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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

Posted in: Chiropractic

Leave a Comment (269) ↓

269 thoughts on “Adverse Effects of Chiropractic

  1. pec says:

    “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.

  2. Blue Wode says:

    @ 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

  3. weing says:

    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.

  4. shadowmouse says:

    Can we please vote pec off the island at the next tribal council??

  5. Laurel says:

    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!

  6. nwtk2007 says:

    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.

  7. 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.

  8. tmac57 says:

    P eeve – E xasperate – C hafe ! ! !

  9. Canucklehead says:

    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.

  10. tmac57 says:

    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.

  11. nwtk2007 says:

    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?

  12. Harriet Hall says:

    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.

  13. LindaRosaRN says:

    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

  14. pmoran says:

    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.

  15. nwtk2007 says:

    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.

  16. wertys says:

    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..

  17. SDR says:

    Really, how many hundreds of times do I have to hear something for it to rise above the level of anecdotal evidence?

    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.

  18. SDR says:

    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.

  19. nwtk2007 says:

    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.

  20. Newcoaster says:

    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?

  21. Fred Dagg says:

    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”.

  22. Joe says:

    @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

  23. Fred Dagg says:

    “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.

  24. pmoran says:

    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?

  25. weing says:

    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?

  26. Mojo says:

    By the reasoning that allows CAMsters to rely on anecdotal evidence (post hoc ergo propter hoc), sure.

  27. nwtk2007 says:

    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.

  28. Karl Withakay says:

    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.

  29. Joe says:

    @ 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.”

  30. Joe says:

    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.

  31. Dacks says:

    “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.

  32. Fred Dagg says:

    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.

  33. Fred Dagg says:

    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.

  34. Wholly Father says:

    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.

  35. Joe says:

    @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.

  36. Joe says:

    @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.

  37. Wholly Father says:

    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.

  38. Prometheus says:

    nwtk2007 asks:

    Really, how many hundreds of times do I have to hear something for it to rise above the level of anecdotal evidence?

    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:

    The issue is not “Chiropractic Manipulation”, as you continually refer to, but “Spinal Manual Therapy”, as performed by Chiropractors, Osteopaths, Physiotherapists and Medical Practitioners.

    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

  39. Fred Dagg says:

    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.

  40. Fred Dagg says:

    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.

  41. Dr. Skeptizmo says:

    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.

  42. Joe says:

    @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.

  43. Joe says:

    @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.”

  44. Fred Dagg says:

    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.

  45. Joe says:

    @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.

  46. Fred Dagg says:

    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.

  47. Fred Dagg says:

    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.

  48. vargkill says:

    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!

  49. Joe says:

    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.

  50. Fred Dagg says:

    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.

  51. PTsickofBS says:

    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

  52. Fred Dagg says:

    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.

  53. Joe says:

    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.

  54. Joe says:

    @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 …

  55. nwtk2007 says:

    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.

  56. Fred Dagg says:

    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.

  57. pmoran says:

    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

  58. pmoran says:

    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

  59. pmoran says:

    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

  60. pmoran says:

    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

  61. pmoran says:

    “– 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.

  62. Fred Dagg says:

    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.

  63. Blue Wode says:

    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

  64. Fred Dagg says:

    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.

  65. Blue Wode says:

    @ 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

  66. Blue Wode says:

    @ 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

  67. Fred Dagg says:

    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.

  68. Blue Wode says:

    @ 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

  69. nwtk2007 says:

    “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.

  70. Joe says:

    @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.

  71. nwtk2007 says:

    Joe – “strong, contradictory evidence”?

    Of what? What were those studies again that were contradictory?

    Strong?

  72. Joe says:

    @ 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.

  73. Fred Dagg says:

    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.

  74. nwtk2007 says:

    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.

  75. pmoran says:

    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.

  76. Versus says:

    @ 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?

  77. Fred Dagg says:

    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.

  78. Joe says:

    @ 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.

  79. Joe says:

    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?

  80. Fred Dagg says:

    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.

  81. weing says:

    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?

  82. Fred Dagg says:

    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????????????????

  83. pmoran says:

    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.

  84. Joe says:

    @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.

  85. Fred Dagg says:

    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.

  86. Fred Dagg says:

    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.

  87. AppealToAuthority says:

    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?

  88. nwtk2007 says:

    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.

  89. Joe says:

    @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.

  90. Joe says:

    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

  91. nwtk2007 says:

    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 ….

  92. Joe says:

    @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?

  93. nwtk2007 says:

    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.

  94. coryblick says:

    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.

  95. Joe says:

    @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.

  96. nwtk2007 says:

    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?

  97. Joe says:

    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?

  98. nwtk2007 says:

    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? ……

  99. pmoran says:

    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.

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