me wonder if inexperienced students can offer a level of safety greater than chiropractors who have graduated and have been in practice for a long time.
I have repeatedly said that the risk of stroke is very small and that we don’t have a reliable estimate. I hope you don’t deny that there is any risk at all.
nobs said,
“I DID answer your “questions”. -AND-, may I add, supplied you with linked sources supporting my answers.”
No you didn’t and the links didn’t.
Harriet-
.” The abstract says “chiropractic” and it doesn’t mention other providers. That article was included in the systematic review, by the way.”
YES- the title and abstract of the paper does INDEED say “chiropractic”. And this is precisely my original point, and WHY such reviews, by their very nature, are flawed…… The information they “search” is flawed.
I will provide you with the full text, detailing the providers, later tonight- gotta go.
I think we are going around and around in circles. Arguing semantics and citation no one bothers to read.
“– going around and around in circles.”
More so a preoccupation with irrelevancies on the part of some. We should be looking at the interests of the patient and working backwards from that.
It seems some chiropractors still want to hold out some hope that this matter will go away. It won’t. Medicine has found itself under more intense and unforgiving pulbic scrutiny in recent decades, yet chiropractors seem to be happy to sit out there on a limb for everyone to take potshots at.
Perhaps we need to start over, with simpler questions –.
Do contributing chiropractors yet accept that neck manipulation can cause stroke? If not, why not?
Hello Pmoran
It is well recognised by those members of the chiropractic profession I have meet, that there is a relationship between spinal manual therapy and the incidence of strokes. There is more research that can be done on this issue, as it is a treatment issue, rather than a “practitioner” issue.
In a very early post, I specified that there needed to be a multi-disciplinary approach to this issue, rather than an attempt to point the finger and blame.
Your comment…..
“yet chiropractors seem to be happy to sit out there on a limb for everyone to take potshots at. ”
Is only your opinion. My experience is that the chiropractors I have meet are very patient care focused. There is also an intense desire for research to be done within the field of neuro-musculo-skeletal medicine.
Here we delve into the politics of research, costs and egos, and best not to go there.
I totally agree with your sentiment that the patient comes first and any research done on this topic should be done to make practitioners safer.
“– there is a relationship between spinal manual therapy and the incidence of stroke”
Do you think this is a causal relationship? (Probably/probably not/can’t tell)
“–There is more research that can be done on this issue”
What kind of research do you have in mind? It will never be practical (or ethical?) to perform prospective randomised controlled trials involving (potentially) hundreds of thousands of subjects, and I wonder whether any other kind of trial could effectively counter the evidence we already have.
I am not a researcher nor anatomist so cannot comment on the difficulties of doing research on this topic. There are many tpic is healthcare that would be difficult to research effectively.
The relationship has been discussed in Bone and Joint Decade as well as other peer reviewed articles, so I need not comment on it.
I am not sure what evidence you are referring too. The evidence we already have says that in comparison to other forms of care, SMT is as safe, if not safer.
“The evidence we already have says that in comparison to other forms of care, SMT is as safe, if not safer.”
Maybe in comparison to SOME other forms of care, but certainly not to ALL other forms of care.
Personally, I think we have flogged this topic to death. We could argue semantics, citations and repeat ourselves ad nauseum, but not really get any further than this state.
Can we at least agree that SMT has frequent minor benign side effects and rare serious complications?
I think the word ”occasional” is more accurate than “frequent”, however that would be being pedantic.
How many CMT induced strokes have occurred since Ms Nette had hers? With all the attention on the potential occurrence and it’s apparent frequent incidence, you would think, after hearing the arguments here, that it must occur almost daily.
Where as we know the dangers of just one drug, ibuprofen, and that causes about 2 – 3 deaths per day. Yet it is still over the counter and still readily available to anyone.
You say the little packet inside describes the risks. Just how literate do you really think the public actually is? Have yo been out in the real world lately? Have you been to the getto and into the immigrant world of most of the USA? Do you really, honestly think people actually read those “little packets” or even the back of the bottle or any such thing that comes with the bottle of ibuprofen? If they did then they might actually know that Advil, Motrin and ibuprofen are the same thing and could actually converse on the dangers and risks associated with it’s use.
And this is just ONE drug available to an unknowing public.
Yes we can agree that CMT has some adverse effects and some very rare serious complications. I am just wondering how many of these serious complications have occurred since Ms Nette’s stroke now that the medical community is so keenly aware of the possibility of it happening?
ZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZ!!!!!!!!!!!!!!!
Wake up Fred!
nwtk2007 – Ibuprofen causes 2-3 deaths per day.
Please cite references – a rate of mortality attributable to a drug would have it removed from the shelves so fast it would make your head spin.
