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269 thoughts on “Adverse Effects of Chiropractic

  1. coryblick says:

    nwtk2007,

    Work hardening is totally overutilized in my estimation. It has its place in a narrow population of chronic pain (not that his population is narrow, but hardening is often used for every worker whose been off work for any period of time). If these are the only clinics in your area and all they are doing is work hardening, you’ve not got a good representation of what PT typically consists of. Most PTs who do any kind of manual therapy would not likely stay long in a clinic such as this, as it tends to be entirely hands off, and so would give a poor sampling of PT in general. Thus your view that PTs don’t like to actually see patients. Likely the same if your only experience is with PTs who work in a chiropractic clinic as I said before, IMO.

    In my practice, we see every patient one on one, no support staff doing any patient care. Only one restroom.

  2. NMS-DC says:

    Looking at the best evidence available, there is good research supporting the use of SMT for mechanical neck pain. Fred Dagg is indeed correct that this document, the BJD Neck Pain Task Force is the GOLD Standard with respect to the best evidence in neck pain management. It was published in 2008 and it was a multi-disciplinary document consisting of DCs, MDs, OTs, PTs, PhDs, etc. Clearly there is a definitive benefit (in comparison to risk) otherwise it wouldn’t have been recommended.

    Nevertheless, there is much confabulation going on here with SMT=chiropractic care. In fact, there are numerous instances where a non-chiropractor performed a cervical manipulative procedure which resulted in a serious adverse event only to be published as a “chiropractic”manipulation.

    Yet, there is research that is SPECIFIC to chiropractic manipulation which involves manipulation done by chiropractors which involved looking at a) adverse events and b) risk/benefit.

    Dr. Rubenstein, DC, PhD recently published his thesis (2008) which specifically looked at adverse reactions in cervical manipulation done by chiropractors and identifying predictors to those events.

    Predictors of adverse events following chiropractic care for patients with neck pain.
    Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW.

    CONCLUSIONS: Of the 60 independent variables examined, only 4 were found to be predictive of adverse events after chiropractic treatment for neck pain, one of which was found to be protective. The chiropractic practitioner can identify 3 of these variables before initiating treatment.

    Next article for consideration:

    Benign adverse events following chiropractic care for neck pain are associated with worse short-term outcomes but not worse outcomes at three months.
    Rubinstein SM, Knol DL, Leboeuf-Yde C, van Tulder MW.

    CONCLUSION: Self-reported benign adverse events after chiropractic care for neck pain are associated with worse short-term outcomes. Intense adverse events are associated with more neck disability and clinically relevant differences at the short-term only. However, there is no association between adverse events and worse outcomes at 3 months.

    However, the smoking gun which specifically looked at risk/benefit appears here

    Adverse events following chiropractic care for subjects with neck or low-back pain: do the benefits outweigh the risks?
    Rubinstein SM.

    Quote

    “The incidence of severe complications following chiropractic care and manipulation is extremely low. The best evidence suggests that chiropractic care is a useful therapy for subjects with neck or low-back pain for which the risks of serious adverse events should be considered negligible.”

    All articles from 2008, all published in respect biomedical journals, all specific to chiropractic care.

    To the dogmatic skeptics out there, the research suggests that a) SMT for mechanical neck pain Grades 1,2 is effective (moreso when combined with exercise) that it relatively safe (benign, minor side effects) and most importantly, the benefits outweigh the risks.

    Please refrain from ad hominems and logical fallacies and stick to the research which is what I am basing my argument on.

    Thank you,
    NMS

  3. Fred Dagg says:

    Oh, thank goodness there is someone else out there who has looked at the peer review research!!!!!!!!!!!!!!!!!!!!!

  4. Joe says:

    @NMS-DC on 08 Jun 2009 at 8:27 pm.

    Rubinstein’s articles are mostly in JMPT, which is written by and for chiropractors and known for its low quality.

    Mr. Dagg, JMPT is for quacks, and the peer-review is by quacks. So, yes it is peer-reviewed; but it is unreliable. People who do good research do aspire to publish there; it is only for shoddy work.

  5. Joe says:

    “People who do good research do aspire to ” should say “People who do good research do not aspire to ” publish in JMPT.

  6. Fred Dagg says:

    Hi Joe

    sounds to me like you have a really bad case of sour grapes.
    Anecdotes and unsubstantiated opinion like yours have only a limited role in a site like this

    Have a nice day.

    Fred

  7. nwtk2007 says:

    Fred,

    Joe has already more than once in past comments admitted that he has not read the studies he has commented on. At most he will look at an abstract, but more often than not, he won’t even look at that.

    My favorite of Joe’s responses are the ones where he comments with mistakes which make it readily apparent that he has NOT read the studies cited.

    Sour grapes indeed.

    Reminds me of Wisdom who comments against chiropractic on the Topix forums.

    I had asked that he actually E-mail me a study he cited in this thread that he claimed to have read on a Web journal that costs 31$ to read the entire article but Joe says he won’t do it for fear of giving out his E-mail as if he couldn’t have a non-descript one like Joe@yahoo.com. Too paranoid. Thinks someone might track him down or something I guess.

  8. Joe says:

    @ nwtk2007 on 10 Jun 2009 at 7:09 am

    I do not comment on things I don’t see (except to cite other, informed opinion), that is disturbed thinking on your part. What I have said is that I have quit looking at quack publications because it is a waste of time since they are so amateurish.

    Often, an abstract is sufficient to know that a study is not definitive. Let me help you out- if the study involves 30 subjects, is not blinded and is not controlled and is based on subjective measures- it is about as useful as an anecdote.

    As for the Spine article I won’t send you, a health professional would know how to get it at no cost, just as I did. Why scrimp, it is your business- don’t you want to know the current thinking about it? Considering that “Spine” publishes a lot of articles concerning chiro, why don’t you subscribe?

  9. Joe says:

    @ nwtk2007 on 10 Jun 2009 at 7:09 am

    What is one to think of a “professional” who does not subscribe to the relevant literature?

  10. nobs says:

    NMS-DC is indeed correct when he posts:

    “Nevertheless, there is much confabulation going on here with SMT=chiropractic care. In fact, there are numerous instances where a non-chiropractor performed a cervical manipulative procedure which resulted in a serious adverse event only to be published as a “chiropractic”manipulation.”

    –which leads to flawed “bottom lines” such as:

    HH—The bottom line: “chiropractic manipulations, especially neck manipulations, carry a small risk of serious consequences, a large risk of minor adverse effects; and, depending on the indication,
    there is little or no evidence that they are effective.”

    To de-construct the confabulation, let’s take a look at a few papers which address this very issue:

    http://www.chiroandosteo.com/content/14/1/16
    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
    Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer-reviewed biomedical literature

    Conclusion:
    The results of this year-long prospective review suggests that the words ‘chiropractor’ and ‘chiropractic manipulation’ are often used inappropriately by European biomedical researchers when
    reporting apparent associations between cervical spine manipulation and symptoms suggestive of traumatic injury. Furthermore, in those cases reported here, the spurious use of terminology seems to have passed through the peer-review process without correction. Additionally, these findings provide
    further preliminary evidence, beyond that already provided by Terrett, that the inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ may be a significant source of over-reporting of the link between the care provided by chiropractors and injury. Finally, editors of peer-reviewed journals were amenable to publishing ‘letters to editors’, and to a lesser extent ‘corrections’, when authors had inappropriately used the title ‘chiropractor’ and/or term ‘chiropractic manipulation’.

    AND

    http://www.ncbi.nlm.nih.gov/pubmed/7636409?dopt=Abstract&holding=f1000,f1000m,isrctn
    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
    Misuse of the literature by medical authors in discussing spinal manipulative therapy injury.

    CONCLUSION: The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical
    organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a nonchiropractor. The true incidence of such reporting
    cannot be determined. Such reporting adversely affects the reader’s opinion of chiropractic and chiropractors.

    One recent example:

    http://www.ncbi.nlm.nih.gov/pubmed/16511634?dopt=Abstract

    Vertebral Artery Dissections After Chiropractic Neck Manipulation in Germany Over Three Years

    J Neurol 2006 (Mar 6); [Epub ahead of print]

    Reuter U, Hamling M, Kavuk I, Einhaupl KM, Schielke E

    Charite-Universitatsmedizin Berlin, Dept. of Neurology, Schumannstr. 20-21, 10098, Berlin, Germany,

    uwe.reuter@charite.de

    Abstract:
    Vertebral artery dissection (VAD) has been observed in association with chirotherapy of the neck.

    However, most publications describe only single case reports or a small number of cases. We analyzed data from neurological departments at university hospitals in Germany over a three year period of time of subjects with vertebral artery dissections associated with chiropractic neck manipulation. We conducted a countrywide survey at neurological departments of all medical schools to identify patients with VAD after chirotherapy followed by a standardized questionnaire for each patient. 36 patients (mean age 40 + 11 years) with VAD were identified in 13 neurological departments. Clinical symptoms consistent with VAD started in 55% of patients within 12 hours after neck manipulation.
    Diagnosis of VAD was established in most cases using digital subtraction angiography (DSA), magnetic resonance angiography (MRA) or duplex sonography. 90% of patients admitted to hospital showed focal neurological deficits and among these 11 % had a reduced level of consciousness. 50% of subjects were
    discharged after 20 +/- 14 hospital days with focal neurological deficits, 1 patient died and 1 was
    in a persistent vegetative state. Risk factors associated with artery dissections (e. g. fibromuscular dysplasia) were present in only 25% of subjects. In summary, we describe the clinical pattern of 36 patients with vertebral artery dissections and prior chiropractic neck manipulation.

    Key words chiropractic – neck manipulation – artery dissection – disability

    ~~~~~~~~~~~~~~

    This abstract blatantly conceals the facts stated in the body of the paper when it states that “we describe 36 patients with vertebral artery dissections and prior chiropractic neck manipulation”.

    Of the 36 “patients”, –18—yup!-50%! were treated by orthopedic surgeons! 2(6%)- by a GP, 1(3%)- by a neurologist, 5(14%)- by physiotherapists, 1(3%) Homeopath, 3(9%) Unknown.

    The factual “bottom line” here is —-89% of the cites were NOT treated by a DC!

    The shoddy, even perhaps biased, construction of the abstract and poor choice of keywords confabulates the contents of the paper. Thusly, misleading all who are searching those terms and keywords. And therby directly contributing to flawed “bottom line” conclusions.

  11. daedalus2u says:

    There is a very interesting report

    http://www.quackometer.net/blog/2009/06/chiropractors-told-to-take-down-their.html

    This may have significant implications.

  12. nwtk2007 says:

    Joe, based upon your recent post I just called five MD’s at random in the Dallas FtWorth area. Not one subscribed to any medical journal at all. They claim to keep up with relevant research through continuing ed seminars and licensing course work as well as through the internet services.

    No doctor subscribes to ALL of the relevant literature. Sorry for this misconception you have about health care providers.

    The real worry are the ones who don’t read it when it is readily available or claim to have read it but haven’t. To limit your reading only to studies of double blinded nature with huge numbers of subjects is a bit silly at best.

    As to the letter from the McTimoney Chiropractic Association, they do mention “advertising for treatments not supported by Chiropractic research”. If you don’t recognize chiropractic research publication as valid then you would have a point to make, but since much of chiropractic is supported by “chiropractic” research then then I suppose you don’t.

    And besides, Joe’s says it doesn’t matter what the “customer” thinks helps so what is the point of research or treatment? If we don’t care what they think helps then all we need do is tell them that they are OK and move on. Thus 500 deaths per day from medical mistakes and errors, I guess of caring or not caring (not sure which) what the “customer” thinks.

  13. Joe says:

    @ nwtk2007 on 10 Jun 2009 at 3:57 pm “Joe, based upon your recent post I just called five MD’s at random in the Dallas FtWorth area. Not one subscribed to any medical journal at all.”

    I believe you, and I believe in the tooth fairy since I used to get a nickel every time I lost a tooth. I am not surprised that you, and your imaginary friends, don’t try to keep up with the literature.

    @ nwtk2007 on 10 Jun 2009 at 3:57 pm “As to the letter from the McTimoney Chiropractic Association, they do mention “advertising for treatments not supported by Chiropractic research”. If you don’t recognize chiropractic research publication as valid then you would have a point to make, but since much of chiropractic is supported by “chiropractic” research then then I suppose you don’t.”

    Hoist by your own petard. “Chiropractic research” does not support the claims they were making. It is not that such “research” is amateurish, it goes to professional evaluation.

    Health professionals have “patients,” lawyers and accountants have “clients,” merchants (such as yourself) have “customers.” Deal with it.

  14. Joe says:

    Dang, formatting problems. The bottom line “chiropractic” research does not support its practices.

  15. pmoran says:

    NMS-DC “Looking at the best evidence available, there is good research supporting the use of SMT for mechanical neck pain. Fred Dagg is indeed correct that this document, the BJD Neck Pain Task Force is the GOLD Standard with respect to the best evidence in neck pain management. It was published in 2008 and it was a multi-disciplinary document consisting of DCs, MDs, OTs, PTs, PhDs, etc. Clearly there is a definitive benefit (in comparison to risk) otherwise it wouldn’t have been recommended. ”

    The executive summary of this document makes NO specific recommendation of neck manipulation. It mentions neck manipulation as one of eight treatments “worth considering”.

