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Brief Note: The Chiropractic Subluxation is Dead

The General Chiropractic Council, a UK-wide statutory body with regulatory powers, has just published a new position statement on the chiropractic subluxation complex:

The chiropractic vertebral subluxation complex is an historical concept but it remains a theoretical model. It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.

They remind chiropractors that they must make sure their own beliefs and values do not prejudice the patient’s care, and that they must provide evidence-based care. Unfortunately, they define evidence-based care as

clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners, including the individual chiropractor her/himself. [emphasis added]

This effectively allows “in my experience” and “the patient likes it” to be considered along with evidence, effectively negating the whole point of evidence-based medicine.

Posted in: Chiropractic

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40 thoughts on “Brief Note: The Chiropractic Subluxation is Dead

  1. BillyJoe says:

    General Chiropractic Council: “clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners, including the individual chiropractor her/himself.”

    Harrriet: “This effectively allows “in my experience” and “the patient likes it” to be considered along with evidence, effectively negating the whole point of evidence-based medicine.”

    If they had said that the primary criteria that the chiropractor should rely on is the best available evidence from research and that, provided that conditon was satisfied, then, and only then, could the practitioner’s expertise and patient preference come into play…

    …but, then again, the only scenario for which there is some evidence for efficacy and safety is manipulation of the non-cervical spine as a treatment for back pain.

    …and, then again, chiropractic in that scenario is no better than simple massage or physiotherapy, which are safer and less expensive.

  2. zeno says:

    It was tenacious questioning of the GCC about the evidence for subluxations by Skeptic Barista that led to this amazing (but long overdue) statement.

    Read more about how this came about on his blog:

    Subluxations: We’ve never considered the research (Part 1)

    Subluxations: We’ve never considered the research (Part 2)

    and on mine:

    Obituary: The death of the subluxation

    In Memoriam

  3. Grant Jacobs says:

    The words “the preferences of the patient” remind me very much of a recent documentary here in New Zealand of a natural health practitioner who treated a “cyst” on the scalp for ~2 years that grew substantially. It proved to be a cancer that worked through the scalp into the brain. In interviews, the natural health practitioner repeated words to the effect that “you have to go along with what they want,” which at the time struck me not so much as avoiding evidence-based medicine (which it does, of course) but as disowning responsibility.

    http://sciblogs.co.nz/code-for-life/2010/03/08/an-horrific-case-of-natural-health-treatment-of-cancer/

    It seems to me that phrase should only be used in the context of offering an evidence-based treatment that the patient wishes to decline, i.e. that you can’t force the treatment on the person. I don’t believe it should be used as a context to work as directed by the “wishes” of the patient, rather than what is known to be effective for the condition at hand.

  4. Dr Aust says:

    And I’ve saluted the subluxation’s demise in mock-poetic form over at my blog:

    Poetry Corner: Subluxation Special

    I’ll repost the verse to save you a click:

    In Memoriam:
    The Chiropractic Subluxation

    So. Farewell
    Then. The Chiropractic
    Subluxation.
    A complicated Word
    For something that
    Does not
    Exist.

    Or perhaps for what
    Was just
    A Metaphor.

    Or rather -
    A Metaphor
    Wrapped up inside
    An Enigma
    Wrapped up inside
    A Paradox.
    Wrapped up inside
    A Huge Invoice.

    Which last
    Chiropractors have been
    Presenting for
    At least
    A Century.

    Very Tricky.

    As a member of
    The Public
    You would probably
    Need X-ray
    Vision to
    Get to the
    Bottom
    Of All This.

    Or at least to make
    Sure you
    Were not being
    Manipulated

  5. Versus says:

    The “vertebral subluxation complex” is not a “theoretical model.” It is something wholly made up. If the subluxation is a theoretical model, we can also call Santa Claus and the Tooth Fairy “theoretical models.”

    I am always intrigued by this concept of “patient preference” and the idea that patients are flocking to SCAM pratitioners because they “want” to use “alternative” medicine. No they don’t. Patients want something that is effective and safe, and they turn to alternative practitioners only because they are being lied to and told that this or that psuedoscientific practice “works.” If they were told the truth, I imagine the alt med business would dry up pretty quickly.

  6. stephend50 says:

    The subluxation is dead! God save the subluxation!

  7. BillyJoe says:

    Versus,

    There are many people who go to alternative practitioners because they are into “natural” treatments as opposed to “unnatural” drugs.

