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Integrative Medicine’s Collateral Damage

Integrative medicine combines the practice of medicine with alternative medicine. Proponents tend to take a paragraph or two to say this, but that is what remains when boiled down to its essence. By putting this more concise definition together with Tim Minchin’s often-quoted observation about alternative medicine, you get: integrative medicine is the practice of medicine combined with medicine that either has not been proved to work or proved not to work. If it is proved to work, it is medicine.

I couldn’t find an official start date for integrative medicine, but it seems to have been around for about 15-20 years. (Osher Center for Integrative Medicine at the University of California, San Francisco, an early adapter, opened in 1997.) Yet despite some lofty pronouncements about transforming patient care, there is still no good evidence that integrative medicine improves patient outcomes. It seems unlikely that such evidence is forthcoming. It is illogical to assume that adding therapies that do not work, or are proven not to work, would benefit a patient except by inducing the ethically problematic placebo response.

Whatever its goals initially, integrative medicine now appears to serve two purposes. First, it attracts funding from wealthy patrons (Samueli, Bravewell) and the government (the military, NCCAM). Second, it is a marketing device used by hospitals, academic medical centers and individual practitioners. As an added bonus, alternative medicine is usually fee-for-service because very little of it is covered by insurance. And whatever its charms as a money-making device, given the lack of proven health benefit it is fair to ask: is integrative medicine worth it? To answer that question, let us look at what might be called the supply side of integrative medicine practitioners’ delivery of alternative medicine. Here we run into some unpleasant facts proponents seem unwilling to acknowledge: integrative medicine’s collateral damage. (more…)

Posted in: Acupuncture, Chiropractic, Energy Medicine, Herbs & Supplements, Homeopathy, Medical Academia, Medical Ethics, Naturopathy, Traditional Chinese Medicine, Vaccines

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Chiropractic Education for Primary Care

Chiropractors would like to reinvent themselves as family doctors. I’ve written about that before and Jann Bellamy has written about it here, here, here, and here. A new study in The Journal of Chiropractic Education alleges that the National University of Health Sciences is nearing its institutional goal of training chiropractic students as primary care practitioners. The data they collected don’t even begin to support that assertion. The study is not only meaningless, it demonstrates a gross misunderstanding of the education required to practice competent primary care. (more…)

Posted in: Chiropractic

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Pump it up: osteopathic manipulation and influenza

First, my bias. I work in Portland and we have medical students, residents, and faculty who are DOs (Doctor of Osteopathy). Before he moved on to be a hospitalist my primary physician was a DO. From my experience there is no difference between an MD and a DO. In my world they are interchangeable. There are many more qualified applicants for medical education than positions in MD programs and some opt for a DO education. Osteopathy has a dark side.
As best I can determine from my colleagues, learning osteopathic manipulation (OM) is the price they pay to obtain an otherwise standard medical education. I have yet to see OM offered by any of my DO colleagues. It may be they know better than to offer such a modality around me given my ranty propensity for all things SCAM.

The literature would suggest that OM is left behind by most DOs upon graduation. DOs are not proud of their OM, and rarely invite them ‘round to dinner. It will be interesting to see if OM fades over time in DO school as the old time true believers die off and are supplanted by a generation of DOs trained with more traditional medical education.

OM, the small pseudoscientific aspect of DO medical school education, is a form of massage and manipulation invented in the 19th century with no basis in reality. OM postulates

the existence of a myofascial continuity – a tissue layer that interlinks all parts of the body. By manipulating the bones and muscles of a patient a practitioner is supposed to be able to diagnose and treat and variety of systemic human ailments.

Studies into the efficacy of OM find it to be ineffective for any process aside from low back pain (is there anything that does not help low back pain?), not surprising for a therapeutic intervention detached from reality. My purpose with this entry is not to review OM per se, which may be a good topic someday, but to focus on a specific application of OM. (more…)

Posted in: Chiropractic, Clinical Trials, History, Science and Medicine

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Chiropractor Breaks Baby’s Neck – A Risk vs Benefit Analysis

It is unfortunately that individual dramatic cases are often required to garner public and regulatory attention toward a clear problem. The Australian press is reporting:

Melbourne paediatrician Chris Pappas cared for a four-month-old baby last year after one of her vertebrae was fractured during a chiropractic treatment for torticollis – an abnormal neck position that is usually harmless. He said the infant was lucky to make a full recovery.

Medicine is a game of risk vs benefit – everything we do, or don’t do, should be evaluated on the potential benefit vs the potential risk, using the best available evidence and scientific rationale. This case is important, not because it is a case of harm, which can happen with any intervention, but because it highlights the risk vs benefit question. Are there any indications for chiropractic care of children, for neck manipulation at any age, and what are the risks?