By the way – if there is agreement on the SMT / CMT discussion, can someone identify which “principles” of chiropractic they follow? I note that the BC College of Chiropractic provides some of the most restrictive practice constraints on their members – although the wide range of therapies offered in by Vancouver DCs seems to ignore this covenant.
Harriet- Here is the full text you requested.
http://www.springerlink.com/content/dtx8628t82177061/fulltext.pdf
“All cervical manipulations were performed in different
private practices. Orthopedic surgeons conducted
the neck manipulation in 18 subjects. Four procedures
were conducted by a chiropractor and 5 by a physiotherapist
while maneuvers performed by neurologists
(n=1), homeopaths (n=1) and general practitioners
(n=2) accounted for 4 incidents.”
Would you kindly provide me with the full text of the referenced systematic review? Thank-you in advance.
I’d also like to comment on THIS: (which you reference in your “chiropractic ‘explanation’”)
HH-” An intriguing study using PET scans concluded that cerebellar hypoperfusion (decreased
blood flow to the base of the brain) may occur after cervical spinal manipulation. This
could explain reports of headache, dizziness, vertigo, nausea, blurred vision, etc. It also
raises the possibility that some of the minor reactions were strokes that almost happened
but didn’t.”
It is important to note, that while you quote this study in your “chiropractic explanation” —-ALL manipulations performed in this study were done by physiotherapists.—
Yesterday you posted a link to a newwpaper column about legislation regarding chiropractic informed consent. – What type of informed consent do you advocate for manipulating MDs and PTs? -Should not that also be part of the legislation here?
nobs,
The full text of the systematic review? There is no free access. You can buy it with the pay-per-view option on the Spine website at http://journals.lww.com/spinejournal/toc/2009/05150
About the legislation: If you will go back and read the link again you will see that the proposal has been modified to also apply to non-chiropractors who use manipulation. Yet chiropractors still feel that they have been singled out.
Yes, studies like the one you cite use imprecise terminology. It’s no wonder. Chiropractic has claimed manipulation as its raison d’etre, and has strongly identified itself with manipulation in the public mind. It is only natural that when others do the same procedure they think of it as “chiropractic.” Interestingly, that study was done in Germany, and chiropractors are not licensed in that country. The semantics might have lost something in translation.
The risk is with the procedure and it is irrelevant who provides it.
My post begins by saying “There is a very good chance that you will feel worse after seeing a chiropractor” and I think there are sufficient data in the review to support that. I could have added “There is a smaller chance that you will feel worse after seeing other practitioners who provide manipulation, because other practitioners use manipulation on a smaller percentage of their patients.”
Dear Citizen,
I only have a couple of minutes so here is a quickie:
http://www.drugwarfacts.org/cms/?q=node/30#nsaid
The resource is JAMA.
Also – “NSAIDs, such as ibuprofen, are among the most widely used drugs in the world for the treatment of chronic pain and inflammation with more than 90 million prescriptions written each year for the treatment of arthritis and other types of mild-to-moderate pain. However, NSAIDs are associated with a range of adverse side effects, which primarily affect the GI tract. Up to 30 percent of patients taking NSAIDs experience GI ulcers, and even more suffer from upper GI symptoms (e.g., dyspepsia, heartburn). Serious NSAID-induced GI toxicity causes an estimated 16,500 deaths and more than 107,000 hospitalizations annually in the U.S. alone.”
This from
http://www.medpagetoday.com/PRDir/PressRelease.cfm?id=2553&sid=77&cid=10
To get the actual sources you’ll have to do some digging if you are so inclined.
That was about 1 min of looking. I’m not on my computer so I can’t give you too many others. It is very easy to see the rates in many different sources. It is essentially common knowledge in the scientific community.
So how many CMT induced strokes since Ms Nette anyway? A very rare occurrance indeed.
Feel worse after seeing a chiro?
Then why do they keep coming back. You would think that if they feel beter after seeing someone they would come back.
I’m just saying.
nwtk2007,
Any risk statistics are meaningless until they are put into perspective with benefit statistics. The question is not how many people have suffered side effects, but what the risk/benefit ratio is. The benefits of neck manipulation for health maintenance are non-existent, so even one Sandra Nette is too many.
The repeated assertions by chiropractors that NSAIDS kill more patients than neck manipulation are technically true, but they imply an unwarranted assumption that those are the only two options, and they completely disregard the fact that the benefits and risks of NSAIDS have been clearly demonstrated and even quantified, whereas the benefits of manipulation are not so clear and the risks are known but not so well quantified.
HH->>”About the legislation: If you will go back and read the link again you will see that the proposal has been modified to also apply to non-chiropractors who use manipulation. Yet chiropractors still feel that they have been singled out.”<<
What it says is:
“Fasano has modified his proposal to say that any PHYSICIAN who performs neck manipulation must practice informed consent. The chiropractors say this still singles them out.” (Italics are mine for emphasis)
Since PTs cannot legally use “physician”, that would nullify them from this legislation. What is your opinion on that?