  8. DevoutCatalyst says:

    Does this spell the end of chiropractic x-rays? Not only needless, but sometimes taken on equipment manufactured ages ago and appearing straight out of Hogwarts.

  9. Fourmyle says:

    @ Versus. I’ve seen examples where the person is being lied to by themselves. When faced with an incurable illness, and feeling powerless and possibly in denial, being told that there is a simple, easy “cure” that is within their power to effect is very seductive. The fact that they want what they are being told to be true, is all it may take to make them actively promote whatever said treatment is. Science is at root a systematic attempt to not fool oneself. I don’t find it surprising that people desperate to refute a fact based conclusion about either themselves or someone they are close to, will reject science. The tragic part is when wishful thinking interferes with useful treatment. As long as we can’t cure everything, with no adverse side effects and right now, there will always be a following for any “alternate system” that promises that.

  10. zeno says:

    That’s a very good point, DevoutCatalyst. That always what they seem to be finding in x-rays. Maybe Skeptic Barista should ask the GCC?

  11. drsinclair says:

    http://en.wikipedia.org/wiki/Luxation

    Luxation = dislocation.

    Subluxation = partial luxation

    Does inflammation occur with damage or injury to a joint sufficient enough to misalign a joint, whether it be fully luxated or subluxated?

    Pressures as little as 10 mm Hg can alter the nerve root and dorsal root ganglion’s abilities to function normally. In the normal range of motion the pressures generated in the IVF may exceed 30 mm Hg.

    And research indicates that with varying degrees of severity of inversion ankle sprains (otherwise classified as ankle subluxation) where partial luxation can and does occur, it requires between 30 mm Hg and the individuals diastolic blood pressure levels to reduce the pressure along with elevation of the limb.

    Conclusion:

    luxation/subluxation/Injury/damage leads to inflammation

    Inflammation – edema, and it requires sufficient pressure in order to reduce said edema by elevation and pressures between 30 mm Hg and diastolic levels and these levels occur in varying degrees of inversion ankle sprains.

    Axonal flow/nerve conduction velocity can be affected by as little 10 mm Hg. The greater the pressure the greater the affect.

    Inflammation occurs in all joints that are contained in a capsule equally – knee, shoulder and/or zygapophyseal/facet joints of the spine, depending on the severity of the damage/injury/luxation/subluxation.

    If pressure on a nerve affects how the nerve transmits signals then it can affect the function of the end organ whether that end organ be a muscle, GTO, muscle spindle or viscera. If a nerve can cause dysfuntion in a muscle then it can cause dysfunction in an organ.

    Now I’m not one to believe that diabetes/cancer etc can be cured by the chiropractic adjustment but that does not mean that it does not play a part in the bodies inability to maintain somatic voluntary/involuntary control or dynamic visceral homeostasis where there is sufficient evidence of the potential of interference between the brain and the end organ.

    It wasnt that long ago that we discovered that evidence of apparent nerve root compression found on MRI has led to misdiagnosis and treatment outcomes due to false positives.

    I do not agree with making false claims and any chiropractor that does should be suspended or had their license stripped away. However, that does not mean there is not some validity that should be studied further.

  12. hippiehunter says:

    Am I understanding this correctly ? The General Chiropractic Council are stating that ” The chiropractic vertebral subluxation complex is BOGUS ?”

    Its of to court we go …Hi Ho Hi Ho

  13. Blue Wode says:

    Thank you, Dr Hall, for another insightful post.

    For anyone wishing to read about the GCC’s inconsistencies on the evidence for the chiropractic ‘subluxation’, see here:
    http://www.zenosblog.com/2010/05/in-memoriam/comment-page-1/#comment-5508

    Readers might also be interested to know that in the recent past, in a letter to the group Action for Victims of Chiropractic, the GCC claimed that Craniosacral Therapy and Applied Kinesiology fell within its definition of evidence-based care. See here:

    Incompetence and the General Chiropractic Council
    http://jdc325.wordpress.com/2009/06/09/incompetence-and-the-general-chiropractic-council/

  14. drsinclair: how many more decades of study do you need? How much evidence of absence do you need? You put all that energy into reminding us (like we didn’t know) that the hypothesis was once vaguely plausible, despite its dubious provenance, but it has already been tested ad nauseum. At what point will you agree that this horse has been beaten to death? When do we give up and acknowledge that, if the phenomenon exists at all, it is just too trivial to produce medically interesting evidence?