    The reviewers also seem to have given undue weight to a single seriously flawed study on the risk of stroke from spinal manipulation, the one claiming that that there were no more strokes after visits to chiropractors than visits to medical practitioners.

    This, together with an emphasis upon its supposed rarety, suggests a bias on these reviewers towards chiropractors, because no other group could completely ignore the implications of the available evidence on stroke. Any other group would see the desirability of discouraging its use as the first line of treatment for conditions that can nearly always be adequately managed without it.

  16. Fred Dagg says:

    Joe, old confuscious saying, applies to you.

    “There are none so blind, as those who will not see”.

    I am sure you will want the last reply to this post, with your normal sarcasm, snide and unsubstantiated remarks. So help yourself.

    However, despite what you think, responsible health care is multi-disciplinary. No one has all the answers and even Evidence Based Medicine contradicts itself.

    You just need to look at the conflicting rates of low back surgery in the U.S.A. in comparrison to the United Kingdom. (Five times the rate).
    I would really like someone to tell me why? Because the cynical and sceptical side of me tells me that there now are some very wealthy orthopaedic surgeons in the U.S.

    Perhaps a brave member of the EBM panel could write a critical analysis of this. I will not hold my breath, as I do not believe people like Harriett Hall have the desire to look in the mirror of medicine as it exists in the U.S.A.

    Evidence Based is looking at all the evidence, and not dismissing it because of the publication it was in.
    Evidence Base is realising there is more than one correct answer and that knowledge is in a continual state of flux. It changes.

    Have a nice day, Joe.

  17. nwtk2007 says:

    Poor Joe,

    You just can’t hide that bias of yours. Were you unsuccessful in your attempt to be a chiro yourself? Did you fail at something that was indirectly attributable to a chiro influence? Do you take orders from chiro’s? Are you just a PT and not a doctor?

    When I see my patients everyday I often think of you. When I take their medical history, review their complaints, perform examinations, order x-rays, other imaging if needed, formulate treatment plans, coordinate their care with other physicians, chart their progress, modify their treatment plan accordingly, etc, etc, yes, I often think of you.

    When my patients thank me for their help and their care, I really appreciate the comments like yours, calling me a merchant and my patients customers. I’m sure they would appreciate it also.

    We all understand the immaturity behind your bias and the overwhelming desire to get revenge on our profession for some past hurt you must have endured at the hands of the profession as a whole.

    Thank you for your bias, it undermines any logical argument you might have against chiropractic and lifts us above the rest, so to speak.

    Thanks Joe.

  18. NMS-DC says:

    Dr. Moran,

    “The executive summary of this document makes NO specific recommendation of neck manipulation. It mentions neck manipulation as one of eight treatments “worth considering”.

    1) Your personal opinion aside, this Task Force was comprised of individuals representing the medical, chiropractic, physical therapy, occupational therapy professions and PhDs. To suggest that DCs somehow convinced all these other clinician-scientists to display bias TOWARDS spinal manipulation is absurd.

    2) The document does indeed recommend spinal manipulative therapy for uncomplicated (Gr 1,2) mechanical neck pain along with other conservative therapies commonly practiced by doctors of chiropractic such as soft tissue therapy (massage), exercise rehabilitation, education/counseling, etc.

    3) The best evidence suggests that serious, adverse events following neck manipulation (in particular upper cervical) manipulation are extremely rare and negligible.

    It is rather distressing to see some posters here who claim to be “evidence-based” and on the “side of science” arbitrarily ignore the literature that refutes their claims which seem to be based more on personal philosophy and dogma than the most current literature.

    NMS

  19. NMS-DC says:

    Joe,

    Is Dr. Ernst a quack? He is a peer reviewer of JMPT.

    Unfortunately, you and many others here will have to learn to accept (or grow accustomed) to evidence-based chiropractors who are informed, knowledgeable and are the experts are manual medicine which is a very legitimate and increasingly popular form of therapy for many neuromusculoskeletal conditions.

    First a general question: is the practice of chiropractic medicine appropriate for neuromusculoskeletal conditions? Your answer will determine whether or not you are rational skeptic or merely dogmatic, idealistic one.

    Remember, this is a science-based blog. Stick to the science. And, if you have questions regarding common chiropractic practice/theory, feel free to ask. I’m here to help, clarify and educate.

    NMS

  20. pmoran says:

    NMS-DC: “The document does indeed recommend spinal manipulative therapy for uncomplicated (Gr 1,2) mechanical neck pain along with other conservative therapies commonly practiced ”

    I don’t have to accept such a statement. I would like to know precisely what this paper says about the efficacy of spinal manipulation, and why it would differ from ether that differs materially from that of an at least equally comprehensive review of the 37 available studies of spinal manipulation for neck pain, which found no significant difference from sham treatment and other commonly used treatments when used alone.

    I am not saying spinal manipulation NEVER works. I am saying it is not obviously superior to other methods and that its risks can be justified only under certain circumstances and with a high standard of informed consent.

    The theory that the vertebral artery dissection precedes the manipulation may explain an occasional case, but it is grasping at straws. It cannot explain all the cases, such as the fatal stroke that occurred after the 11th cervical manipulation for tension headaches and those cases where the patient had no symptoms, or different ones prior to the manipulation. Then there are the cases where the patient collapses or is paralyzed immediately, or that have bilateral VAD coincidentally with NM.

  21. Harriet Hall says:

    “is the practice of chiropractic medicine appropriate for neuromusculoskeletal conditions?”

    That depends on what you mean by “chiropractic medicine.” If you mean finding and correcting subluxations, no it isn’t appropriate, because chiropractic subluxations are mythical. If you mean “whatever a chiropractor does” then the answer is yes, but only if the chiropractor uses spinal manipulation therapy for appropriate indications and/or uses exercise, heat, massage, lifestyle advice, etc. appropriately and avoids inappropriate treatments like neck adjustments for low back pain.

    Edzard Ernst said that “Chiropractors… might compete with physiotherapists in terms of treating some back problems, but all their other claims are beyond belief and can carry a range of significant risks.”

    Is spinal manipulation therapy appropriate for neuromusculoskeletal conditions? Yes, for certain limited ones. But it is not superior to other treatments. And it carries risks. And it can be done by physical therapists.

    In essence, the only “appropriate” things “chiropractic medicine” offers are the same things physical therapists can offer. One might question whether it is “appropriate” to seek those services from a chiropractor whose education was based on a myth and on pseudoscience.

  22. Fred Dagg says:

    Hello Harriett

    as you do not reference any of your comments, so they will be treated as anecdotal or opinion.
    Your desire that chiropractors use methods e.g. heat and massage, that are essentially un-substantiated by peer review literature is interesting. Please provide me with the references that cite physical therapy modalities such as heat, massage and ultra-sound are effective and for that matter ethical. Cerival mobilization, a treatment used by all practitioners of Spinal Manual Therapy is not without its risks. Please tell me that the manipulative treatment styles are different? I do not know and I have witnessed examples of all the styles, as I have pointed out to you in the past.

    You quote Edzard Ernst. Well done, but we have shown you time and time again that those comment from him about the dangers and risks relate to “Spinal Manual Therapy”as opposed to chiropractic care. Ernst is wrong to say those things, as has been proven to you in previous posts by me and several other contributors to this site. In fact, because he is so “anti-chiropractic”, it makes his comments irrelevant. He would be considered a hostile witness in a court of law. This has been pointed out to you as well.

    You compare chiropractic treatment to that of physical therapy. Great!!!!!!!!!!!! The dangers are still the same, irrespective of the practitioner. I have pointed this out to you as well. Now we need to see from you as a contributor to “Evidence Based Medicine” is a report to show that a physical therapist, osteopath or medical practitioner is more effective in the treatment they provide.

  23. pmoran says:

    “Please provide me with the references that cite physical therapy modalities such as heat, massage and ultra-sound are effective and for that matter ethical.”

    I don’t think Harriet mentioned ultrasound, but the paper that NMS-DC suggested should be regarded as the “Gold Standard” on neck pain lists massage as among the treatments apparently equally “worth trying”. I am sure heat would produce temporary ease. Here is their list.

     Education

     Exercise

     Mobilization

     Manipulation

     Acupuncture

     Analgesics

     Massage

     Low level laser therapy

    http://www.wfc.org/Website/wfc/Graphics.nsf/Graphics/Neck Pain Task Force Key Findings/$file/NPTF Key Findings.doc

    More of their comments –

     Pain relief is often modest and short-lived.

     Be cautious of treatments that make “big” claims for relief of neck pain.

     Short episodes of care may be helpful: lengthy treatment is not associated with greater improvements.

    As with low back pain, it is possible that no treatment actually terminates the condition and that most act mainly via placebo influences.

  24. nobs says:

    The link above does not work-”no website found”
    Please repost?

  25. NMS-DC says:

    Harriett,

    Thank you for responding. I’ll take time to address your points in 2 separate posts, first with the comparison of physical therapy.

    It seems as of late, PTs are doing their very best to become full fledged clinicians (in the US at least) as they move towards a full Doctor of Physical Therapy (DPT) program. More than ever, they are including SMT in the core curriculum as they attempt to replace DCs are the expert in manipulative therapy. Physical therapists are well needed and definitely have a role in MSK arena, but they do not duplicate the services or expertise offered by chiropractors.

    Unfortunately, the comparison between DCs and PTs does not do chiropractors justice for many reasons. First, PTs have no formal training in diagnostic imaging, either in taking radiographs or interpreting them. Nor do they have the training to order and interpret laboratory diagnostic tests like blood and urine work. These are in the undergraduate component of the chiropractic programme as well. Also, the majority of chiropractic schools offer differential diagnosis in ORGANIC/VISCERAL conditions in addition to neuromusculoskeletal. I don’t suggest my diagnostic skill set in organic pathology is as polished as an MD, but I can at least provide reasonable differentials and perform basic exams in EENT, abdomen, thorax/lungs and know when to refer when the condition falls outside my scope of practice.

    Lastly, to those who are concerned about the safety of SMT, then it is dubious to suggest that PTs are better equipped to perform this psychomotor skill since they rarely a) use it clinical practice and b) devote little time to learning adjusting techniques. Proper delivery of SMT requires time, experience and skill. Letting other professions perform manipulation without the recommended training as per the WHO is compromising patient safety.

    Hence, while it may seem to be appropriate to compare DCs to PTs and see a redundancy, chiropractors are establishing the cultural authority in manipulative medicine and in becoming the spinal health care experts.

    I will address your comment regarding the chiropractic subluxation in a subsequent post.

    NMS

  26. pmoran says:

    Nobs, if you mean the Executive summary of the BJD Neck Pain Task Force that I was quoting from, this tinyurl may help.

    http://tinyurl.com/mddqqu

  27. nwtk2007 says:

    Just a word on the PT’s here in Texas NMS:

    Every legislative term the PT’s try to pass laws allowing them to perform SMT. They can already do joint mobilization but they want to “pop” necks and backs because patients almost always say it is extremely helpful for their pain and function.

    The ones I have observed really, really, really want to be doctors and to be free of the doctor referral they need to see patients.

    The ones I have observed do very little, however, and tend to talk down to patients as well as doctors; MD’s, DO’s and DC’s alike.

    They are extremely territorial and extremely anal about trivial things.

    Most of the PT’s I have worked with, not all mind you, think they know everything; more than any doctor could.

    I will say, however, the hospital PT’s I know are very good people, very gracious and very helpful. I really like to refer to them when the opportunity arises. This statement alludes to tone made by coryblick a few comments back. I think that might be where they do their best work and should probably stay there. It’s just my experience with them and so, I am just saying.

    On a different note, why is it that the anti-chiro, anti-SMT folks always so venomous in their resistance when there is so much to clean up in the medical profession in general? It is as if they have some personal vendetta against chiropractors and try to lump them up into one package: subluxation practioners.

    Why is it that guys like Joe won’t even read the works he cites as evidence of his position? How is it that chiro’s and anti-chiro’s or anti-SMT’s read the same thing and both come to such a different conclusion? It reminds me of democrats vs republicans. But if “everyone” is “independent” as they say, then why do only the democrats or the republicans get elected?

    Digression but analogous.

  28. nobs says:

    pmoran:

    Nobs, if you mean the Executive summary of the BJD Neck Pain Task Force that I was quoting from, this tinyurl may help.

    http://tinyurl.com/mddqqu

    ~~~~~~~~~~~~~~~~~~~

    I don’t think that is a link to site you posted above as:

    http://www.wfc.org/Website/wfc/Graphics.nsf/Graphics/Neck

    This(above) is the errant link I was referring to.

    Thank-you

  29. NMS-DC says:

    Harriett,

    In my follow I want to address the “mythical” chiropractic subluxation. I also want to state emphatically that I support the physical therapy profession and they are skilled at what they do. But DCs fulfill a very important niche as well, one they they are experts at: manual therapy and, in particular spinal manipulation.

    That brings me to my next point. What exactly are ANY manipulative practitioners manipulating/adjusting? What is there purpose and what is their target if any? Specificity, like coryblick alluded to is a different ballgame (although there are many valid arguments that moving cephalad it is far easier to palpate joint dysfunction and to target a specific spinal motion segment than it is in the lumbar spine.