HH- >>”Yes, studies like the one you cite use imprecise terminology. It’s no wonder. Chiropractic has claimed manipulation as its raison d’etre, and has strongly identified itself with manipulation in the public mind. “<<
In the “public mind” perhaps, but surely we should expect more accuracy in scientific publications. Do you not agree?
nobs asked “Since PTs cannot legally use “physician”, that would nullify them from this legislation. What is your opinion on that?”
I thought by now my opinion would be crystal-clear to everyone. Any legislation should apply equally to anyone offering the procedure.
nobs said, “In the “public mind” perhaps, but surely we should expect more accuracy in scientific publications. Do you not agree?”
Well of course I agree! We should always strive for precision of terminology. Unfortunately, public understanding has a strong influence on our language. I use the term “alternative medicine” even though I don’t accept that there is any validity to that concept. It’s easier to use the popular term than to explain my thinking every time. Sometimes I call it “so-called alternative medicine.” Maybe I should say “so-called chiropractic treatment which is really just the same spinal manipulation therapy that other providers use.”
HH- >>”Well of course I agree! We should always strive for precision of terminology”<<
Yes- Scientific papers and so-called scientific-medicine op-ed pieces should not contribute to further confounding the public, with improper language and misuse of terminology.
Harriet (one T, not two)
You do not seem to address the issue of how many people take NSAIDs, for maintenance, just in case they get a headache, or just because they feel the odd niggle.
Is every one of those scripts necessary? I do not think so.
Does every person read the enclosed information sheet?.
Well, in my experience they are written in very small print, and in such a way that they are incomprehensible to the average U.S. reader.
You just about need a medical degree just to make sense of these sheets. This would hardly be considered to be adequate informed consent or even good information.
“You do not seem to address the issue of how many people take NSAIDs, for maintenance, just in case they get a headache, or just because they feel the odd niggle. Is every one of those scripts necessary? I do not think so.”
I don’t think so either. Please read what I wrote about overuse of medications at http://www.sciencebasedmedicine.org/?p=126 Incidentally, NSAIDS do not require a script – they are available over the counter.
I didn’t address overuse of NSAIDS because that was not the issue. You did not address the issue of how many chiropractic patients get adjusted for maintenance and other bogus indications, either. I didn’t address the cost of treatment or a lot of other things. You keep complaining about what I didn’t say, and you quibble about my use of words, but you haven’t actually disagreed with what I did say: that a significant number of patients report mild adverse effects and that there are rare serious complications from neck manipulation.
nwtk2007 said
“Feel worse after seeing a chiro?
Then why do they keep coming back. You would think that if they feel beter after seeing someone they would come back.
I’m just saying.”
Apparently he didn’t notice that I had asked the same question and answered it in the post. I didn’t elaborate on the psychological factors that can keep patients coming back, but they are legion.
I have to say that I was surprised when ibuprofen was made available over-the-counter. But it has now been available for short term pain relief in relatively low dosage for over two deacdes in most advanced countries, so I suppose it is proving about as safe as paracetamol, antihistamines and many other OTC drugs. I just hope our ADR reporting system is working as it should.
Trying again to convey the gist of our concerns, chiropractic gets singled out in relation to the stroke issue because of the perception that the vast majority of the neck manipulation performed within chiropractic is unnecessary medically.
It is believed that unnecessarily long programs of treatment are advised (against BJD advice), even life-long supposedly preventative treatments — even in children, AND sometimes babies, whose necks are like jelly.
There are other treatments that will SERVE “work” about as well for neck pain, the major indication. Neck manipulation may well yet have a place with neck pain but it is up to chiropractors and others who wish to use neck manipulation for that purpose to lay down some ground rules so that a minimum number of necks are at risk for the greatest likely benefit. We don’t see that happening within chiropractic, even in the BJD material.
There is no good evidence that CMT works for anything else *other than as placebo* and only highly unusual circumstances might justify even the tiniest risk from placebo treatments. There are plenty of quite safe ones to choose from.
What do you have to say to this?
“Medical treatments kill people too”, is in my opinion a childish response. Patients prefer not to be killed or to know at minimum that any risks are justified by unique properties of the treatment offered.
Harriet, of course I read your answer to your own question which I just re-iterated.
I guess chiropractors are just really good at the “psychology” of patient compliance. Perhaps we should conduct some work shops for medical doctors in this regard and thus improve their compliance to their treatments such that these patients would not come running to us for help when their medical doctor has failed them.
But again, I’m just saying.
And I am still surprised that ibuprofen OR tylenol were made OTC. The warnings are an empty gesture at best. Come down to the ghetto or even to the average “people” world and lets take a poll on the risks of the drugs people take in such huge amounts.
I know, it’s not the issue.