  15. APM says:

    Dear Dr. Sinclair,

    I’m having several problems with this statement and what you seem to want to use it for (i.e, chiropractic subluxation causing visceral disease):

    “If pressure on a nerve affects how the nerve transmits signals then it can affect the function of the end organ whether that end organ be a muscle, GTO, muscle spindle or viscera. If a nerve can cause dysfunction in a muscle then it can cause dysfunction in an organ.”

    Dysfunction is a long way off from disease and can range from non-existent upwards. Even if it’s just dysfunction then does it even matter? So what the case here?

    The impact of the autonomic nervous system on visceral organs is mostly for “fine tuning.” The major effects come from the endocrine system. I believe that people even have operative procedures that entirely remove connections of the sympathetic nervous system from organs without having any visceral diseases associate with whatever visceral dysfunction (if any) that may accompany these procedures.

    Also, why aren’t other clinicians like orthopedists, physiatrists, and physical therapists seeing these effects and reporting them in the literature?

    These other types of clinicians see patients with disc injuries that cause nerve compression. Some patients have had these for years. I have had an inflammatory lumbar disc condition for about 7 years. It’s now at a point where I have mostly minor altered sensations in the foot that are aggravated by compressive loading situations. No parasympathetic nervous system associated visceral diseases and no visceral dysfunction either as far as anyone can tell at anytime.

    Please correct me if I’m wrong but this would be textbook material by now in many disciplines. My understand is it’s not … even in up-to-date chiropractic textbooks.

    So what gives?

  16. APM says:

    Please update my previous post with the following.
    ———————————–

    Dear Dr. Sinclair,

    I’m having several problems with this statement and what you seem to want to use it for (i.e, chiropractic subluxation causing visceral disease):

    “If pressure on a nerve affects how the nerve transmits signals then it can affect the function of the end organ whether that end organ be a muscle, GTO, muscle spindle or viscera. If a nerve can cause dysfunction in a muscle then it can cause dysfunction in an organ.”

    Dysfunction is a long way off from disease and can range from non-existent upwards. Even if it’s autonomic nervous system associated dysfunction of any degree then does it even matter? So what the case here?

    My understanding is that the impact of the autonomic nervous system on visceral organs is mostly for “fine tuning.” The major effects come from the endocrine system. I believe that people even have operative procedures that entirely remove connections of the sympathetic nervous system from organs. They don’t get any visceral diseases associate with whatever visceral dysfunction (if any) that may accompany these procedures.

    Also, why aren’t other clinicians like orthopedists, physiatrists, and physical therapists seeing these effects and reporting them in the literature?

    These clinicians see patients with disc injuries that cause nerve compression. Some patients have had these for years. I have had an inflammatory lumbar disc condition for about 7 years. It’s now at a point where I have mostly minor altered sensations in the foot that are aggravated by compressive loading situations. No parasympathetic nervous system associated visceral diseases and no visceral dysfunction either as far as anyone can tell at anytime.

    Please correct me if I’m wrong but this would be textbook material by now in many disciplines. My understand is it’s not … even in up-to-date chiropractic textbooks.

    So what gives?

  17. drsinclair says:

    Mr. Ingraham: I have seen numerous tests that disprove the vertebral subluxation complex that chiropractors hold so near and dear to their hearts but I also know that same testing was commissioned by corporations and associations that stand to lose their corner of the market. I honestly do not believe any information in todays market is not skewed to benefit one groups POV and opinions over anothers. Its a classic conflict of interest.

    This evidence of absence you speak of goes against deductive reasoning as I’ve outlined in my previous post. I simply find it hard to believe that we can believe that nerve compression from disc material can cause severe symptoms but evidence of less pressure cant cause less severe symptoms. And that chronic low grade pressure has no effect at all.

    I agree with you that this horse has been beaten to death but I’m not sure the horse needed to be put down just because you couldnt break it. Someone else might be able to make a good horse out of it. You (not you specifically but you get the point) just might not have the temperament to properly break it.