    So, let’s get back to it. Subluxation. It would help to dissociate subluxation PHILOSOPHY (in particular straight chiropractic philosophy) which essentially in 1895 suggested that vertebral joint dysfunction caused a disruption in innate/energy which was responsible for disease. Like the water/hose analogy. It doesn’t take a genius to know this is absurd. This was a turn of the century idea.

    However, skeptics seem to think that time has stood still and that chiropractic medicine has failed to evolve or to provide plausible models for subluxation. Subluxation is known in osteopathic medicine as somatic lesion, and is synonymous with segmental dysfunction, joint restriction/fixation/dysfunction, etc. The mortise joint in the ankle, could be subluxated (chiropractically speaking). So, it’s important for the medical community to realize first and foremost the main component of the chiropractic subluxation: abnormal BIOMECHANICS. The joint is not moving correctly in some way shape or form.

    I graduated from CMCC where the term subluxation isn’t used and we basically just called it joint fixation/restriction and to be honest I don’t like the term subluxation because its baggage and the fact it has such a negative connotation outside (and inside) the profession.

    But, nonetheless, the concept of structure affecting function, i.e. improper joint mechanics affecting at the very least neuromusculoskeletal function is valid.

    Next, I shall present some of the more recent research on chiropractic subluxation/joint dysfunction and help present the contemporary view so that, at the very least, the critics can attack the research and stop spewing nonsense from 1895 that is neither valid nor reliable in 2009.

  30. NMS-DC says:

    First, the subluxation is essentially a biomechanical lesion in the spine. Dr. James DeVocht, DC, PhD has a good paper that provides an updated model on subluxation: a manipulable lesion. Providers of SMT are manipulating SOMETHING that doesn’t feel quite right (to them and the patient).

    Clin Orthop Relat Res. 2006 Mar;444:243-9.

    History and overview of theories and methods of chiropractic: a counterpoint.

    There is also some good research lately on animal models of the consequences of joint fixation/subluxation from a biomechanical perspective:

    Introducing the external link model for studying spine fixation and misalignment: current procedures, costs, and failure rates.

    Henderson CN, Cramer GD, Zhang Q, DeVocht JW, Sozio RS, Fournier JT.

    J Manipulative Physiol Ther. 2009 May;32(4):294-302.
    PMID: 19447266 [PubMed - in process]

    Introducing the external link model for studying spine fixation and misalignment: part 2, Biomechanical features.
    Henderson CN, Cramer GD, Zhang Q, DeVocht JW, Fournier JT.
    J Manipulative Physiol Ther. 2007 May;30(4):279-94.
    PMID: 17509437 [PubMed - indexed for MEDLINE]

    Introducing the external link model for studying spine fixation and misalignment: part 1–need, rationale, and applications.
    Henderson CN, Cramer GD, Zhang Q, DeVocht JW, Fournier JT.
    J Manipulative Physiol Ther. 2007 Mar-Apr;30(3):239-45. Review.
    PMID: 17416279 [PubMed - indexed for MEDLINE]

    There is also some good, nascent research on the effects of SMT on neuroimmunological function:

    Enhancement of in vitro interleukin-2 production in normal subjects following a single spinal manipulative treatment.
    Teodorczyk-Injeyan JA, Injeyan HS, McGregor M, Harris GM, Ruegg

    Chiropr Osteopat. 2008 May 28;16:5.

    Spinal manipulative therapy reduces inflammatory cytokines but not substance P production in normal subjects.
    Teodorczyk-Injeyan JA, Injeyan HS, Ruegg R.
    J Manipulative Physiol Ther. 2006 Jan;29(1):14-21.

    The least understood component of spinal manipulation is its effects on the autonomic nervous system and its role in somato-visceral responses. Nonetheless, there is likely a subgroup of indivuals who do respond to SMT for certain organic conditions and the research, over time will bear this out. But, let’s stick to the science when we’re debating here and avoid logical fallacies and ad hominems.

    NMS

  31. pmoran says:

    Nobs, its the same document.

  32. NMS-DC says:

    Well, based on review of the majority of the posts here we can summarize the evidence such as

    1) there is good evidence for the use of manual therapy, including spinal manipulation for uncomplicated mechanical neck pain grades 1,2

    2) the best evidence that looks specifically at chiropractic care and cervical manipulation, as performed by Dr. Rubinstein suggests the serious adverse reactions are negligble and that the benefits outweigh the risks

    3) there are numerous documented instances where medical journals have published case studies detailing a serious adverse event following a “chiropractic” neck manipulation only to see that in some instances, 89% where not done by a DC which is misleading the public and health professionals

    4) Claims that PTs should become the default providers of SMTs proves that some posters here are more anti-chiropractic than SMT and would prefer that less adequately trained professionals provide a mode of therapy that is “potentially fatal”

    5) the majority of skeptics rely on the “evidence” presented by Dr. Ernst who can now surely be called a anti-chiropractic extremist who attempts to denigrate and distort ANY possible good coming from the profession. Based on his stance which now borders on zealotry RATIONAL skeptics should seek to produce ORIGINAL high quality practice-based clinical trials that refute the evidence that has steadily accrued the past 2 decades in support SMT.

    Moreover, Ernst’s “evidence’ (an army one 1) is being soundly refuted by multi-disciplinary panels of musculoskeletal medicine experts in Europe and North America whose papers carry more weight academically than the “systematic reviews of systematic reviews” of Dr. Ernst.

    6) No one has even mentioned the blossoming specialization of animal/veterinary chiropractic (here comes Dr. Ramey!) which is increasingly becoming popular with pet owners, DCs, and DVMs as animals can benefit from manual therapy to increase their function and quality of life. Note to PTs out there who claim SMT is THEIR expertise: It’s called animal chiropractic, not animal orthopaedic manual physical therapy ;)

    NMS

  33. pmoran says:

    ” the best evidence that looks specifically at chiropractic care and cervical manipulation, as performed by Dr. Rubinstein suggests the serious adverse reactions are negligble and that the benefits outweigh the risks”

    What “best evidence”? And death is a negligible risk for a treatment that some chiropractors dish out for almost anything?

    Anyway I am glad that you are now acknowledging the risks.

    Since your own “Gold Standard” paper sees other methods as having equal efficiacy to neck manipulation for neck pain but without the risks (e.g. acupuncture), what do you now see as the proper place of SMT in the treatment of neck pain?

    While you are here, comment upon neck manipulation’s widespread use by chiropractors for headache, certain childhood complaints, and general “wellness”.

  34. coryblick says:

    nwtk07,

    I’m not sure what your hospital statement alludes to from my post. `Wanna hear about my experiences with chiros and some generalizations based upon them? Would that be a sensible argument of the state of your profession?

    The PTs in Texas want the right to manipulate because it is within their skill set and expertise and this has the support of the evidence.

    NMS-DC said:

    “Claims that PTs should become the default providers of SMTs proves that some posters here are more anti-chiropractic than SMT and would prefer that less adequately trained professionals provide a mode of therapy that is “potentially fatal”’

    Save the fear mongering for the statehouse. In order for chiropractors to keep SMT firmly in their legislative grasp they have to continue to show that 1) PT are inadequately trained- a fallacy 2) Patients are therefore less safe in their hands- a fallacy 3) chiro’s are more effective- a fallacy.

    Evidently, to be “adequately trained” you must have spent years and thousands on learning to feel movements with a specificity and apply movements with a specificity which have been shown to be bogus perceptual fantasy. I’d say that’s worse than inadequate, that’s a waste! However, the more you spend on a ship the more likely you are to grasp to it tightly as it sinks.

    Truth is that SMT is enty level education for PTs at this point. Student PTs are “adequately trained” and this has published research behind it. Also problematic for the chiros, I’d guess, is that the evidence continues to narrow the populations of patients for whom SMT is appropriate and likely to be pain reducing.

    What the hell is your point on the animal chiro thing? I don’t know a single PT who would claim to provide any kind of chiropractic. We’re not chiropractors. That would be like a chiropractor claiming to perform physiother……oh wait.

  35. Harriet Hall says:

    (1) A Cochrane review found HVLA neck manipulation no better than mobilization, and neither worked alone; they had to be combined with exercise programs.
    (2) The benefits may outweigh the risks for appropriate manipulations below the neck, but I’m not convinced that they do for neck manipulation. Manipulators and nonmanipulators draw different conclusions from the same evidence. Obviously those who use manipulation routinely or who use it exclusively are going to be biased.
    (3) It’s pointless to quibble about who did the manipulation. We’re not trying to fix blame, but to establish the risk of the procedure, whoever performs it. Of course it gets associated in our minds with chiropractors because SMT is their main claim to fame.
    (4) I don’t remember ever suggesting that PTs be the default providers of SMT. What I did was question whether chiropractic offers anything a well-trained PT couldn’t offer. Why is chiropractic special?
    (5) Ernst is not a zealot. He is a professor of complementary medicine who leads a team that has researched the literature for something like 14 years now, who used to support alternative medicine and has gradually been forced to change his mind because he has recognized that the evidence just isn’t there. His opinion is supported by evidence, for instance by the independent Cochrane review showing manipulation for low back pain was no more or less effective than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner. Your poor opinion of Ernst does not change the evidence he and others have found.
    (6) “animals can benefit from manual therapy to increase their function and quality of life.” Oh really? Where is the evidence? I hope our resident veterinarian will comment.

    For the nth time, I have no vendetta against chiropractors. I would be delighted if they would reject the subluxation myth and provide appropriate short-term care of musculoskeletal problems without any of the quackery like applied kinesiology that so many of them have fallen for. I recognize that some chiropractors have become very skilled at SMT and that some of them have good diagnostic skills and can recognize red flags and refer appropriately. I would support any chiropractor who practiced science-based medicine.

  36. nwtk2007 says:

    Harriet Hall – “A Cochrane review found HVLA neck manipulation no better than mobilization, and neither worked alone; they had to be combined with exercise programs.”

    These reviews are weak at best but I would agree with their findings. In my experience, it seems that combining any form of physical medicine with exercise definitely shortens the treatment time for many, if not most, patients. I sometimes wonder if it is just their lack of desire to perform exercises that shortens their treatment time. I would also say that a huge contributing factor to many musculoskeletal problems is lack of exercise. I still find that most patients, 80 to 90%, are in piss poor condition and it is no wonder that they are so easily injured.

    Harriet Hall – “Manipulators and nonmanipulators draw different conclusions from the same evidence. Obviously those who use manipulation routinely or who use it exclusively are going to be biased.”

    The reverse can also be said about the bias view of evidence. There is plenty of “evidence” of it seen by the comments of “some” of the folks who comment here regularly.

    Harriet – “It’s pointless to quibble about who did the manipulation. We’re not trying to fix blame, but to establish the risk of the procedure, whoever performs it. Of course it gets associated in our minds with chiropractors because SMT is their main claim to fame.”

    Isn’t that an admission of bias, albeit a logical statement of the cause of the bias? Just asking.

    Harriet – “I don’t remember ever suggesting that PTs be the default providers of SMT. What I did was question whether chiropractic offers anything a well-trained PT couldn’t offer. Why is chiropractic special?

    I don’t think it was you, Dr Hall, that suggested it. As to what makes chiro’s special as compared to PT’s: not much except for the training in examination and diagnosis for conditions which a PT might not recognize based upon lack of training. Treatment wise, chiropractors are, to me, just glorified PT’s. They can offer little more than PT’s in actual treatments, but can manage care thru referral and coordination with other health care providers.

    Harriet – “Ernst is not a zealot. ”

    Isn’t he the guy who claimed to be some sort of consultant for some Canadian health agency’s but wasn’t? Back in the 70′s?

    Harriet – “I would be delighted if they would reject the subluxation myth and provide appropriate short-term care of musculoskeletal problems without any of the quackery like applied kinesiology that so many of them have fallen for”

    Me too. The subluxation myth is a thorn in our sides to be sure. The word needs to be wiped from the earth as does the belief that it’s removal can cure all ills.

  37. Mojo says:

    @nwtk2007:

    Isn’t he the guy who claimed to be some sort of consultant for some Canadian health agency’s but wasn’t? Back in the 70’s?

    Do you have any evidence to back up this suggestion?

    I’ve not heard of it, and given the CAM industry’s repeated efforts to discredit Ernst, it seems unlikely that they wouldn’t have cottoned onto such an allegation.

  38. NMS-DC says:

    coryblick

    That’s great that you have strong research to support your claims, and I know that Childs, Cleland and other good researchers have done some OK work.

    So, if you could provide the hours spent on learning SMT in a typical DPT curriculum so we can compare the two professions. Also, given the fact that the majority of experienced manipulators say that it takes years of practice to truly master (see Byfield, Chiropractic Manipulative Skills) and the fact that I’m still refining and learning my techniques on a daily basis your claims somehow ring shallow.

    Lastly techniques used by PTs, such as the ones described in your research by Childs et. al are not only far less likely to be specific, but they are, in a biomechanical sense, far more dangerous even in the lumbar region since the published “PT” techniques (which are really adopted osteopathic ones) use long levers which produces more torque and overall force and has less specificity than a short lever technique which is biomechanically more efficient and safer as forces are more controlled.