For an overview of chiropractic see my prior summaries here and here. Overall the evidence suggests some benefit for manipulative therapy for acute uncomplicated lower back strain, but probably no better than physical therapy or even minimal intervention. The risks of chiropractic are not sufficiently studied, and other indications have not been established by adequate evidence. (more…)

Posted in: Chiropractic

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CAM Docket: Functional Endocrinology Update

Sometimes the media gets it right.

From time to time, SBM has reported on the disheartening credulity of reporters when they cover so-called “alternative” medicine. Denver’s Channel 7, an ABC affiliate, is a happy exception to the rule. Reporter Theresa Marchetta first broke the story of Brandon and Heather Credeur, chiropractors practicing “Functional Endocrinology.” And for three years Marchetta, with the assistance of reporter Phil Tenser, followed up, interviewing hundreds of patients who lost thousands of dollars paid to the Functional Endocrinology Center of Colorado for treatment of their diabetes and other endocrine disorders. They’ve reported regularly as the Credeurs legal travails progressed through various judicial and administrative forums. Channel 7 and its reporters deserve substantial credit for pursing this story. The Credeurs might have escaped further censure without their persistence.

Another recurring frustration at SBM is medicine’s embrace of alternative medicine, expressed repeatedly at SBM in posts on quackademic medicine and the branding device known as integrative medicine. We’ve also lamented the seeming complicity of the state medical societies in allowing quackery to be legalized in the form of complementary and alternative medicine provider practice acts.

But sometimes medicine gets it right.

The Colorado Medical Board has somewhat redeemed itself in ordering Brandon and Health Credeur to cease and desist the unlicensed practice of medicine. That’s right. A medical board has finally put its collective foot down and pushed back against chiropractic’s increasingly aggressive push to practice medicine.

And sometimes SBM appears to be making inroads into the hostile incursion of alternative medicine.

I recently discovered that if you google “functional endocrinology”, first up on the list is CAM Docket: Functional Endocrinology, the very post updated today. Admittedly, it appears at the head of a depressingly long list of chiropractic websites advertising the practice, but at least we get a first crack at anyone who might be considering paying thousands of dollars and wasting time, and perhaps their health, on this useless nonsense.

A trifecta in the war on quackery! Revel in this victory, supporters of science-based medicine, for it is small and the victory may be fleeting. Let’s see how the battle is going. (more…)

Posted in: Chiropractic, Health Fraud, Herbs & Supplements

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Quantum Neurology

As the resident neurologist on SBM, my ears always prick up when I come across a new neurology-based scam, and my colleagues often send such items my way. In addition the word “quantum” has become a standard marketing term of alt. med quackery. So how could I resist taking a bite out of “quantum neurology”?

One might think (if one were a completely naïve rube) that those claiming to practice quantum neurology have, through diligent research, discovered how certain quantum principles apply to nervous system function and disease, leading to new treatment modalities. On the other hand, a more savvy consumer of such health claims (such as regular readers of SBM) would likely suspect that quantum neurology will turn out to be the same-old mix of nonsense and snake oil in a shiny new package.

Let’s have a look.

(more…)

Posted in: Chiropractic, Neuroscience/Mental Health

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Chiropractic Vs. Conventional: Dueling Perspectives On Infant Colic…..

Infant colic, while not a deadly disease by any stretch of the imagination, is an extremely troubling entity. Not only can it be quite distressing to caregivers, it is also a well-established risk factor for neglect and abuse of the child. Excessive crying in general, whether diagnosed as infant colic or not, is a frequent impetus for seeking advice from medical professionals. How science-based providers approach the evaluation of babies with excessive crying, and the management of infant colic if diagnosed, can have a powerful impact on how families perceive the health of their child and on future interactions with the healthcare system.

Infant crying is about as bread and butter as it gets in pediatrics. It is a problem which we are constantly exposed to during our training. We discuss it with families in our continuity clinics, where we learn how to truly be primary care providers. We address it on the inpatient wards, where children often cry because of illness or pain, and during our months of service in the newborn nursery. We frequently are called upon to talk anxious parents through it while taking overnight phone calls, and we learn over time with variable success the seemingly preternatural ability to understand what babies are trying to tell us with their cry.

Crying happens for a variety of reasons in young infants, ranging from the benign and expected to the life threatening. Discussing excessive crying, regardless of why it occurs, requires effective communication skills. And the evaluation of unexplained excessive crying often tests the limits of our ability to practice non-defensive medicine, avoiding unnecessary laboratory testing and imaging. Because of all this, I believe that infant crying, and in particular the entity known as infant colic, serves as a useful entry point into a discussion of the differences between a science-based approach to medicine and one based on pseudoscience like chiropractic.