Also, there is an article by DrVertebrae at
http://www.TruthinTreatment.blogspot.com
about full disclosure that I find interesting when talking about informed concent.
I advocate that for all proceedures a patient undergoes from a registered health care provider, that they are informed of the dangers of this proceedure. The patient/consumer is informed of the likely risks of complications and signs a waiver to say that they understand the risks involved.
That will also include all OTC medications such as NSAIDS, Asprin and Tylenol etc.
The savings to the U.S. community will be huge. No more mal-practice cases and no more drug companies being sued, unless they with-hold information from the public as to the dangers. (Just like the tobacco companies)
Any problems with that?
.Informed consent is not sufficient to prevent malpractice suits, and the cost of all the paperwork would be immense. Trees would die. If people had to sign an informed consent to get an aspirin, they would be majorly annoyed.
Talk about “slippery slope.” You could extend the concept to include getting on a bus or plane, buying a bicycle, buying a hammer, getting a shampoo in a beauty parlor, visiting a beach
Even going outdoors is hazardous to your health (sunlight, skin cancer, wrinkles). You can’t require informed consent for everything. The existing situation is a reasonable compromise.
Harriet,
“What is good for the goose, is also good for the gander”,
a common expression in the British Commonwealth.
We are only talking of Registered HealthCare Providers, in this circumstance. While it may be inconvenient, it is also fair and safe.
Trees will not die, but electrons and digital signing would be appropriate.
People may get annoyed, but that will be the price they pay to be informed.
I wonder if the literacy skills would be up to suitable standard so that consumers actually understood what they were signing. Now, that is a major concern!!!!!!!!!!!!!
@Fred Dagg on 16 Jun 2009 at 6:32 pm “I wonder if the literacy skills would be up to suitable standard so that consumers actually understood what they were signing.”
That would put you out of business. Maybe, even, prevent you from going to chiro school.
Fred,
You haven’t actually disagreed with what I said in my post: that a nontrivial number of patients report mild adverse effects and that there are rare serious complications from neck manipulation. Can we just agree on that and end this discussion? It has gotten way off topic.
Hi Harriet
yes, we are off topic. No need for snide remarks from Joe.
I will look forward to your next item on the “Perils of Informed Consent”.
Now we can concern ourselves on the use of the word “Science”.
nwtk2007 – you cited a pro-legalization marijuana page which then references a 1997 article on gastropathy in elderly patients in a small study in Canada. You must be out of your mind. This is not indiciative of mortality due to NSAIDS – which cover far more than Ibuprofen.
If you’re going to cite something – know where it leads.
ZZZZZZZZZZZZZZZZZZZZ!!!!!!!!!!!!!!!!!
Wake me up when someone says something important.
(1996): “Each year, use of NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) accounts for an estimated 7,600 deaths and 76,000 hospitalizations in the United States.” (NSAIDs include aspirin, ibuprofen, naproxen, diclofenac, ketoprofen, and tiaprofenic acid.)
I guess you didn’t see this. Or this:
The side effects related to Ibuprofen, though fewer in number, can be more intense in symptoms. The most common side effects are GI (gastrointestinal) in origin. They include complaints of nausea, vomiting, anorexia, diarrhea, and abdominal pain and occasionally even ulcers of the upper intestinal tract. There are other possible and less frequent side effects involving the central nervous system, liver and even allergic reactions like rashes.
Heavy use of nonaspirin pain relievers does increase the risk for high blood pressure. In one groundbreaking study, women who took nonsteroidal anti-inflammatories (NSAIDs), such as ibuprofen, 22 times a month or more were 86% more likely to have high blood pressure than those who did not take NSAIDs. Those taking acetaminophen were twice as likely to be hypertensive. Aspirin did not increase the risk.
or this:
Adverse drug reactions affect a far greater number of hospital patients than was previously thought and may rank as high as the fourth leading cause of death in the United States, according to a report in the April 15th issue of The Journal of the American Medical Association.
Jason Lazarou, and Drs. Bruce H. Pomeranz and Paul N. Corey of the University of Toronto in Ontario, Canada, conducted a meta-analysis of 39 prospective studies that occurred between 1966 to 1996 and focused on the incidence of adverse drug reactions in US hospitals.
For purposes of the study, an adverse drug reaction was defined as “…any noxious, unintended and undesired effect of a drug, which occurs at doses used in humans for prophylaxis, diagnosis, or therapy.” Incidents involving errors in drug administration, noncompliance, drug abuse, overdose or therapeutic failure were not included.
“The overall incidence of serious [adverse drug reactions] was 6.7%,” the researchers conclude, “…and of fatal [adverse drug reactions] was 0.32%.” For the year 1994, this amounted to an estimated 106,000 adverse drug reaction-related fatalities. The researchers say that adverse drug reactions may be the fourth to the sixth leading cause of death in the US.
or this:
This medicine can cause ulcers and bleeding in the stomach and intestines at any time during treatment. Ulcers and bleeding can happen without warning symptoms and can cause death.