    That’s OK though, you can continue to believe that less training on SMT in biomechanics and actual lab hours results in safer, better manipulators, because that just makes common sense. Lastly, does the DPT programs that teach SMT skill acquisition meet the minimum guidelines suggested by the WHO in terms of total hours spent?

    I’d appreciate some fresh research in your reply coryblick, since I’m aware of the one’s you cited and I would call it preliminary at the very best.

    Cheers
    NMS

  39. Joe says:

    http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53681

    After saying that “education” in manipulation consists main of practicing on fellow students, this Chiro wrote:

    “…As a greenhorn DC, I clearly recollect the first patient who told me, straight out, that he needed a “good cracking.” … “Just roll my hips”, he offered, “and that should do it. And don’t be afraid to give ‘er all ya got!” Since I was just out of school and without any meaningful experience, this seemed perfectly reasonable.” [italics added]

    That does not sound like you really learn much in school.

  40. Citizen Deux says:

    As a consumer (and purchaser of insurance plans for a large groups of employees), I have a bone to pick with DCs, especially in the United States. They frequently misrepresent their training, capability and divert people from care which would be efficacious.

    Individuals who seem to most benefit from visiting a DC would be better served by a PT and some lifestyle counseling. They must reimburse them out of pocket (although most plans I buy include some chiro reimbursement, along with massage and health club membership).

    I would like to see a fundamental statement of the efficacy of therapies whcih can be offered by a chiro. For example, a general dentist will offer prophylactic care, prenentative dentistry and some minor repair of caries – but maxillofacial surgery would not likely be in their repetoire.

    The argument over the SMT issue is interesting, but it belies the more sinister and dangerous aspect of chiropractic, delay of effective treatment and a financial drain on the medical system.

  41. nwtk2007 says:

    Sorry Mojo, the doctor I was thinking of ws Dr Katz.

  42. coryblick says:

    NMS,

    As I stated before, wasting time learning various forms of perceptual fantasy, regardless of how long it takes, is a waste. Chiros spend much more time with SMT, the question is why?

    You cite a book written by a chiropractor as evidence that years are required for mastery? Years may be required to learn elaborate schemes of patient encounter which impact patient expectation. Just look at accupuncture. This has nothing to do wtih the skill necessary to manipulate.

    In fact, the research shows that it is not the skill nor the specificity of application that predicts outcome, but the person it is being performed on (Flynn, Childs) and thier expectation (Steven George).

    You state that PT techniques are less specific. Even if there was such a thing as “the PT technique” it wouldn’t matter if its less specific and this is supported. Specificity of application does not lead to improved outcome and in fact the evidence demonstrates that thinking you can even be specific is a fallacy, as I stated above it is perceptual fantasy. You also state that “the PT technique” is less safe. PT application of manipulation being less safe is not supported.

    Have you even read this WHO document that is posted all over the place as being proof chiros are the only ones adequately trained to perform SMT? The 2200 course hour and 1000 hour of clinical focus is the WHO recommendation to become a chiropractor, not to perform SMT.

    Cory

  43. NMS-DC says:

    Thanks for your reply cory.

    As DCs are the experts in manipulation, and since skeptics have a doubt regarding it’s safety, don’t you feel that more training in the biomechanics and psychomotor skill development would be essential?

    Wasting time according you you, and perceptual fantasy talk leads me to believe you’ve been spending too much time hanging out with Diane Jacobs and Barrett Dorko.

    Technique is important from a mechanical perspective one because you want to minimize unnecessary torque and excessive force on structures. Hence, long lever techniques, as demonstrated by Childs, Flynn etc. are mechanically less desirable. Short lever technique are preferred, from a mechanical standpoint.

    And you have failed to address my point is that respected clinician scientists such as Dr. Byfield and Dr. Breen as well as the experience of thousands of DCs support the inherent truth that the ART of spinal manipulation takes time to develop. Also, certain patients have better responses to certain manual manipulative techniques, which is the now the focus on ongoing research.

    You also failed to address my point regarding the DPT curriculum and training in SMT. How much time is spent learning and practicing SMT in the average DPT program?

    To answer your question, DCs spent more time with SMT because it is their expertise. Only recently have research funds been available to study mechanisms of action (which have validated that it definitely acts on the nervous system) and any research of SMT that looks at neurological outcomes or changes (fMRI for example) is really investigating “chiropractic”. Ironic since some PTs are eager to demonstrate the neurological link between SMT which is simply validating part of the chiropractic hypothesis.

    I’m not sure if you are naiive about the subject or inexperienced in the application of spinal manipulative therapy but I find it somewhat disconcerning that you’re lecturing me about acquiring mastery in the art of spinal manipulation.

    Don’t forget to bring some evidence of the DPT curriculum regarding SMT lecture/practice hours. I’m curious.

    NMS

  44. NMS-DC says:

    Citizen Deux

    Demonstrating clinical effectiveness and therapy dosage is essential. I definitely agree there is a segment of straight/subluxation-based chiropractic that promotes overtreatment and makes claims that are unsupported by the literature. Yet, it is a segment, and this segment is a minority in the profession in North America and especially so in Europe and world-wide.

    People need to be informed and make the best decision based on the best evidence. In that regard, the chiropractic profession as developed clinical practice guidelines regarding management of low back disorders. It’s an evidence-based guideline and it talks about appropriate dosage (treatment) of SMT in particular, for back pain.

    It can be found here

    http://www.jmptonline.org/article/S0161-4754(08)00277-7/abstract
    http://www.jmptonline.org/article/S0161-4754(08)00276-5/abstract

    The best advice I can give to you, is find a good chiropractor that uses multi-modal manual therapies (soft tissue, mobs/manips) exercises/stretches, self care, education etc.

    There is an interesting article about what to look for in a “good” chiropractor (one that deals primarily with MSK complaints) I believe the article is free of charge to the public.

    http://www.chiroandosteo.com/content/17/1/3

    PTs have their expertise and time and place (for example I could not be bothered with rehabing a post-surgical ACL repair) but I don’t doubt my ability to complement a PTs work after the fact by ensuring proper biomechanical joint function as well as optimal myofascial healing. This area is new in the research, but fascia is a whole new ball game in understanding MSK and, in some cases, internal disorders.

  45. Citizen Deux says:

    NSM-DC, your articles (unaccessible via link) are very narrow and address only the simple aspects of chiropractic. The ACA – a leading advocacy group for your profession – provides the following;

    CHIROPRACTIC DEFINITION – ACA MASTER PLAN
    “Chiropractic is a branch of the healing arts which is concerned with human health and disease processes. Doctors of Chiropractic are physicians who consider man as an integrated being and give special attention to the physiological and biochemical aspects including structural, spinal, musculoskeletal, neurological, vascular, psychological, nutritional, visceral, emotional and environmental relationships and are trained in diagnosis so they may treat patients effectively and make timely referral to appropriate health care providers. (ACA Master Plan, ratified by the House of Delegates June 1964, amended June 1979, June 1989, July 1994 and September 2000)

    Wow! Psychological! Environmental! Vascular! All that’s missing is endocrinology.

    Whoops, here it is.

    CYTOTOXIC LEUKOCYTE TEST
    ACA recommends that the cytotoxic leukocyte test be considered experimental, and that without stronger evidence from well-designed controlled clinical studies, the procedure not be employed in the evaluation of patients suspected to have adverse reactions to foods. The test lacks acceptable sensitivity, and its use may result in a high number of false positive findings. Moreover, there is evidence that the procedure is of limited value in confirming the presence of food allergy and other adverse reactions.
    The cytotoxic leukocyte test is also tedious and time-consuming, two factors that render the procedure impractical and costly. Interpretation of the test is also highly subjective so that the training and experience of technicians performing the procedure may assume major importance with respect to its accuracy and reproducibility. (Ratified by the House of Delegates, June 1986).

    Why on earth would DCs be engaged in food allergy testing – and why would a governing body see fit to disavow its use – despite the fact that it is still in use by many DCs?

    Here is the bottom line – DCs have a narrow, easily substituted area of clinical effectiveness. It is an area easily supported by existing medical professionals (MDs, NPs, DOs, PAs, PTs and other scientifically trained and licensed practioners – even LMTs).

    They have sought to expand their role via fraudulent claims of efficacy for “adjunct” therapies. This despite statements of adherence by the ACA to evidence based medicine, opposition to fraud and quackery and other unsupported practices.

    The DC is NOT a general practioner. They lack sufficient medical training, skills and licensing. Depsite the appearance of adhering to “EBM” and professional standards – a straightforward reading of the ACA Master Plan would reveal a number of dangerous contradictions and questionable definitions.

    If you are a DC, do you consider yourself a specialist or a GP? If you are a DC do you engage in activities which may be considered contrary to your governing body’s (recognizing that there are at least 3 bodies for DCs) recommendations?

    The danger is not in the manipulations, or the lack of evidence the danger is in the fraud of chiropractic itself.

  46. Citizen Deux says:

    And finally, the final course in the un-scientific category, the ACA’s stand on vaccines;

    VACCINATION
    Resolved, that the American Chiropractic Association (ACA) recognize and advise the public that:
    Since the scientific community acknowledges that the use of vaccines is not without risk, the American Chiropractic Association supports each individual’s right to freedom of choice in his/her own health care based on an informed awareness of the benefits and possible adverse effects of vaccination. The ACA is supportive of a conscience clause or waiver in compulsory vaccination laws thereby maintaining an individual’s right to freedom of choice in health care matters and providing an alternative elective course of action regarding vaccination. (Ratified by the House of Delegates, July 1993, Revised and Ratified June 1998).

    Seems to be at odds with the rest of the scientific community.

  47. Citizen Deux says:

    And lastly, since you referenced this journal – what is your position on this article?

    How can chiropractic become a respected mainstream profession? The example of podiatry

    The assertion, rightly, is that chiropiractic remains outside respected, mainstream professions.

    My apologies for the combative nature. These are very important questions which should be examined and answered.

  48. Joe says:

    NMS-DC on 12 Jun 2009 at 12:07 pm “As DCs are the experts in manipulation, and since skeptics have a doubt regarding it’s safety, don’t you feel that more training in the biomechanics and psychomotor skill development would be essential?”

    http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53681

    After saying that “education” in manipulation consists main of practicing on fellow students, this Chiro wrote:

    “… As a greenhorn DC, I clearly recollect the first patient who told me, straight out, that he needed a “good cracking.” … “Just roll my hips”, he offered, “and that should do it. And don’t be afraid to give ‘er all ya got!” Since I was just out of school and without any meaningful experience, this seemed perfectly reasonable.” [italics added]

    It does not sound like chiros are experts in manipulation. In fact, http://www.ptjournal.org/cgi/content/full/79/1/50 this article shows you are bad at it; at least, when it comes to serious adverse consequences.

  49. pmoran says:

    “And you have failed to address my point is that respected clinician scientists such as Dr. Byfield and Dr. Breen as well as the experience of thousands of DCs support the inherent truth that the ART of spinal manipulation takes time to develop. ”

    That’s odd. My understanding is that within chiropractic there are numerous very different styles fo manipulation, all strongly supported by their adherents, but that it has not been possible to clearly demonstrate superiority of one over the other.

    And simple mobilisation works as well in the studies. All this suggests that they all “work” about the same and for the same reasons and that it is the practitioner’s ability to evoke placebo responses or patient subordination that improves with time.

  50. coryblick says:

    NMS,

    you said:
    “As DCs are the experts in manipulation, and since skeptics have a doubt regarding it’s safety, don’t you feel that more training in the biomechanics and psychomotor skill development would be essential?”

    I’d say that determining risk to benefit is essential. The risk involved with manipulation of the upper cervical spine despite the biomechanical load placed is unnacceptable and undefensible in my view. There is no delineation between a safe and unsafe amount of manip force in the cervical spine. In the lumbar and thoracic spine the risk is much lower and I’ve no knowledge of evidence of reduced risk with psychomotor skill development beyond that of the entry level clinician in terms of manip. Personally, while manipulation is sufficient to reduce pain in certain populations, I feel that the evidence points to it not being necessary. So, for me, even in the lumbar/thoracic spine the risk is not acceptable although it is much more defensible. In my view, manipulation risk is best reduced by limiting its usage. As the research continues to identify more and more narrow populations of potential responders, this should be exactly what happens for manual therapists who are following the research.

    While I don’t speak for Diane or Barrett, my guess is that they’d likely agree with me. Was I supposed to be embarrassed in regards to my knowing them? Quite the contrary.

    “the inherent truth that the ART of spinal manipulation takes time to develop. ”

    The skill of spinal manipulation can be learned relatively quickly. The non-descript ART that you speak of describes the patient/clinician interaction. I agree that takes time. Especially when the interaction is built upon complicated models of joint symetry/mobility/alignment/balance/etc that are unnecessary and unsupported. Also, this interaction is not specific to manipulation.

    I didn’t ignore your request regarding the DPT curriculum. I acknowledged that chiros get lots more. Lets say its 30 times as much (not sure. You can look it up yourself if you want a number.). But, to what gain? What is supported is that PT students are able to identify potential responders and apply the intervention with adequate expertise.