    The phenomenon may not produce medically interesting evidence but I do know there are a significant number of individuals that are written off by the medical community for “lack of pathological evidence”. These same people have gone to a chiropractor and received the relief that they’ve been looking for without putting them on pain relievers, anti-inflammatories and muscle relaxers which definitely dont fix anything but quell symptoms and allow whatever IS causing the symptoms to build a stronger foothold and progress to something more serious. Now I know this puts more money in all our hands but is that what is best for the patient? Are we just supposed to write them off?

    I think there may be a middle ground that can be reached between M.D.’s and D.C.’s as long as the D.C.’s will stop trying to claim miracles. The last person to create miracles walked on water and I havent seen a D.C. walk on water yet.

  18. drsinclair says:

    APM: So at what point did the definition of health become absence of disease. The idea here is we wouldn’t drive our automobiles with dysfunctional parts or systems and if we did how long would they run until they gave out? I havent seen or heard of any research by a true independent body that has studied the effects of long term dysfunction in an organ and how long before it leads to a diseased state. BTW I’m not claiming that dysfunction does lead to disease, I’m simply using probability and trying to find a way to work to the benefit of the patients and maybe, just maybe lower some healthcare costs.

    I cant believe your even saying, “does it even matter”. Every piece and part in our body has a function and we werent made with any extra parts that wouldnt matter if it werent there. How egotistical we’ve become?! Whether the function be for fine tuning or gross control, a body functioning at less than optimal is dysfunctional and not expressing true health.

    And that endocrine system works from feedback to the brain via afferent nerves which then interprets the feedback and produces the proper endocrine response to the stimuli.

    “Also, why aren’t other clinicians like orthopedists, physiatrists, and physical therapists seeing these effects and reporting them in the literature?”

    I had a conversation a few years ago with a colleague that was treating a women that was vomiting 8 – 10 times/day for nearly 6 months. For whatever reason, she visited a chiropractor and within a week the vomiting had reduced to 1 – 2 times/day and after 3 weeks had been completely eliminated. She is still to this day free from her ailment and has had no other treatment. Now I dont know how or why it worked but it did. For me there is enough there to give it the benefit of a moment of reflection.

    Why arent others seeing these effects and reporting them? I cant answer for them but I could certainly see why one would want to keep their mouth shut for fear of being ostracized. This same thing happened back during the civil rights movement for fear of being labeled a (insert offensive “N” word here) lover. It was appalling then and it is possible that this same thing would happen or is happening today keeping these ideas stifled.

    And this inflammatory lumbar disc condition that is now producing minor symptoms, how does the level of degeneration at that joint compare to joints above and below that area? Or are you simply looking at symptomatology. Also, what other kinetic chain abnormalities have developed in your attempt to avoid pain associated with this condition as the symptoms slowly lessened.

    We will just have to agree to disagree about the parasympathetic NS having no effect on the viscera, if that is in fact what you are saying?

    Again, I state why would this material be textbook if it leads to someone losing a portion of the market share. It seems that medicine has become more about money than about helping people.

  19. Harriet Hall says:

    drsinclair said “I dont know how or why it worked but it did.”

    No, you don’t know that it did work. You don’t know that the symptoms wouldn’t have resolved just as fast with no treatment due to the natural history of the disease.

    You offer us testimonials and speculation. We’re waiting for some real evidence. We’ve been waiting for well over a hundred years now.

  20. Regarding the “patient preference” thing: the GCC’s inclusion of it is pure pandering to their constituency. Most chiropractors are ignorant of EBM and hostile to it, and buy into the alt-med propaganda that science is heartless and excludes all other considerations from care. If that bias wasn’t pandered to, they would reject the statement out of hand.

    I am sure that the GCC had to fight to make this statement in any form, but that patient preference inclusion looks ridiculous to those actually familiar with EBM.

  21. drsinclair: like virtually everyone who matters, including many of your own colleagues, I find the evidence of absence satisfying and compelling, leaving no further room for interesting debate. It consists not only of direct evidence of absence, but a failure to produce evidence of a phenomenon or effective therapy. Chiropractors have had a century to produce such evidence, anything that shows that therapeutic interventions for alleged subluxations make any detectable difference in people’s health (either eliminating disease or optimizing health, since you insist on that irrelevant distinction).

    Either it doesn’t happen, or it’s so subtle that you can’t make me care. There are other medical fish to fry.