This is a general search which to about 1 minute. If you actually try to look then you will find much more. Still not on my computer so this will have to suffice.
For a science based web cite I shouldn’t even have to site evidence such as this. It is common knowledge in the entire scientific community. You might as well have me cite articles and studies showing the formula for water.
Is science about ignoring that which we already know?
More bias.
HH->>”A retrospective study of medicolegal cases suggested that chiropractors may have failed to recognize a stroke in progress. “The sudden onset of acute and unusual neck and/or head pain may represent a dissection in progress and be the reason a patient seeks manipulative therapy that then serves as the final insult to the vessel leading to ischemia.” Strokes occurred at any point during the course of treatment and there was no dose-response relationship.”<<
Harriet- It did not suggest that at all. First of all, this study was not about chiropractors, and your attribution to chiropractors is a total distortion Then you wonder why the general public is confused? I know you know better. Here is the actual quote I suspect you were “explaining”:
“The results of this study suggest that stroke, particularly vertebrobasilar dissection, should be considered a random and unpredictable complication of any neck movement including cervical manipulation. They may occur at any point in the course of treatment with virtually any method of cervical manipulation. The sudden onset of acute and unusual neck and/or head pain may represent a dissection in progress and be the reason a patient seeks manipulative therapy that then serves as the final insult to the vessel leading to ischemia.
wonhttp://www.springerlink.com/content/dtx8628t82177061/fulltext.pdf
There are also some very important findings in the body of the work that you chose not to “explain”.
The authors report:
“There has also been increasing utilization of manual manipulation by medical physicians and physical therapists around the world.”
AND:
“Eight of these 16 patients were seen in an emergency room or by their family physician prior to seeking spinal manipulation.”
AND:
“These data do not, however, exclude the possibility that skill plays a role in etiology of these complications.”
AND:
“Our data raise the possibility that in certain cases manipulation may not be the primary insult causing the dissection but rather an aggravating factor or coincidental event precipitating ischemia. It is clear that the majority of reported vertebrobasilar artery dissections occur and progress to brain ischemia without manipulation.”
From Harriet’s “explanation”, It is hard to even recognize this study, and Harriet’s “Adverse Effects of Chiropractic” “explanation” is unraveling, chiropractically. Very little of her cited supporting evidence has to do with chiropractors at all. I have just noted the third study where the major players were not DCs at all. There are more.
I think this is falling on deaf ears.
Harriet has moved on to the subject of “science”, where she has got confused between “science”, (”If you do not believe me, you are a pseudo-scientist”), and the scientific method. In this post, apparently being a “skeptic” is seen as qualification enough to criticize anything she does not agree with.
However, I believe, everybody should sign informed consent prior to any treatment being received. Funnily enough, she did not agree with me. Gave some woo excuse!!
“# Harriet Hall on 16 Jun 2009 at 1:15 pm
nobs asked “Since PTs cannot legally use “physician”, that would nullify them from this legislation. What is your opinion on that?”
I thought by now my opinion would be crystal-clear to everyone. Any legislation should apply equally to anyone offering the procedure.”
THEREFORE:
Since the legislation in question here, as it stands, does not “apply equally to anyone offering the procedure”, Shall we consider you a party that is non-supporting of this bill?
“However, I believe, everybody should sign informed consent prior to any treatment being received. Funnily enough, she did not agree with me. Gave some woo excuse!!”
While certainly needed, I fear that even informed consent will not enable a “steady as she goes” approach to neck manipulation.
Fully informed consent would include imparting the knowledge that there may be similarly effective but safer forms of management (including simply waiting a bit longer for things to resolve themselves– works better for most conditions than most people think).
With relatively rare events informed consent can aslo end up being applied in such a desultory manner that there will still be strokes ending up in the law courts and hence the newspapers.
Nobs, what makes you think we are not familiar with every aspect of this argument?
So, some patients may have a VAD (vertebral artery dissection) in progress. This CANNOT explain many of the cases — those with no relevant prior symptoms, or chronic or recurring complaints.
It may well explain a few, but even that has implications for sensible use of neck manipulation, suggesting delay if the history of high neck pain or occipital pain is short or atypical. Stretching a dissecting artery can only make matters worse, helping to explain sudden onset of neurological symptoms after manipulation .
So, even going to the hairdresser can be associated with a VAD. But is it not ridiculous assert that ANY movement of neck can precipitate a VAD in susceptible people but that having the neck more purposefully manipulated by a chiropractor cannot — not even in all likelihood in people with a less vulnerable anatomical associations of the vertebral artery to C1? (which raises the matter of the very strong plausibility — no artery in the body is so vulnerable to stretch)
The fact that other doctors and physiotherapists also cause the problem is accepted. But there is no question that chiropractors cause many too. Ask those carrying your malpractice insurance if you have douvts concerning that.
ZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZ!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Wake me up when somebody says something new, that is not just a rehash of what has already been discussed.
I am not so sure that this VAD is actually related to CMT, at least in the sense that manipulation of segments below C2 are involved. I am also not so sure there could be any connection between the so called HVLA manipulation.
In some of my treatment of my patients today I looked closely at my “technique” for lack of a better word. In the cervical spine manipulations, I move the lower and mid cervical joints to the end if a somewhat lateral, only slightly rotated position and simply give a slight thrust, no more than a fraction of an inch, in a slightly anterior/medial direction and attain a very effective manipulation of the segment I have contacted and the one above and below it in a very consistent manner.
The “gentle mobilization” I have observed performed by both chiro’s and PT’s involves a lot or rotation as well as extension of the neck, particularly at the C1/C2 segment, it is held and then repeated in the opposite direction.
Based upon the “mechanism” of “injury” as described by Dr Hall in her previous post, I just don’t see how the manipulation as I do it could be any where close to as dangerous as the “gentle mobilization”.
Perhaps the upper cervical manipulations could be more risky, but as I understand it, there is no rotation at all involved in those manipulations.
Based upon what I have seen of CMT, there are moves that I would think would or could compromise the vertebral artery as it undulates around and over C1 from it’s position at C2. Those moves involve full rotation followed by a thrust increasing the rotation.
Based upon the anatomy, I am surprised that there are not more VAD’s in the population involved in sports, or even while driving as in actively checking one’s “blind spot”, for example. This represents a great deal of rotation and if the move is sudden, would be nearly the equivalent of the rotational moves in mobilization and the rotational CMT moves.
Are any of the patients who haave had the alleged VAD after manipulation known to have had recent MVA’s or other types of related activities occur?
Just to reiterate a previous point about the dangers of OTC NSAIDS, didn’t the New England Journal of Medicine say, in 1999, that chronic use of NSAIDS like ibuprofen caused more deaths than myeloma, asthma, cervical cancer and Hodgkin’s disease combined? that something like 50,000 or 100,000 people are hospitalized each year due to complications related to the use of OTC NSAIDS.
I guess people just aren’t reading those warnings and informed consents on the little papers in the bottles after all.
I would also guess that if they were only available by prescription then all these harmful effects would cause a significant rise in malpractice cases after all. At least with them being OTC, the victims can only blame them selves and the poor education society has given them, not their doctor.
nwtk2007 on 18 Jun 2009 at 11:39 am “Just to reiterate a previous point about the dangers of OTC NSAIDS”
Just reiterate a previous point, your argument does not convince us that chiro is safe and/or effective.
I know there is no convincing you (us) Joe, but you (them) have not convinced me or any other chiro that NSAIDS like ibuprofen aren’t a thousand thimes more dangerous, yet you (us) ask for informed consent and warn against the “dangers” of chiropractic, specifically CMT while denying the need for informed consent for medicines like ibuprofen which truly should not be sold OTC in such an uncontrolled way.
Bias, hyprocricy, what ever it is, I know that I won’t change your mind.
Hello Joe,
I am sure this will raise your blood pressure!!!!!!!!!
http://www.youtube.com/watch?v=5TTzKwvNbP0&feature=PlayList&p=1077234FE2C07552&playnext=1&playnext_from=PL&index=5
What I appreciated was the very ethical and honest response from the AMA.
Looks like Harriet went mia. Darn- She left before answering several of my questions.
ADDITIONALLY-
I also would like her to comment on the evidence I brought to her attention in this thread: the inappropriate use of, and misuse of “Chiropractic” and “chiropractic terminology” in the literature; and it’s subsequent mal-influence on information synthesis(eg. systematic reviews). In particular, I would like to know how she is going to use and incorporate this new-found information in her upcoming presentation in Las Vegas: Scientific Critique of Chiropractic (Harriet Hall, MD) What aspects of her presentation is she going to change/alter in light of this information?
Harriett
is it possible to get a transcript of your talk in Las Vegas, before you present it, so that is can be scanned for obvious errors.
Fred, Harriet’s (one “t”) talk is a continuing education course. She may deliberately put errors in it for the audience to catch.
Fred Dagg on 20 Jun 2009 at 2:09 pm :”Harriett is it possible to get a transcript of your talk in Las Vegas, before you present it, so that is can be scanned for obvious errors.”
Mr. Dagg, we have no evidence that you can find errors beyond a sophomore, high-school level of “sophistication.” That is the sort of pedantry up with which we shall not put. (W. Churchill)
nwtk2007 “Are any of the patients who haave had the alleged VAD after manipulation known to have had recent MVA’s or other types of related activities occur?”