    “and any research of SMT that looks at neurological outcomes or changes (fMRI for example) is really investigating “chiropractic”. ”

    It is? Chiropractic holds the patent on neurologic outcomes does it? This is a strange argument.

    I’m not lecturing you about anything regarding your “ART mastery.” But I’m not about to sit here and listen to spouting of the typical gibberish that may work in the statehouses but has no authority over science.

    “This area is new in the research, but fascia is a whole new ball game in understanding MSK and, in some cases, internal disorders.”

    Oh, don’t even get me started on fascia! You want to talk pseudoscience. Whoa nellie!

  51. NMS-DC says:

    Cory,

    Despite your knowledge of the pain sciences, it’s clear that you do not truly understand the science of spinal manipulation or the purpose of manipulative medicine in general.

    The risk to benefit has ALREADY been established as the cited paper by Rubinstein (2008) demonstrated. The Neck Pain Task Force also addressed the validity of manual therapy, including SMT.

    You write

    “Personally, while manipulation is sufficient to reduce pain in certain populations, I feel that the evidence points to it not being necessary.”

    Manipulation is proven to be just as, if not more effective for mechanical spinal pain syndromes. There is strong evidence for manipulative therapy in every area of the spine as demonstrated by the clinical chiropractic guidelines which is provided a literature synthesis to produce evidence-based guidelines.

    http://www.ccgpp.org/

    You claim to be scientific yet you ignore the basic science on effectiveness of manipulative therapies while arguing PTs should provide manipulations.

    Much like Diane and Barrett you let your personal philosophy get in the way of accepting the science and value of manipulation. On one hand you criticize chiropractors for using manipulation as a means of therapy in spinal pain, and yet advocate a method, Simple Contact which is based on the ideomotion whose literature base is quite frankly non-existent compared to PROVEN methods of care.

    Quote

    “Chiropractic holds the patent on neurologic outcomes does it? This is a strange argument.”

    It’s not strange, and if you’re up on the neurosciences (which you should be at SomaS) you know that there the effects of manipulation are primarily neurological than biomechanical. It is a mechanical stimulus, that, by process of mechanotransduction, results in reflex neuromodulation of the neuromusculoskeltal
    system, but in particular the brain and its effects at the sensorimotor cortex. Chiropractic has ALWAYS been about the fundamental relationship between joint manipulation and neurological function. So, no, chiropractic doesn’t hold the patent on neurological outcomes, but when we are discussing MANUAL THERAPY and neurological outcomes you are talking about the principle of chiropractic medicine.

    Regarding fascia, I think I’m going to go with the findings and work of the of the scientific committee of the fascia congress than listen to your claims of pseudoscience….

    http://www.fasciacongress.org/2009/committees.htm

    It’s amazing how people’s personal philosophy blinds them from the truth. There is obviously SOMETHING valuably inherent in fascia; it serves an amazing important purpose. Yet you discard it as if it was clinically irrelevant in physical function.

    Anyways, we are far off track, but I’m not advocating any gibberish and your arguments on the safety and efficacy of SMT for spinal pain far exceeds the evidence of the ideomotor response in treating spinal pain. Just sayin’.

    NMS

  52. NMS-DC says:

    Cory

    1) risk to benefit has been determined and we cited the paper, Rubinstein 2008 as well as the Neck Pain Task Force

    “Personally, while manipulation is sufficient to reduce pain in certain populations, I feel that the evidence points to it not being necessary”

    2) The evidence suggests that it is effective in treating all mechanical spinal pain (www.ccgpp.org)

    3) While you may feel fascia is pseudoscience, I think that I’ll side with the scientifc panel of the Fascia congress

    http://www.fasciacongress.org/2009/committees.htm

    I use the best available evidence to help my patients function. You use ideomotion which has far, far, far less evidence and could easily be construed as quackery by members here. Manipulation science far exceeds in depth and breadth that a Tx method you advocate.

    Lastly, the principle of chiropractic medicine is about the improvement of neurological outcomes through manual therapy. If you know your neurosciences and research, you’d see that the SMT primarily works on the nervous system via mechanotransduction. While chiropractic doesn’t “hold the patent on neurologic outcomes” the relationship between manual therapy and neurological function is what defines the chiropractic profession.

    Citizen Deux

    The cited material in your posts are so old and irrelevant, they are a red herring that requires no rebuttal. The ACAs stance is not chiropractic’s stance and evidence-based DCs support vaccination as does many national chiropractic association such as Canada’s. Chiropractic medicine has a place in public health and contemporary chiropractors can play an important role. There is research to support this as well.

    Your view of contemporary chiropractors is distorted at best, deliberately ignorant at worst. I do not consider myself a general physician, but I do consider myself a chiropractic doctor who is primarily a neuromusculoskeletal specialist whose expertise is in manual medicine. My training, and many other DCs who have trained in university-based programmes are legitimate health care providers who serve an important niche and it’s time for skeptics to accept that chiropractic doctors are valid as neuromusculoskeletal specialists.

  53. NMS-DC says:

    test

  54. nobs says:

    pmoran inquires:

    >>”Since your own “Gold Standard” paper sees other methods as having equal efficiacy to neck manipulation for neck pain but without the risks (e.g. acupuncture), what do you now see as the proper place of SMT in the treatment of neck pain?

    While you are here, comment upon neck manipulation’s widespread use by chiropractors for headache, certain childhood complaints, and general “wellness”.”<>”For the nth time, I have no vendetta against chiropractors.”<<
    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    Really? Your claim rings very disengenuous. I remain skeptical and unconvinced.

    If your claim, was indeed genuine, your op/ed piece would have been titled: “Adverse of Effects Manual Medicine”(or something similar).

    Does it search better with “chiropractic”? Get cited more with “chiropractic”? Provoke more attention/comments with “chiropractic”? I highly suspect the answer is “YES” to all.
    Truthful? Resoundingly “NO”

    Please review:

    http://www.ncbi.nlm.nih.gov/pubmed/7636409?dopt=Abstract&holding=f1000,f1000m,isrctn

    Misuse of the literature by medical authors in discussing spinal manipulative therapy injury.

    AND

    http://www.chiroandosteo.com/content/14/1/16

    Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer-reviewed biomedical literature

  55. nobs says:

    My Last post got goofed- I will repost it here:

    pmoran inquires:

    >>”Since your own “Gold Standard” paper sees other methods as having equal efficiacy to neck manipulation for neck pain but without the risks (e.g. acupuncture), what do you now see as the proper place of SMT in the treatment of neck pain?

    While you are here, comment upon neck manipulation’s widespread use by chiropractors for headache, certain childhood complaints, and general “wellness”.”<<
    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    Allow me to direct you to the sites below that address your query:

    Council on Chiropractic Guidlines and Practice Parameters
    http://www.ccgpp.org/articles.htm

    This link from that site, is for the document on neck pain
    http://www.ccgpp.org/neck_related_disorders.pdf

    It is important to keep in mind, that irrespective of the provider, a universal truth is that: a “best practice” health care model includes not only research/evidence, but also clinical decision-making and patient values/preferences.

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

  56. nobs says:

    And here:

    Harriets posts:

    >>”For the nth time, I have no vendetta against chiropractors.”<<
    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    Really? Your claim rings very disengenuous. I remain skeptical and unconvinced.

    If your claim, was indeed genuine, your op/ed piece would have been titled: “Adverse of Effects Manual Medicine”(or something similar).

    Does it search better with “chiropractic”? Get cited more with “chiropractic”? Provoke more attention/comments with “chiropractic”?

    I highly suspect the answer is “YES”. Is it truthful? Resoundingly “NO”.

    Please review:

    http://www.ncbi.nlm.nih.gov/pubmed/7636409?dopt=Abstract&holding=f1000,f1000m,isrctn

    Misuse of the literature by medical authors in discussing spinal manipulative therapy injury.

    AND

    http://www.chiroandosteo.com/content/14/1/16

    Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer-reviewed biomedical literature

  57. Fred Dagg says:

    The issue of the poor reporting of accidents to SMT being attributed to “Chiropractors” was pointed out to Harriett very early on in the post. She has yet to acknowledge she erred on this topic, despite all the citations provided. Shame.

  58. Citizen Deux says:

    Alright, NMS, let’s take your comments at face value;

    The cited material in your posts are so old and irrelevant, they are a red herring that requires no rebuttal. The ACAs stance is not chiropractic’s stance and evidence-based DCs support vaccination as does many national chiropractic association such as Canada’s. Chiropractic medicine has a place in public health and contemporary chiropractors can play an important role. There is research to support this as well.

    Your view of contemporary chiropractors is distorted at best, deliberately ignorant at worst. I do not consider myself a general physician, but I do consider myself a chiropractic doctor who is primarily a neuromusculoskeletal specialist whose expertise is in manual medicine. My training, and many other DCs who have trained in university-based programmes are legitimate health care providers who serve an important niche and it’s time for skeptics to accept that chiropractic doctors are valid as neuromusculoskeletal specialists.

    If you dissociate yourself with the ACA, then which association speaks for you?

    What place does chiro have in public health (I would support the view of the Osteo magazine which is a podiatry model).

    What do you consider the base accredidation for DC education?

    I hardly think these views are out of date and the VAST majority of DCs in the US offer therapies for which they are neither adequately trained, educated or supported by science.

  59. Citizen Deux says:

    And finally, if the ACA is irrelevant – which is a specious argument, then explain their masthead statement.

    The American Chiropractic Association
    Based in Arlington, VA, ACA is the largest professional association in the world representing doctors of chiropractic. ACA provides lobbying, public relations, professional and educational opportunities for doctors of chiropractic, funds research regarding chiropractic and health issues, and offers leadership for the advancement of the profession

  60. Harriet Hall says:

    Fred Dagg,

    “The issue of the poor reporting of accidents to SMT being attributed to “Chiropractors” was pointed out to Harriett very early on in the post. She has yet to acknowledge she erred on this topic”

    I didn’t err. This article was written to explain the findings of a new systematic review that was titled “Safety of CHIROPRACTIC interventions: a systematic review.” and the great majority of the studies it reviewed specifically involved CHIROPRACTORS. It specifically showed that a large percentage of patients who visited a CHIROPRACTOR had short-term adverse effects, and most of the studies didn’t even specify what treatment was given. There are several studies BY CHIROPRACTORS themselves identifying short-term side effects from what they themselves call CHIRORACTIC TREATMENT or CHIROPRACTIC SMT.

    I have already acknowledged that it is the procedure we are concerned with, not who does it., and that the risk of stroke is with SMT, whoever provides it. Chiropractors have claimed SMT for their own, and their practice is based on it. They are the ones who are known for doing SMT, even though a minority of manipulations are done by others. . YOU are the ones who have identified SMT with chiropractic. I’ve never seen a chiropractic ad or website stressing that they offered SMT to treat musculoskeletal problems. Instead they claim to be practicing chiropractic” and treating subluxations. You guys are hoist on your own petard; I didn’t do it.

    Just curious: why do you use the word “accidents” rather than side effects? I doubt if you would call adverse effects of NSAIDS “accidents.”

    By the way, I noticed that Dagg has two G’s. You didn’t notice that Harriet has only one T. If you read that carelessly, it makes me wonder if you read the scientific studies carelessly too. If your error is due to a neurologic deficit like dyslexia, I apologize for bringing it up; I wouldn’t want to insult the handicapped.

  61. coryblick says:

    NMS,

    “Despite your knowledge of the pain sciences, it’s clear that you do not truly understand the science of spinal manipulation or the purpose of manipulative medicine in general.”

    Really? Are you saying the purpose of manpulative medicine and the science behind it something other than resolution of pain?

    You missed my whole point on effectiveness. I agree its been shown to be effective in certain populations. I also acknowledge that risk/benefit ratios have been established. My point is that even though manip is sufficient it is not necessary to relieve pain. When that is the case the tolerance to risk becomes zero, at least as a first line treatment. Thanks for continuing to call me naive and ignorant though. Great argument!

    To this point, I think if you read through my posts above you’ll see that I’m not advocating that PTs be providing manipulation. Only that they are more than adequately trained and that any claims of pts being endangered by seeing a PT vs. a chiro are pure propaganda.

    I notice that your argument has shifted from the propaganda onto me myself. Nice argument tactics. I’m curious to know what my personal philosophy is exactly, since you seem to know, and how it is important to the points being made? While simple contact has nothing to do with this argument, I feel complelled to provide a brief defense now that you’ve put it in a context with quackery. It simply states that people will seek an end state of comfort if not compelled to do otherwise (a documented phenomenon called the end state comfort effect), that the mechanism of action is ideomotor movement (again documented), that a non-threatening context is necessary for expression toward this end state (consistent with placebo research for example), and that manual contact is one method (but not the only way) of communicating this context. It is hypothesized that this method may be effective at relieving mechanical pain only. This is testable and has preliminary evidence warranting further study. Rampant quackery, eh?

    You’re arguing that neuroscience equals chiropractic when it comes to manipulation as the item of investigation. This is strange. Here I thought it remained neuroscience. The chiropractic “theory” of nerve pathways is not supported. Mechanotransduction may be the mechanical mechanism by which the applied force becomes a nerve impulse, but the recent evidence by Steven George (a PT) indicates temporal summation through descending inhibition to be the mechanism of action, at least in the scenario he studied. Thanks for the condescension though. I thought I, being a PT, was supposed to be the expert at that? Right nwtk07?