  22. APM says:

    Dr. Sinclair,

    You seem to have a model of the human body that is very mechanistic and not biological. We aren’t washing machines but systems that can adapt and repair. That capacity is why we don’t break down like cars, washing machines or refrigerators.
    Take for example, that minor injuries of the low back do not add up to lead to severe low back injuries. Also, under you machine model one would see an clear increase in disabilities like low back injuries with age. That isn’t what the data shows … at least that’s what I’ve learned over the years from dealing with my back problem. Is more scattered and doesn’t imply that I’m just a machine like a watch or hand drill.

    So it seems you have a problem with the model as well. Maybe it’s different for other areas of the body but then again maybe it’s not but the fact that the machine model doesn’t hold up well at least with low back pain should make you pause and think about everything else.

    Having said that, I have no problem with there being a connection somewhere and I have no problem paying for repeat visits to a chiropractor to loosen up my back and relieve the stress that has build up over the week. I suspect many people go for that reason alone.

  23. drsinclair says:

    Hall: Knowing the facts of the case, I’m satisfied that all medical means had been exhausted and with the duration of the patients condition having had over a year to resolve on its own, all things being equal, the simplest explanation is for this patient, chiropractic worked.
    There also seems to be a significant level of patient satisfaction with chiropractic, so I’m not opposed. Being that chiropractic is a relatively young profession, if we compare the 1st 100+ years of “organized” medicine, there were some sketchy practices back then that werent proven or science based but thanks to logical reasoning it has progressed to what we have today and I’m certainly thankful it has.

    Mr. Ingraham: being a “health”care provider, its impossible for me to simply cast aside the notion of optimizing health. My job is not only to help the sick but to also help patients be as healthy as they want to be. As long as patient satisfaction is primary concern, I’ll consider all options.

    APM: I think most orthopedic specialists have a mechanistic POV and know for a fact that P.T./ATC’s do. As someone that works with athletes of all levels, I disagree that minor injuries do not add up to lead to severe problems. I’ve seen it first hand, so the evidence speaks to the contrary.

    I wish you all – the best but its obvious this is not a subject most of you are willing to consider, whether the public is satisfied with the results they receive from chiropractors or not. I would hate to think that I’d missed something by being unwilling to consider all options no matter how plausible they may seem.

    Yours In Health,

    Dr. S

  24. Robin says:

    Subluxation may be dead but acupuncture is still breathing:

    http://bit.ly/bQeltq

  25. drsinclair: I said that the “optimization of health” distinction was irrelevant to this discussion, not that it is a valueless concept in general (that’s a different debate). There’s no evidence that treating for “subluxations” has any effect, either on pathologies or as a health tonic.

    I would be “willing to consider” the subject only if you can get past speculation. Otherwise, yeah, it’s just not enough to hold my interest.

  26. APM says:

    Dr. Sinclair,

    You state:

    “APM: I think most orthopedic specialists have a mechanistic POV and know for a fact that P.T./ATC’s do. As someone that works with athletes of all levels, I disagree that minor injuries do not add up to lead to severe problems. I’ve seen it first hand, so the evidence speaks to the contrary.”

    I agree a lot do have an unreal mechanistic POV that is much to reductionistic. That is a related issue which I witnesses first hand. However that does not change what we are talking about here which is the scientific evidence or whether one even has a plausible theory.

    I want to be clear, I do agree that if we go past the capacity of our body to heal adequately between injuries then they add up to a serious injury and sports is a place that can happen.

    In fact that is exactly what happened to me.

    (BTW I did get chiropractic, physical therapy, physiatry and orthopaedic care for my back injury).

    Also, I can assure you that I did read scientific research articles a couple years back looking at hundreds of twins over many years that examined the relationship of minor back injuries to a major episode and there was no evidence of them adding up to cause a major injury.

    This just makes my case.

    We are biological organisms not watches or washing machines. Even if we where a like a watch or washing machine then any mechanical engineer will tell you that systems are build to tolerances and work within tolerances. Tolerances are ranges not points. Any machine that was build to real point tolerances — if that is even physically possible — would not make it to a customer. The reason should be obvious. It would be so sensitive to the most microscopic disturbances that the system would fall apart. Image getting a Lexus and a gust of wind would cause the doors, wheels and drive train to fall apart.

    Maybe all this visceral disease talk it just a matter of being more profound than what’s real.

    Having one foot in the realm of a doctor that deals with painful necks, backs and other muscle/joint injuries and the other foot in the realm of the fitness industry providing wellness visits isn’t “profound” enough.