I don’t know, but the anecdotal evidence associating CMT with stroke remains very strong and the correlation is strong in nearly every study that has looked at the problem,
Only one study contradicts such an association. I have not been able to examine that fully, but the abstract suggests many possible flaws including that patients with neurological symptoms from an emerging VAD such as giddiness would be more likely to attend a doctor than a chiropractor, and many of the patients attending a chiropractor may have also attended a doctor.
From what you say, your technique may be unlikely to cause a VAD, or at least no more than many other common activities.
Thit, I suppose, suggests another reasonable response for chiropractic — to try and find a safer way of manipulating the neck. I am fairly sure that those dinky little toys that some DCs use are unlikely on their own to be harmful. Difficult research, though. with such an infrequent condition. Also, the less the “manipulation” actually does to the neck the more it looks like placebo.
I would have thought that if Harriet had nothing to hide, she should provide a transcript.
However, as you say that she may put obvious errors in it for the audience to determine. By someones own admission on this site, about the American education system, where they do not know what 25% of 100 is, and cannot identify China on a map, how do you think they are going to be able to find obvious errors in Harriet’s talk.
If it is on “Continuing education”, how can she object to peer review, before giving the talk?
Fred, it’s peer review.
So far you have demonstrated no basic knowledge of the subject that would indicate you could do any such review.
Nice one Whitecoat, however, as it is peer reviewed, I hope, there are enough people on this site with some very good degrees who could audit it. Not just me. If Harriet had nothing to hide, she should let us all have a look at it.
I will not hold my breath.
Fred, if you want to see Harriet’s presentation, you should pay for it like everyone else. I am quite sure that there will be a question and answer session following her presentation and I have no doubt that there will be some very knowledgeable people in the audience who will not let any errors slip by. You could be there too. Perhaps you might learn something about how real SBM is done.
”Harriett is it possible to get a transcript of your talk in Las Vegas, before you present it, so that is can be scanned for obvious errors.”
“I would have thought that if Harriet had nothing to hide, she should provide a transcript.”
I try very hard, as much as I would like to, not to make personal comments on the blog and to date I have not.
But.
Jesus.
What a……..
There. I still haven’t.
But the temptation is so strong.
So strong.
Thank you Mark for your comment.
However, asking Harriet Hall to talk about Chiropractic is wrong. She is not a Chiropractor and she has a “propagandist Quackwatch” stance. I am surprised that she did not say to the organizers, “I am not a Chiropractor.,To discuss the science of Chiropractic, you would be best to have a Chiropractor present the required information”.
I do not see how this cannot be seen fair. I am sure anyone in the audience who queried it, would be able to do so.
It is an arrogant approach and inflammatory.
Dr Hall is also very biased with regards to chiropractic, at least as goes the “scientific” evidence for CMT causation for stroke.
@Fred, there is no science in chiropractic. Chiropractors have written a lot of books and articles that anyone can read and critique.
The British Chiropractic Association has recently a furnished a list of 29 papers that they say “support” chiro efficacy for pediatric complaints (colic, asthma, etc.). http://layscience.net/node/598 Several of them are totally irrelevant, and the rest are seriously flawed. After 114 years of claiming to treat those problems they cannot find one proper study to support any claim. Just looking at those papers tells us that chiros don’t know squat about science.
Hi Joe see,
http://www.youtube.com/watch?v=5TTzKwvNbP0&feature=PlayList&p=1077234FE2C07552&playnext=1&playnext_from=PL&index=5
No.
Next question.
(I’m with Mark Crislip, BTW, except that occasionally, try as I might not to, I do succumb to the temptation to make personal comments when the offense is bad enough. Not this time. For the moment.)
Fred, “peer review” doesn’t mean, “gimme a copy NOW cuz i wanna”. Peer review is a process done prepublication by someone’s PEERS. Talks are not subject to your whim. If they were, you would at least need to by Harriet’s professional peer, meaning an expert in human medicine with a clear understanding of science-based medicine.
You will never, however, be her personal peer as a compassionate professional who has bravely served her patients and country for years.
Courtier’s reply.
Fredd this one seems especially hypocritical coming from you, you’ve been talking about, and criticizing people on all sorts of things that you clearly don’t know the first thing about.
Where there is an objective truth, one does not need to be “balanced” or “fair”. If we were talking about civil rights, we could just have a civil rights leader talk. We wouldn’t need to balance him or her with a white supremacist.
Fred-
# Peter Lipsonon 21 Jun 2009 at 7:49 am posted:
“Fred, “peer review” doesn’t mean, “gimme a copy NOW cuz i wanna”. Peer review is a process done prepublication by someone’s PEERS. Talks are not subject to your whim.”
…………………….
Fred- While this is a flip and sarcastic representation of “peer review”, it does, indeed, have a few elements of accuracy.