    Fascial therapies typically quickly leave the realm of science and enter the realm of microtubules and quantum physics and quantum consciousness, and a whole bunch of other BS. What brand of fascial therapy are you NMS? Pray tell, what kinds of NMSk and visceral conditions are fascial in origin?

    Cory

  62. pmoran says:

    Nobs, Why can I not get direct answers to simple questions? Here they are again. You wasted my time by referring me to sites that contribute nothing new and nothing of relevance.

    Here are the questions again.

    >>”Since your own “Gold Standard” paper sees other methods as having equal efficiacy to neck manipulation for neck pain but without the risks (e.g. acupuncture), what do you now see as the proper place of SMT in the treatment of neck pain?

    While you are here, comment upon neck manipulation’s widespread use by chiropractors for headache, certain childhood complaints, and general “wellness”.”<<

  63. Fred Dagg says:

    Hello Harriet,

    my apologies for the incorrect spelling of your name.

    In regard to the use of the word “accident” rather than “side effect”. In the context of this discussion, the alternate use is irrelevant. We could argue semantics until the cows come home, but I am sure we all know what each other means.

    I would call any adverse effect to care provided by a registered health care professional, practicing responsibly, within his scope of practice, where the intent is to provide good and ethical care, an “accident” or “side effect”.

    You have avoided the issue, (Oh crap, she has done it again), that a significant proportion of strokes have been attributed to chiropractors”, when in fact, it was not Chiropractors that provided the treatment.

    I cannot comment on your viewing of websites and chiropractors. Perhaps that is more of a problem you have, rather than the sites themselves.

  64. pmoran says:

    “You have avoided the issue, (Oh crap, she has done it again), that a significant proportion of strokes have been attributed to chiropractors, when in fact, it was not Chiropractors that provided the treatment.”

    That is so obvious to anyone following the literature on this matter, as have Harriet and I, and others, as to be not worth the mention.

    It is even possible that some non-chiropractors, such as GPs who may occasionally dabble in it, are a greater risk to the public. They may be less aware of the potential for stroke than chiropractors, who will more certainly have learnt about it during their training (even if adopting a “what, us cause stroke?” stance later). In fact I believe most currently practicing chiropractors will have been taught certain now discredited manoeuvres that were supposed to detect patients at risk of stroke.

    So this is not something recently cooked up by medicos, with which to persecute chiropractors. It is a real problem that should be generally impacting upon the use of neck manipulation, reserving it for use as a relatively late resort in a limited number of conditions when other methods have not helped.

  65. Harriet Hall says:

    To my knowledge, I have never attributed a stroke to a chiropractor if it was caused by a non-chiropractor. I have attributed them to SMT. There are plenty of documented cases directly attributed to chiropractors. We don’t have good data, but two studies have indicated that around 60% of manipulation-induced strokes were due to chiropractors and the rest to a combination of other practitioners. If chiropractic and SMT are conflated in the public mind, the chiropractors themselves are to blame.

    I don’t know of any reliable statistics to show the relative or absolute risk of SMT as performed by chiropractors, physical therapists, osteopaths and other providers. It doesn’t matter. Even if we haven’t quantified it accurately, we have good reason to believe the procedure is risky, no matter who performs it.

    I do know that chiropractors offer SMT for conditions where it is not indicated, such as neck manipulation for low back pain and for routine “health maintenance.” I have seen studies showing that at least some chiropractors offer neck manipulation to a very large percentage of their patients, surely a larger percentage than other providers do. Because of those factors, I suspect the risk of seeing a chiropractor is greater; but there are no data to prove it.

    There are clear data in the systematic analysis to indicate that a large percentage of patients who visit a chiropractor have short-term side effects (accidents?). So my title was correct, even though there are also data showing side effects after SMT by other providers.

    Would you have been happier if my title had been “Adverse Effects of Visiting a Chiropractor or of Visiting Other Providers Who Do What Chiropractors Do?

    It sound like you’re trying to defend chiropractic by saying that chiropractors aren’t the only ones who hurt people. That’s a tu quoque argument. How about taking full responsibility for the strokes caused by chiropractors and warning about strokes caused by anyone else who does SMT?

  66. Fred Dagg says:

    How about “Adverse Effects to Spinal Manual Therapy”.

    Precise, simple and honest.

    Then perhaps a short introductory paragraph on who provides spinal manual therapy throughout the world, not just the U.S.A. and even a short paragraph on how these tragedies are mis-reported within literature.

    Nothing too controversial there, but then that depends on the spin you may want to put on.

    You could even, if you were brave, write something about the intent of the authors in doing the research.

    A comparative analysis would be on the relative dangers of other forms of care for spinal pain of bio-mechanical origin e.g. NSAIDS, surgery, etc. Quoting Bone and Joint Decade results as one source of your information.

    Despite what you claim, your Barrett inspired, Quackwatch, anti-chiropractic propagandist agenda has come through.
    You have ended up in becoming sarcastic and aggressive, when if you had written the article properly it would have been a really good learning experience, for all practitioners of SMT and for all readers of EBM.

  67. Harriet Hall says:

    “How about “Adverse Effects to Spinal Manual Therapy”.
    Precise, simple and honest.”

    But not the title of the study I was describing.

    A comparative analysis was not part of the study I was reporting.

    You keep criticizing me for what I DIDN’T write. Perhaps you would comment on the actual results of the study. And perhaps you would answer Peter Moran’s question: what do you now see as the proper place of SMT in the treatment of neck pain?

  68. Fred Dagg says:

    Well, Harriet (one t, not two), see Bone and Joint Decade results for the inclusion of SMT in the treatment of neck pain. It includes SMT in the treatment profiles for Neck Pain. As valid as anything else.

    This is Evidence Based Medicine, how about taking a “global” look at the issue of adverse effects, rather than “cherry picking”.

  69. daedalus2u says:

    Fred, this is Science Based Medicine not Evidence Based Medicine. The two are quite distinct and the differences are well described by Kimball Atwood and others.

    This was the blog post that caused the scales to fall from my eyes so that I could see the difference between EBM and SBM.

    http://www.sciencebasedmedicine.org/?p=48

  70. nobs says:

    Fred Dagg on 13 Jun 2009 at 2:36 pm posts:
    >>”The issue of the poor reporting of accidents to SMT being attributed to “Chiropractors” was pointed out to Harriett very early on in the post. She has yet to acknowledge she erred on this topic, despite all the citations provided. Shame.”<>”I didn’t err. This article was written to explain the findings of a new systematic review that was titled “Safety of CHIROPRACTIC interventions: a systematic review.” and the great majority of the studies it reviewed specifically involved CHIROPRACTORS.It specifically showed that a large percentage of patients who visited a CHIROPRACTOR had short-term adverse effects, and most of the studies didn’t even specify what treatment was given. There are several studies BY CHIROPRACTORS themselves identifying short-term side effects from what they themselves call CHIRORACTIC TREATMENT or CHIROPRACTIC SMT”<>”This is the paper that appeared in Spine and which claimed to be a
    systematic review of adverse events following chiropractic
    manipulation. It put all RCTs, prospective and retrospective studies,
    case studies, and surveys under one roof and, although claiming that
    hard conclusions were impossible due to the heterogeneity of the
    studies, still managed to give them equal weight. This, in my opinion,
    leads to disaster.

    What amazed me, for instance, was how the authors in one breath could
    claim that the “frequency of adverse events varied between 5 strokes/
    100,000 manipulations to 1.46 serious adverse events/10M
    manipulations.” Notwithstanding the fact that both these figures were
    drawn from mere surveys [one, by Carlinni, was thoroughly discredited
    by Scott Haldeman and others], you’re looking at a 100-fold variation
    of incidence–assuming that a stroke is indeed a “serious adverse
    event.” Somehow, it just impresses me that without a review of the
    validity of the studies, themselves, that poor data such as that
    brought forward by Carlinni is given another breath of life when in
    fact it deserves just the opposite–as argued over 14 years ago by Lou
    Sportelli.

    Frequencies of complications, large and small, were reported to range
    from 33%-60.9%. Yet not a single reference seems to have been made to
    studies which report lower rates of, or no, significant problems–such
    as by Haymo Thiel or Jaskoviak. I found the summary statement at the
    conclusion of the article to the effect that “complications associated
    with chiropractic procedures are frequent” to be unfounded.

    Finally, I was bothered by a reference to something I had published in
    Spine, attributing my work to documenting intracranial hypotension. In
    truth, it was precisely the opposite. It was a Letter to the Editor
    which questioned the validity of the original study which had
    attempted to attribute this condition to spinal manipulation. The
    original study, it turns out, appears NOT to have been cited in the
    paper in Spine. Another reference by the authors to a paper that I had
    published with Joe Morley attacking Edzard Ernst for improperly
    presenting evidence had nothing to do with claiming that “there were
    few properly designed randomized trials, such that the results were
    frequently inconclusive.” Yet this was plainly suggested by the
    authors of this so-called systematic review. Is this scholarship? One
    has to wonder whether this paper has, in fact, made a substantial
    contribution to the literature at all.

    Am I missing something? Other than serving as a repository of data
    concerning adverse outcomes, I am not certain that this particular
    publication has helped advance our knowledge base. In at least a few
    instances, it has presented corrupted information instead.

    Gouveia LO, Catanho P, Ferreira JJ. Safety of chiropractic
    interventions: A systematic review. Spine 34(11): E405-E413.

    Anthony L. Rosner, Ph.D., LL.D.[Hon.]”

    ~~~~~~~~~~~~~~~~~~~~~~~~~~

    HH->>”I have already acknowledged that it is the procedure we are concerned with, not who does it., and that the risk of stroke is with SMT, whoever provides it.”<>”Chiropractors have claimed SMT for their own, and their practice is based on it. They are the ones who are known for doing SMT, even though a minority of manipulations are done by others.”<>” YOU are the ones who have identified SMT with chiropractic. I’ve never seen a chiropractic ad or website stressing that they offered SMT to treat musculoskeletal problems. Instead they claim to be practicing chiropractic” and treating subluxations.”<>”By the way, I noticed that Dagg has two G’s. You didn’t notice that Harriet has only one T. If you read that carelessly, it makes me wonder if you read the scientific studies carelessly too. If your error is due to a neurologic deficit like dyslexia, I apologize for
    bringing it up; I wouldn’t want to insult the handicapped.”<<

    THIS ad hom is an extremely disappointing, childish cheapshot. No further comment necessary.

  71. nobs says:

    This site has some strange formatting going on(also noted by others). It looked just fine before I hit submit. I am reposting the above.

    Fred Dagg on 13 Jun 2009 at 2:36 pm posts:
    >>”The issue of the poor reporting of accidents to SMT being attributed to “Chiropractors”

    was pointed out to Harriett very early on in the post. She has yet to acknowledge she erred

    on this topic, despite all the citations provided. Shame.”<>”I didn’t err. This article was written to explain the findings of a new systematic

    review that was titled “Safety of CHIROPRACTIC interventions: a systematic review.” and the

    great majority of the studies it reviewed specifically involved CHIROPRACTORS. It

    specifically showed that a large percentage of patients who visited a CHIROPRACTOR had

    short-term adverse effects, and most of the studies didn’t even specify what treatment was

    given. There are several studies BY CHIROPRACTORS themselves identifying short-term side

    effects from what they themselves call CHIRORACTIC TREATMENT or CHIROPRACTIC SMT”<>”I have already acknowledged that it is the procedure we are concerned with, not who

    does it., and that the risk of stroke is with SMT, whoever provides it.”<>”Chiropractors have claimed SMT for their own, and their practice is based on it.

    They are the ones who are known for doing SMT, even though a minority of manipulations are

    done by others.”<>” YOU are the ones who have identified SMT with chiropractic. I’ve never seen a

    chiropractic ad or website stressing that they offered SMT to treat musculoskeletal

    problems. Instead they claim to be practicing chiropractic” and treating subluxations.”<>”By the way, I noticed that Dagg has two G’s. You didn’t notice that Harriet has only one T. If you read that carelessly, it makes me wonder if you read the scientific studies

    carelessly too. If your error is due to a neurologic deficit like dyslexia, I apologize for

    bringing it up; I wouldn’t want to insult the handicapped.”<<

    THIS ad hom is an extremely disappointing, childish cheapshot. No further comment necessary.

  72. nobs says:

    Please ignore my above posts. Sorry. I don’t have any more time right now to try and figure out what the problem is, but I will re-attempt later. If they can be taken off- that would be great. Thank-you

  73. nobs says:

    OK- My third attempt. Thank-you in advance for your patience.