    In my opinion, that’s what the public (i.e, the market) see chiropractors as mostly anyway. The other “cures everything” approach probably turns more people “off” than it does “on.”

    So it’s more Adam Smith’s “invisible hand” has made the decision for you than the science or lack of it.

  27. APM says:

    Paul you wrote:

    “… not that it is a valueless concept in general (that’s a different debate). There’s no evidence that treating for “subluxations” has any effect, either on pathologies or as a health tonic.”

    I don’t know how much health benefit it has when people don’t have pain, stiffness, etc. People go for the simple reason that they “like” it. It’s similar to the fitness, message, spa and cosmetic industries.

  28. trrll says:

    “The impact of the autonomic nervous system on visceral organs is mostly for “fine tuning.” The major effects come from the endocrine system. ”

    Not to defend subluxation theory, but this is a gross overstatement. The autonomic nervous system controls heart rate, blood pressure, glandular secretion. Lack of autonomic function is bad enough. There is a good reason why ganglionic blockers are not used much in medicine any more–the side effects are too severe. Without autonomic function, you are in danger of passing out any time you try to stand up. And autonomic dysregulation is even worse–look up “familial dysautonomia.”

  29. APM says:

    Hi trrll,

    OK my bad. I got that on this blog somewhere and it was posted by a chiropractor.

    In any case, aren’t you also saying that the disruption has to be big enough to make a significant impact? If so then again that still makes my case that our body have capacities and tolerances to dysfunctions, injuries or perturbations than the various machine models.

    On the other hand, if the autonomic nervous system is sensitive like some chiropractors think … then I may need to make an appointment.

  30. APM says:

    Ignore the last post … bit of a rush.
    ——————————–
    Hi trrll,

    OK my bad. I got that on this blog somewhere and it was posted by a chiropractor.

    In any case, aren’t you also saying that the disruption has to be big enough to make a significant impact?

    If so then that makes my case.

    Our bodies have capacities and tolerances to dysfunctions, injuries or perturbations much larger than the various machine models suggest.

    On the other hand, if the autonomic nervous system is sensitive like some chiropractors think … then I may need to make an appointment.

    [I'll leave it for you folks to battle this autonomic system stuff out.]

  31. Joe says:

    Back to the death of the chiropractic subluxation in the UK. I am not sure what the General Chiropractic Council’s role is in this. They seem to just maintain a log of who qualifies for the title. Their nonchalant reply that it is not scientifically supported apparently leaves their members free to provide quackery as usual, and to keep it alive as a notion.

  32. If the autonomic nervous system is sensitive like a majority of chiropractors think, then anyone with scoliosis, stenosis, radiculopathy from any cause, etc, should pretty much be crippled by an array of autonomic malfunctions. There is no such effect. I have known many hale and hearty souls with spinal nerve roots that were surely greatly impinged by the standards set by many chiropractors. Many didn’t even suffer from back pain, let alone illness!

    This logical inconsistency has always been one of the most blatant problems with the subluxation hypothesis. If subtle impingements exist and have biologically interesting effects, then significant ones should be REALLY interesting. But they aren’t: they just make your nerve roots twinge. Sometimes.

  33. “Why arent others seeing these effects and reporting them? I cant answer for them but I could certainly see why one would want to keep their mouth shut for fear of being ostracized. This same thing happened back during the civil rights movement for fear of being labeled a (insert offensive “N” word here) lover.”

    Now, I sense a Hitler analogy coming…

    Yes, a serendipitous medical observation is a great place to begin a line of health-related scientific inquiry. You might get ostracized. But if you are correct, the evidence will eventually bear you out.

    The key word there is “begin.”

  34. APM says:

    Paul, let me get this straight. You are saying that some chiropractors promote subtle impingements that don’t even make it to the level of producing any symptoms?

    “If subtle impingements exist and have biologically interesting effects, then significant ones should be REALLY interesting.”

    Absurd is a better word than interesting. This can’t be what’s being said, that’s like claiming we were born dead.

    What creature could survive evolutionary pressures of a harsh environment if just the subtle effects of leaning up against a tree or sleeping wrong around a fire would trigger a self-destruct mechanism to the organs from the very thing meant to protect the organs. The armor of our bodies.

    It’s like having a Lexus with the end of the exhaust pipe placed inside the car and windows don’t roll down.

    It’s got to be real pinched nerves that people feel, etc.