Any journal, (or op/ed piece), can claim to be “peer-reviewed, (eg. Barrett’s SRAM). This claim is meaningless, and misleading, if one does not understand, or is misled by the term: “peer-review”.
Credible papers are published in and referenced by —–INDEXED—–”peer-reviewed” journals. That requires, as Peter posts, a pre-publication review by the journal’s peer-review board. Their review determines if a submission meets standards for publication. Being—-INDEXED—–is key. (Barrett has repeatedly applied to get his “SRAM” journal indexed, and because it fails to meet ‘indexed’ standards, has been repeatedly denied listing in the index).
Harriet is not submitting her “critique” for publication in a “peer-reviewed” journal.
Since she is not submitting her “talk” to an indexed, peer-reviewed journal, she does not have to submit to the scrutiny of a peer-review, and thusly defend/document her “critique”.
She is being paid to give a “talk”, and as such, she can say anything she chooses……..be it: true, misleading, biased, appropriate, inappropriate, informed, uninformed, ……………………even “tweek it” to the ilk of those that are paying her.
What I DO find a bit confounding is, that this “conference” is elgible for CMEs…….
She is being paid to give a “talk”, and as such, she can say anything she chooses……..be it: true, misleading, biased, appropriate, inappropriate, informed, uninformed, ……………………even “tweek it” to the ilk of those that are paying her.
What I DO find a bit confounding is, that this “conference” is elgible for CMEs…….
This is the most relevant part of the last few posts. When I go to the local hospital to listen to lectures and gain CME points, I expect and so do all of the audience, the facts to be unbiased and correct. The fact that Harriet may not do this, with your agreement, is somewhat perplexing for me. I wonder if the organizers of the talk know that Harriet may not be totally accurate in her talk.
Fred, your concept of what a medical talk, or a CME activity are is fundamentally flawed. CME isn’t always, “what is the BUN/Cr ratio c/w prerenal azotemia.” It’s usually less basic and more interesting.
However, if someone showed up at grand rounds, which is a CME activity, and presented “evidence” that chiropractic might help anything but a sore back, they’d be torn apart in seconds by their betters.
You truly are ignorant of how the SBM conference is being put together. First off, we are organizing it. Specifically, Steve is in charge of organizing it, and we are giving talks. None of us are being paid. Originally, we were going to get nothing more than free registration to TAM7 for our efforts. In other words, when we all agreed to this, we did so with the expectation that we would all have to pay our own travel and lodging in order to keep costs down, although the latest news is that we may now be getting some travel reimbursement. Be that as it may, when we agreed to do this conference, we all did it with the expectation that we would lose money because we’d have to pay all of our airfare and lodging. Even if we do end up getting some travel reimbursement, we speakers will not exactly be making money on this. We will all have put significant funds of our own into coming to give these talks.
No, Steve organized this conference, and we agreed to give talks there not for the purposes of being paid, but rather because we all believe in science-based medicine.
CME conferences are not peer-reviewed publications or grant applications. There are certain requirements that need to be met by a lecture or conference in order to qualify for CME credit. The curriculum and materials to be used for the SBM conference have met these requirements. End of story.
Your “demands” to see Harriet’s slides beforehand so that you can subject them to “peer review” are, quite frankly, risible.
SRAM–The Scientific Review of Alternative Medicine–is not “Barrett’s” journal. It was founded and edited for 10 years by our fellow blogger Wally Sampson. I am currently the acting editor.
SRAM is indexed by Google Scholar and CINAHL, but not by the National Library of Medicine (NLM), whose website is PubMed. This is not because SRAM ‘failed to meet indexed standards,’ however. Dr. Sampson explained the reasons here, and also showed that the NLM indexes several “CAM” advocacy journals that have no credible claim to objectivity or science.
>>>
“is it possible to get a transcript of your talk in Las Vegas, before you present it, so that is can be scanned for obvious errors.”
“I would have thought that if Harriet had nothing to hide, she should provide a transcript.”
EPIC FAIL/FACE PALM:
Pick a thousand conferences with presenters at random, and ask every one of the presenters for those conferences the same question and let us know what kind of success you have.
“I am surprised that she did not say to the organizers, “I am not a Chiropractor.,To discuss the science of Chiropractic, you would be best to have a Chiropractor present the required information”.”
EPIC FAIL/FACE PALM #2:
By this reasoning, Reductio Ad Absurdum:
Never listen to anyone but child molesters about what child molesters do.
The police are not the people to listen to about crime prevention; buglers, rapists, and murderers are the people you want to talk to.
To avoid financial ruin, seek the advice of a deposed Nigerian prince.
[...] they can feel fairly comfortable visiting a chiropractor. They should be educated about the possible drawbacks of chiropractic and keep the chiropractor very far away from their neck. Lastly, parents should [...]