    Fred Dagg on 13 Jun 2009 at 2:36 pm posts:
    >>”The issue of the poor reporting of accidents to SMT being attributed to “Chiropractors” was pointed out to Harriett very early on in the post. She has yet to acknowledge she erred on this topic, despite all the citations provided. Shame.”<>”I didn’t err. This article was written to explain the findings of a new systematic review that was titled “Safety of CHIROPRACTIC interventions: a systematic review.” and the great majority of the studies it reviewed specifically involved CHIROPRACTORS. It specifically showed that a large percentage of patients who visited a CHIROPRACTOR had short-term adverse effects, and most of the studies didn’t even specify what treatment was given. There are several studies BY CHIROPRACTORS themselves identifying short-term side effects from what they themselves call CHIRORACTIC TREATMENT or CHIROPRACTIC SMT”<<

    That statement rings to me as a biased excuse, not a valid reason. The title of the paper you are claiming to ahem-”explain” is “SAFETY OF CHIROPRACTIC INTERVENTIONS”. From that, you choose to title your ahem-”explanation”/op/ed piece “ADVERSE EFFECTS OF CHIROPRACTIC”? You are right- that does explain…a.lot!

    The “review” you are claiming to “explain”, is constructed from flawed studies, ambiguous nomenclature, and corrupt data. Your “explanation” fails to address this. AND- The study is so invalid, I am questioning why you bothered to “explain” it at all. It appears that when it comes to a chiropractic paper or issue, you need to “boil it down”, or “explain”. Why not call it what it really is?—–your personal comments/opinion.

    OK-Back to the study that started all this…….

    It’s amazing what happens when a study such as this begins to unravel.

    Here is another, academically sound, “explanation” of the same study:

    “This is the paper that appeared in Spine and which claimed to be a
    systematic review of adverse events following chiropractic
    manipulation. It put all RCTs, prospective and retrospective studies,
    case studies, and surveys under one roof and, although claiming that
    hard conclusions were impossible due to the heterogeneity of the
    studies, still managed to give them equal weight. This, in my opinion,
    leads to disaster.

    What amazed me, for instance, was how the authors in one breath could
    claim that the “frequency of adverse events varied between 5 strokes/
    100,000 manipulations to 1.46 serious adverse events/10M
    manipulations.” Notwithstanding the fact that both these figures were
    drawn from mere surveys [one, by Carlinni, was thoroughly discredited
    by Scott Haldeman and others], you’re looking at a 100-fold variation
    of incidence–assuming that a stroke is indeed a “serious adverse
    event.” Somehow, it just impresses me that without a review of the
    validity of the studies, themselves, that poor data such as that
    brought forward by Carlinni is given another breath of life when in
    fact it deserves just the opposite–as argued over 14 years ago by Lou
    Sportelli.

    Frequencies of complications, large and small, were reported to range
    from 33%-60.9%. Yet not a single reference seems to have been made to
    studies which report lower rates of, or no, significant problems–such
    as by Haymo Thiel or Jaskoviak. I found the summary statement at the
    conclusion of the article to the effect that “complications associated
    with chiropractic procedures are frequent” to be unfounded.

    Finally, I was bothered by a reference to something I had published in
    Spine, attributing my work to documenting intracranial hypotension. In
    truth, it was precisely the opposite. It was a Letter to the Editor
    which questioned the validity of the original study which had
    attempted to attribute this condition to spinal manipulation. The
    original study, it turns out, appears NOT to have been cited in the
    paper in Spine. Another reference by the authors to a paper that I had
    published with Joe Morley attacking Edzard Ernst for improperly
    presenting evidence had nothing to do with claiming that “there were
    few properly designed randomized trials, such that the results were
    frequently inconclusive.” Yet this was plainly suggested by the
    authors of this so-called systematic review. Is this scholarship? One
    has to wonder whether this paper has, in fact, made a substantial
    contribution to the literature at all.

    Am I missing something? Other than serving as a repository of data
    concerning adverse outcomes, I am not certain that this particular
    publication has helped advance our knowledge base. In at least a few
    instances, it has presented corrupted information instead.

    Gouveia LO, Catanho P, Ferreira JJ. Safety of chiropractic
    interventions: A systematic review. Spine 34(11): E405-E413.

    Anthony L. Rosner, Ph.D., LL.D.[Hon.]“

  74. Harriet Hall says:

    “THIS ad hom is an extremely disappointing, childish cheapshot”

    You are right. I apologize.

    “not a single reference seems to have been made to
    studies which report lower rates of, or no, significant problems–such as by Haymo Thiel or Jaskoviak”

    I couldn’t find Haymo or jaskoviak, but the abstract of the Thiel study seems to support the findings of the systematic review:

    “This translates to an estimated risk of a serious adverse event of, at worse approximately 1 per 10,000 treatment consultations immediately after cervical spine manipulation, approximately 2 per 10,000 treatment consultations up to 7 days after treatment and approximately 6 per 100,000 cervical spine manipulations. Minor side effects with a possible neurologic involvement were more common. The highest risk immediately after treatment was fainting/dizziness/light-headedness in, at worse approximately 16 per 1000 treatment consultations. Up to 7 days after treatment, these risks were headache in, at worse approximately 4 per 100, numbness/tingling in upper limbs in, at worse approximately 15 per 1000 and fainting/dizziness/light-headedness in, at worse approximately 13 per 1000 treatment consultations. CONCLUSION: Although minor side effects following cervical spine manipulation were relatively common, the risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low.”

    It sounds from the abstract like they recorded spontaneous complaints by patients but did not survey the non-complainers in a systematic way, as most of the studies in the systematic review did. The reported neurologic side effects are very worrisome, as they could represent a stroke that almost happened but didn’t.

    Every study has essentially reported frequent minor side effects and rare serious ones. We are only quibbling about the numbers. and the data aren’t good enough to resolve the debate.

  75. nobs says:

    HH->>”I have already acknowledged that it is the procedure we are concerned with, not who does it., and that the risk of stroke is with SMT, whoever provides it.”<>”Chiropractors have claimed SMT for their own, and their practice is based on it. They are the ones who are known for doing SMT, even though a minority of manipulations are done by others.”<>” YOU are the ones who have identified SMT with chiropractic. I’ve never seen a chiropractic ad or website stressing that they offered SMT to treat musculoskeletal problems. Instead they claim to be practicing chiropractic” and treating subluxations.”<>”By the way, I noticed that Dagg has two G’s. You didn’t notice that Harriet has only one T. If you read that carelessly, it makes me wonder if you read the scientific studies carelessly too. If your error is due to a neurologic deficit like dyslexia, I apologize for bringing it up; I wouldn’t want to insult the handicapped.”<<

    THIS ad hom is an extremely disappointing, childish cheapshot. No further comment necessary.

  76. nobs says:

    HH->>”I have already acknowledged that it is the procedure we are concerned with, not who does it., and that the risk of stroke is with SMT, whoever provides it.”

    Harriet please- “Not who does it”"?? Really?? I am unconvinced. Here are a few reasons why:
    - Changing “SAFETY OF…” to “ADVERSE OF….”
    - Refusal to acknowledge the inapproprite, misuse of “chiropractic” in the studies cited.
    - failure to correct your “explanation” when this was brought to your attention.
    - failure to take to task, the significant percentage of non-DC providers involved with serious adverse events(one study I provided to you showed 50% were orthopedic surgeons/89% non-DCs).

    It appears to me, that when it comes to chiropractic, you somehow feel it necessary to “boil it down” or “explain”. Why not just call it what it is….Your personal opinion/comments?

    (btw- Please direct me to any pieces you have authored on SMT and providers of SMT, other than DCs).

    HH- >>”Chiropractors have claimed SMT for their own, and their practice is based on it. They are the ones who are known for doing SMT, even though a minority of manipulations are done by others.”

    Yes- We are definately associated with SMT. Not because it is the ONLY option of treatment we are professionally trained to offer, ….BUT because, we are the only providers that are professionally masters of SMT. There are others may dabble in it, watch a video, maybe even take a weekend course. This creates, shall we say, “piano-players”. While DCs are “pianists”.
    Which would you choose for a bypass, appendectomy, hip replacement, even a dermatology consult…… a piano-player, or a pianst? Honestly.

    Since “a minority of manipulations are done by others”, this statisticly bodes very well for DCs- the majority of adverse
    events occur with non-DC manipulations. Perhaps a valid safety reason for keeping manipulation out of “others” practice scope?

    HH->>” YOU are the ones who have identified SMT with chiropractic. I’ve never seen a chiropractic ad or website stressing that they offered SMT to treat musculoskeletal problems. Instead they claim to be practicing chiropractic” and treating subluxations.”

    C’mon……Really?? You claim you have seen NO DC ads or websites offering treatment for low back pain, hip pain, sciatica, neck pain…………? C’mon. I just can’t buy that.

    Be honest.

  77. Harriet Hall says:

    “you have seen NO DC ads or websites offering treatment for low back pain, hip pain, sciatica, neck pain”

    That’s not what I said. They offer “chiropractic treatment.”

    “the majority of adverse events occur with non-DC manipulations.”

    Really? See figure 2 at http://www.ptjournal.org/cgi/content/full/79/1/50 It indicates just the opposite.

    What percentage of your patients with neck pain do you treat with SMT? How do you decide which ones to treat? Do you use HVLA or mobilization? Why? And please comment upon neck manipulation’s widespread use by chiropractors for headache, certain childhood complaints, and general “wellness”.

    “Which would you choose for a bypass, appendectomy, hip replacement, even a dermatology consult…… a piano-player, or a pianst?”

    I agree that chiropractors are more skilled at providing SMT. But I question whether they are skilled at deciding which patients to treat. Especially the ones who offer neck manipulations to the great majority of their patients, even those who are well and only seeking “health maintenance.” I would choose an experienced surgeon to do my appendectomy, but first I would want to make sure that I really had appendicitis.

  78. pmoran says:

    Yes, Harriet, this is evolving exactly as have most other discussions of adverse events with chiropractors. How to get chiropractors to think of neck manipulation in risk/benefit terms ? Many have tried.

    And how precious it is for chiropractors to be affronted at being a primary target in such debates!

    No other component of medicine has members who subject patients to unnecessarily prolonged, even life-long programs of neck manipulation. No other branch accepts, though professional neglectfulness and ill-discipline, the use of neck manipulation for innumerable dubious reasons.

    Sadly for chiropractors, also, no other profession has such an investment in neck manipulation as to have great difficulty in substituting equally effective, but safer treatments.

    If these perceptions regarding the current state of chiropractic are wrong, I deeply apologize, but the reluctance of the present crop of chiropractic contributors to answer simple questions as to how they shape their current practices says much.

  79. nwtk2007 says:

    Sorry pmoran, I just don’t see it that way. Chiro’s understand the risk to benefit concept, it is the medical community that doesn’t.

    The anti-chiro bias you possess is why you see such great risk in chiropractic but not in even simple meds like ibuprofen. I see the evidence against CMT as sketchy, unsubstantiated and weak at best.

    Your view of chiropractors is purely biased and thus totally subjective. I have in the past pointed out your inability to apply the same standards to medical science: thus the “smoking gun theory” as I have heard so many times here.

    I, however, have a great deal of experience in all fields of science and have had incredible experience in working with and dealing with all medical professionals. Some are good and some suck, just as some chiro’s are good and some suck. It is a pity that the medical profession does not really deeply consider the risk to benefit ratio with their standard treatment, that being drugs. It is also a pity that they do not get the idea of preventive medicine and the concept of in-depth doctor/patient relationship that would allow for true preventive medicine to occur.

    Funny how the chiro’s seem to be able to gain such a trust of patients that the “placebo” effect you say they utilize is so effective. Why is that pmoran?

  80. Harriet Hall says:

    If you say the same lies over and over, that doesn’t make them true.

    The medical community DOES understand the risk/benefit concept – in fact, I think if you go back in history you will find that it was the medical community that developed that concept.

    We most certainly DO recognize the risks of ibuprofen. There are far more medical references for NSAID risks than chiropractic references for the risks of neck manipulation.

    It is a false dichotomy to think ibuprofen and neck manipulation are the only two options.

    I have never said there is “great risk” in chiropractic. I have said that studies have shown a significant rate of reported benign side effects and a small risk of serious complications.

    We ARE applying the same standards to chiropractic as we do to other treatments. If chiropractic were a new drug, it would not have been approved based on the kind of evidence you have provided.

    We ARE biased – but only against treatments based on a myth and treatments that have not been shown to offer a significant benefit.

    The medical profession absolutely DOES get the idea of preventive medicine. And the concept of the in-depth doctor/patient relationship. It was a doctor, Francis Peabody, who said in 1925 “… the secret of the care of the patient is in caring for the patient.”

    It’s easy to accuse me of bias and subjectivity, but it’s far more difficult to provide objective evidence supporting HVLA neck manipulation.

    And now you comment on how chiropractors elicit the placebo response. Yes, I think that is a large part of what they do. We know many of the factors that enhance the placebo response. There is a great body of literature about that. There is also the effect of keeping patients occupied until the natural course of disease relieves the symptoms.Effective treatments also elicit the placebo response; why not use an effective treatment with a good risk/benefit ratio. There is no need to fool patients about bones out of place and imaginary subluxations.

  81. nwtk2007 says:

    Harriet – “There is no need to fool patients about bones out of place and imaginary subluxations.”

    You know good and well from my previous posts that I don’t treat “bones out of place and subluxations” so don’t go getting all personal just as my previous comment was not directed at you personally.

    Harriet – “If chiropractic were a new drug, it would not have been approved based on the kind of evidence you have provided. ”

    So referring to JUST ibuprofen, given the risks that are well published, how did it get OTC status? and why is it so widely prescribed in huge quantities to patients every single day at amounts double that of the OTC strength. (3300 deaths per year and the number two cause of peptic ulcer.) And this is just ibuprofen.