  35. wertys says:

    @drsinclair

    I had a patient who had significant back pain which I was unable to help to any great degree. She had a fall down a step while dropping her grand-daughter at child care, and tells me that she has barely had any pain since.

    Contrary to DD Palmer’s approach, I did not found a healthcare system based on dropping people off steps.

  36. In an otherwise good posting, you criticize the definition of evidence based medicine (EBM) that incorporates individual patient preferences and physician experience because “This effectively allows “in my experience” and “the patient likes it” to be considered along with evidence, effectively negating the whole point of evidence-based medicine.”

    While it is indeed true that this definition of EBM allows for some abuse, you can’t really define EBM without considering patient preferences. Consider a drug that has a side effect of male sterility. I know some men, who would sacrifice one of their limbs before they would consider giving up their ability to father children. For others, such as a man with a vasectomy, such a side effect would be totally irrelevant. And for yet other men, the side effect would be perceived as a bonus.

    Ignoring patient preferences creates a “one size fits all” medicine and destroys much of the progress on individualized medicine.

    Allowing physician experience to enter the equation is also tricky. Physicians should not be so arrogant as to believe that their personal knowledge and experience can trump any amount of evidence. But you cannot afford to totally ignore physician experience, as that creates cookbook medicine.

    Steve Simon

  37. Harriet Hall says:

    Stephen Simon says “you can’t really define EBM without considering patient preferences.”

    I disagree. Evidence-based or science-based medicine provides the knowledge. Applying that knowledge to the individual patient is the stage where patient preference comes into play. Good clinicians always consider the preferences of the individual patient, and their clinical experience is clearly important to the process of applying the knowledge from SBM to the care of the individual patient.

  38. APM says:

    Stephen Simon you are right and there is more to it besides. I think that science-based-medicine (sbm) and evidence-based-medicine (ebm) are different.

    The way I understand SBM is that RCT’s are required first before clinical applications. This is both unrealistic and is meant to serve the agenda of academics and researchers seeking grant money. The stance can also be used to attack opponents. A scientist friend said there are many flaws/problems with this approach that aren’t being discussed on blogs like this one but are talked about among researchers. Buyer beware. It’s a very unworkable position, goes against innovation, entrepreneurship and free-markets.

    The way I understand EBM is that scientific evidence requirements are less stringent. This means that large RCT’s are not needed at first. Instead, a plausible mechanism and supporting data from the real world is required. More errors *maybe* involved but it could actually be just the opposite! At the same time more innovation can happen without the burden of going first to RCT’s.

    Wholly academic concerns like SBM are not held in the highest regard outside the university community. At a business conference I’ve heard an academic described as someone not satisfied with something working well in practice until they have tried it out in theory. Also, a theorist was described as someone willing to assume anything except responsibility. There is a lot of truth to this despite rhetoric to the contrary. I think blogs like this are representative of this unrealistic position.

    Ultimately, I think the invisible hand of the free markets is a better guide to what works and what doesn’t especially when scientific data is sparse or poor quality.

    1. Harriet Hall says:

      APM,
      You’ve got it wrong. SBM does not require RCTs. RCTs are the gold standard but they are not always feasible, and then we accept lesser standards of evidence. But we always look for the best available evidence, and SBM pays more attention to plausibility than EBM does. The free market is a good guide to what people want, but not to what really works. People can fool themselves, and the scientific method is the only corrective.

  39. twaza says:

    Harriet

    Your brief post has certainly provoked quite a discussion. I want to comment on the comments, not the post itself.

    I can’t see much point in distinguishing between spinal manipulation done by chiropractors of any sect, osteopaths, or physical therapists (unless the issue is the different placebo effects these approaches might have).

    Similarly, I can’t see the point in distinguishing between SBM and EBM, when the pertinent issue is what works and what is bogus.

    Here is a quote from David Sackett, one of the founders of the EBM/SBM movement that might throw some light what “best available evidence” and “clinical expertise” ought to mean.

    “The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. ”

    “By individual clinical expertise we mean the proficiency and judgment that we individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care.”

    “By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.”

    http://www.ncbi.nlm.nih.gov/pubmed/9190027

    The problem with the phrase “clinical expertise” is, as you explained, that it can be used to trump the evidence, “effectively negating the whole point of evidence-based medicine”. The GCC “Code of Practice and Standard of Proficiency” conveniently does not explain what they mean by “expertise”.

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