    Don’t tell me or any other chiro that the medical profession applies the same standard to drugs that this blog applies to chiropractic or CMT.

    This is a TRUE bias. No doubt about it!

    Harriet – “It is a false dichotomy to think ibuprofen and neck manipulation are the only two options.”

    Well of course doctor! Once again you think that all chiropractors do is CMT. Bias once again.

  82. pmoran says:

    I have explained the reasons for what you like to call “anti-chiro bias”? Do you wish to challenge any of those? I’m listening.

    Based upon the executive summary of YOUR own stated “golf standard” of evidence (BJD), I have suggested that the only place for neck manipulation within medicine is as a relatively late resort for some patients with musculoskeletal neck pain that has not responded to simpler measures including massage and, possibly, gentle mobilisiation.

    Over to you. What are YOUR indications, and why the reluctance to tell us?

  83. Fred Dagg says:

    Oh Harriet (one t, not two)

    It is not only HVLA manipulations that are the cause is these incidents (I use the word “incident”, so as we do not spend hours arguing over semantics and the use of words and phrases such as “accidents” or “adverse effects”). You are, I believe, trying to divert the discussion away from the issue that it is SMT, irrespective of the type and practitioner, that is the cooncern. So is going to the hairdresser, yoga or just putting ones neck into a position that may occlude of disrupt the arteries in the neck. So when I read your comment……….

    “It’s easy to accuse me of bias and subjectivity, but it’s far more difficult to provide objective evidence supporting HVLA neck manipulation.”

    I actually wonder why on earth this debate is continuing. You are trying to hide behind semantics to justify what was, I believe, a poorly written article. One, which I believe, had it been on the topic of “Adverse Effects of (a certain aspect of medical care)” you would not have written.

    SMT is used in the world, not just in the U.S.A. by a number of different practitioner groups. All of them are cognisant to the dangers of its use.

  84. Harriet Hall says:

    Why was ibuprofen approved? Because first it was clearly shown to be EFFECTIVE. Then the side effects were taken into account and it was determined that the benefits outweighed the risks in general. We can identify some patients who are at higher risk, and any good clinician takes risk into account and prescribes ibuprofen selectively. The risk/benefit ratio was so good that it was even approved as an OTC drug. The package insert (and any good clinician) advises patients about the risks.

    Fredd Dag (just kidding) :-) says everyone who uses SMT is aware of its dangers. Maybe, but they’re not telling all their patients. Sandra Nette and others who had strokes were never warned of any risk. There is a movement to require any provider who performs neck manipulation to practice informed consent. See http://www.courant.com/news/local/columnists/hc-chiropractor-informed-consent-rgmar17-column,0,2557162.column
    This article indicates that some chiropractors think manipulation is “the safest” form of treatment and some still deny that there is a risk. The chiropractors say this still singles them out. It seems they have the same chip on their shoulder?

    “The chiropractors are all over this. It’s a lot of pressure,” Fasano said. “Legislators are getting called left and right. They are very vocal. They are saying things that are not quite accurate, like we are singling out chiropractors and there is no such thing as a stroke” caused by cervical manipulation.”

    The sad thing is that some chiropractors are using “informed consent” forms that unfairly minimize the risks, don’t provide good evidence for benefits, and amount to blatant propaganda for chiropractic treatment.

    If someone wrote an systematic review about side effects of treatment by a dermatologist, I hope they wouldn’t complain it was unfair because family physicians, pediatricians, and internists also provided the same treatments. I hope they would incorporate the information into their practice and expect the other specialities to follow suit.

  85. Fred Dagg says:

    Hello Harriet,

    I do not have any complaints about your comments about informed consent being a requirement. I suppose I was talking about providers of SMT in my country. What amazes me, is that it is not used more often here, by other members of the health care fraternity.

    Several dentists I know of do not use it and I believe that there is a presumption by some Healthcare Providers that patients know and accept the risk, despite it not being made aware of the (the “Doctor knows best” mentality). I am sure you and I as well as other members of this site can think of many proceedures in healthcare, that if the patient was made aware of the risk, they would not participate in it.

    I suppose the main problem I see in continuing this discussion is that there are geographical differences. What is acceptable and unacceptable care differs in whatever country one practices in. I pointed that out to you, when one looks at the use of spinal surgery rates in the U.S. when compared to the U.K. Who is right? I am not sure. I hope that the intent of the surgeons is to get a good result.

    In regard to your comment about treatment by dermatologists, I agree with you, however what would be criticised would be the treatment, rather than the fact that it was more dangerous provided by one group rather than the other. As an analogy, is Isotretien more dangerous when provided by a dermatologist or G.P.? The danger is in the medication, not the practitioner who responsibly prescribed it. In this case you singled out Chiropractors rather than Spinal Manual Therapy and that is where I have a problem.

  86. Harriet Hall says:

    Who is right? The difference in surgery rates has been a frequent topic of discussion in the medical literature. It seems that spinal surgery only improves short term response but has no long-term advantages over nonsurgical treatment. Is there a longer waiting list in Britain? Are patients in the US more demanding about wanting relief NOW? Do Americans have a different perspective about surgery? I don’t know, but these are questions that doctors themselves are trying to answer. The same questions are constantly being asked about the optimum rate of c-sections and other procedures.

    If you think patients in the US are not made aware of risks, just plow through a few medication package inserts and read some of the informed consents we have to sign for even minor procedures like mole excisions. We used to joke about what a TRULY informed consent would be: “Your surgeon might have a heart attack and fall on you during the procedure. An earthquake might shake you off the table….” We carefully document in the medical record that we have obtained informed consent after the risks and benefits of the procedure were fully explained and the patient had the chance to ask questions and indicated that he understood.

    Your implied criticisms of mainstream medicine say nothing about the risk/benefit ratio of neck manipulation. The questions you raise are appropriate for discussion elsewhere, but they are irrelevant to the topic of this post. the fact that you bring them up suggests an attempt to distract us from the real question, and is smacks of the tu quoque fallacy.

    Please tell us what the indications for neck manipulation are in the US and in your country. The science should be the same everywhere, even though customs and decisions may differ.

    You seem to have a problem with my choice of words; I have a problem with your lack of evidence and your evasion of simple questions.

  87. Fred Dagg says:

    Hello Harriet (one T, not two)

    I feel I have answered all of your questions. Maybe this is the adversarial way in the U.S. where there is a competition to “out-cite” each other. The desire to be seen to be right, without realizing that in the process, the casualties will exist.

    However, the Bone and Joint Decade results do give a good indication that SMT for neck pain is indicated, in Grades 1 and 2. (It does not specify the provider). It out-cites the Cochrane review.

    I am sure I did not infer that patients in the U.S. are not made aware of informed consent. If that is your impression, then that is not what I intended.
    One would hope that the science is the same, but it is not. The science of “medicine or healthcare” is not the same, between countries and between generations. Examples of this can be seen with the use of anti-depressants in Germany as opposed to the U.S.A. Less dependence on Prozac type medications and better use of psychological counseling and St. Johns Wort in Germany. In fact it has been proven that anti-depressants for mild and moderate depression are no better than placebos.

    http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050045

    Yet the dollars that are wasted in the use of these antidepressants and the potential side effects must be horrendous. Does it ever worry you?

    Generational differences can be seen by reviewing the historical state of “United States medicine” pre and post the Flexner Report of the early 20th Century.

    So where does the science apply to this issue?. Is it “Clinical Science”, “Physiological Science” or even “”Pharmaceutical Science”. I would hope that common sense has a bit of influence here.

  88. Citizen Deux says:

    What worries me is that treatments, like chiropractic, which are narrowly efficacious are continued throughout the world. Other treatments, when subjected to any sort of scientific rigor – are discarded.

    FD, as you clearly practice in another country (Canada?) – I am interested as to what association guides your standards of care. Do you offer – in your practice – therapies other than “traditional chiropractic”?

    Within an open, scientific field – the desire is to be accurate. Thus providing the best options for practioners and patients. There is no relativism in science.

  89. Harriet Hall says:

    Please tell us what the indications for neck manipulation are in the US and in your country. The science should be the same everywhere, even though customs and decisions may differ.

  90. nobs says:

    # pmoranon 13 Jun 2009 at 5:21 pm

    Nobs, Why can I not get direct answers to simple questions? Here they are again. You wasted my time by referring me to sites that contribute nothing new and nothing of relevance.

    Here are the questions again.

    >>”Since your own “Gold Standard” paper sees other methods as having equal efficiacy to neck manipulation for neck pain but without the risks (e.g. acupuncture), what do you now see as the proper place of SMT in the treatment of neck pain?

    —————————-

    I DID answer your “questions”. -AND-, may I add, supplied you with linked sources supporting my answers.

    Since you refer to my documented/referenced/linked answers to your “questions” as: “wasted my time” and “nothing of relevance” …..It is, in fact, ME that wasted my time, reponding to your disengenuous questions. You are entitled to your dogmatic bias. I politely request that you don’t waste any more of my time with your feigned “questions”.

  91. nobs says:

    “the majority of adverse events occur with non-DC manipulations.”

    HH- >>”Really? See figure 2 at http://www.ptjournal.org/cgi/content/full/79/1/50 It indicates just the opposite.”

    Really? See: http://www.ncbi.nlm.nih.gov/pubmed/16511634?dopt=Abstract IT indicates just the opposite. 89% cases were non-DC, 14% being Physical Therapists.

    HH->>”I couldn’t find Haymo or jaskoviak,…..

    The Jaskoviak study reported that not a single case of vertebral artery stroke occurred in approximately five million cervical manipulations at the National College of Chiropractic Clinic from 1965 to 1980.

  92. Harriet Hall says:

    nobs,

    Re strokes caused by non-chiropractors: The article you cited says “We analyzed data from neurological departments at university hospitals in Germany over a three year period of time of subjects with vertebral artery dissections associated with chiropractic neck manipulation.” The abstract says “chiropractic” and it doesn’t mention other providers. That article was included in the systematic review, by the way.

    The Jaskoviak study makes me wonder if inexperienced students can offer a level of safety greater than chiropractors who have graduated and have been in practice for a long time.

    I have repeatedly said that the risk of stroke is very small and that we don’t have a reliable estimate. I hope you don’t deny that there is any risk at all.

  93. Harriet Hall says:

    nobs said,
    “I DID answer your “questions”. -AND-, may I add, supplied you with linked sources supporting my answers.”

    No you didn’t and the links didn’t.

  94. nobs says:

    Harriet-
    .” The abstract says “chiropractic” and it doesn’t mention other providers. That article was included in the systematic review, by the way.”

    YES- the title and abstract of the paper does INDEED say “chiropractic”. And this is precisely my original point, and WHY such reviews, by their very nature, are flawed…… The information they “search” is flawed.

    I will provide you with the full text, detailing the providers, later tonight- gotta go.

  95. Fred Dagg says:

    I think we are going around and around in circles. Arguing semantics and citation no one bothers to read.

  96. pmoran says:

    “– going around and around in circles.”

    More so a preoccupation with irrelevancies on the part of some. We should be looking at the interests of the patient and working backwards from that.

    It seems some chiropractors still want to hold out some hope that this matter will go away. It won’t. Medicine has found itself under more intense and unforgiving pulbic scrutiny in recent decades, yet chiropractors seem to be happy to sit out there on a limb for everyone to take potshots at.

    Perhaps we need to start over, with simpler questions –.

    Do contributing chiropractors yet accept that neck manipulation can cause stroke? If not, why not?

  97. Fred Dagg says:

    Hello Pmoran

    It is well recognised by those members of the chiropractic profession I have meet, that there is a relationship between spinal manual therapy and the incidence of strokes. There is more research that can be done on this issue, as it is a treatment issue, rather than a “practitioner” issue.
    In a very early post, I specified that there needed to be a multi-disciplinary approach to this issue, rather than an attempt to point the finger and blame.

    Your comment…..

    “yet chiropractors seem to be happy to sit out there on a limb for everyone to take potshots at. ”

    Is only your opinion. My experience is that the chiropractors I have meet are very patient care focused. There is also an intense desire for research to be done within the field of neuro-musculo-skeletal medicine.
    Here we delve into the politics of research, costs and egos, and best not to go there.

    I totally agree with your sentiment that the patient comes first and any research done on this topic should be done to make practitioners safer.

  98. pmoran says:

    “– there is a relationship between spinal manual therapy and the incidence of stroke”

    Do you think this is a causal relationship? (Probably/probably not/can’t tell)

    “–There is more research that can be done on this issue”

    What kind of research do you have in mind? It will never be practical (or ethical?) to perform prospective randomised controlled trials involving (potentially) hundreds of thousands of subjects, and I wonder whether any other kind of trial could effectively counter the evidence we already have.

  99. Fred Dagg says:

    I am not a researcher nor anatomist so cannot comment on the difficulties of doing research on this topic. There are many tpic is healthcare that would be difficult to research effectively.
    The relationship has been discussed in Bone and Joint Decade as well as other peer reviewed articles, so I need not comment on it.

    I am not sure what evidence you are referring too. The evidence we already have says that in comparison to other forms of care, SMT is as safe, if not safer.

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