Readers of this blog should be well aware of the push by alternative medical practitioners for recognition as primary care providers, with the chiropractic community leading the charge. In this post I will compare and contrast the common understanding of the etiology and treatment of infant colic held by conventional medical doctors and doctors of chiropractic. You will see that in some ways they do not differ as much as we might expect, but have little in common where it truly matters. (more…)

Posted in: Chiropractic

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CAM practitioners as primary care providers under the Affordable Care Act: Part 2

In the last post, we took another look at Section 2607 of the Affordable Care Act, which prohibits “discrimination” against licensed CAM practitioners by insurers, and how chiropractors are continuing their PR campaign to rebrand themselves as primary care physicians. This time, we review a recent white paper by the Academic Consortium of Complementary and Alternative Healthcare, an organization that might be seen as CAM’s answer to the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM). The Academic Consortium for Complementary and Alternative Health Care (ACCAHC) is a group of “complementary and alternative medicine” educational organizations representing chiropractors, naturopaths, acupuncturists, homeopaths, ayurvedic practitioners, direct entry midwives and massage therapists. The executive director is John Weeks, a relentless promoter of “integrative medicine,” both on the Integrator Blog website and in the Huffington Post. The ACCAHC is dedicated to ensuring that its members and the practitioners they represent are included in all aspects of health care, such insurance reimbursement, financial resources for education and delivery models. ACCAHC’s stock-in-trade is its practitioners’ supposed expertise is being patient-centered, holistic, taking into account the whole person and such, as well as an alleged emphasis on healthy lifestyles, nutrition, well-being, and the like.

In fact, the stated vision of the ACCAHC is remarkably similar to that of the CAHCIM:

ACCAHC envisions a healthcare system that is multidisciplinary and enhances competence, mutual respect and collaboration across all healthcare disciplines. This system will deliver effective care that is patient centered, focused on health creation and healing, and readily accessible to all populations.

The CAHCIC’s vision is:

A comprehensive and compassionate health care system offering seamless integration of effective complementary and conventional approaches to promote healing and health in every individual and community.

Indeed, there is an overlap in governance of the two organizations. Benjamin Kligner, MD, Adam Perlman, MD, Mary Jo Kreitzer, PhD, RN, and Aviad Haramati, PhD, are all on the ACCAHC’s Board of Advisers, as well as being either current or former members of the CAHCIM’s Executive Committee. The Board of Advisers also includes other integrative medicine luminaries such as Brian Berman, MD, Wayne Jonas, MD, and David Katz, MD. The two organizations have worked together in several endeavors. One wonders why the they don’t just go ahead and merge. (Actually, one knows perfectly well why they don’t.)
(more…)

Posted in: Acupuncture, Chiropractic, Legal, Naturopathy, Politics and Regulation, Traditional Chinese Medicine

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Chiropractic Practice Building: A Doctor’s Confession and the Report of Findings

“I’ve got to get this off my chest!”

Dear chiropractic practitioner,

Confessions are tough…Real tough. They are painful, awful things. But, sometimes a confession can set the record straight, and I want to give credit where credit is due. Before I talk about my confession though, let me say a few other things first. You may want to sit down.

You know, when I meet people in town they usually say, “Oh, yeah, I know you, you’re Dr. Jones. I’ve seen your posts with that picture of you and the two cute little girls.” Well, I’m the guy on the left. Aren’t they cute? Now do you feel like you can trust me?

Years ago, something happened to me that changed my life forever. And I would love to tell you all about it, but first I need to give you my report of findings.

I’ve correlated the findings of your examination, and I’ve put it into a package that I’m going to review and send home with you, so you’ll know what we found and what we’re going to do to help you. In the next 10 minutes or so I’m going to review what we found, explain what these findings mean, recommend a course of action and discuss the results you can expect in the future. Feel free to ask any questions as we go along.

First a quick review. You’ve come to our website suffering from an inability to recognize your complete lack of effectiveness in the treatment of headaches, ear infections, asthma, or any other condition with the possible exception of acute musculoskeletal pain involving the back. You have difficulty accepting that any treatment you offer which is effective is provided by physical therapists, minus all the ”baggage”, and that nothing you offer which is unique to chiropractic is effective. You are in denial over how the majority of your profession is woefully ignorant of, or exists in a state of denial of, so many of the advancements in modern medicine, like life-saving vaccines, made since chiropractic was invented by D.D. Palmer in 1895.
(more…)

Posted in: Chiropractic

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CAM practitioners as primary care providers under the Affordable Care Act: Part 1

Section 2607 (42 U.S.C. Sec. 300gg-5) of the Affordable Care Act (the “ACA” or “Obamacare”) prevents “discrimination” against any health care provider acting within the scope of his or her state license. The provision, supported by the American Chiropractic Association and other CAM practitioners, was inserted, without a hearing, under the leadership of Sen. Tom Harkin. Sec. 2607 is of concern to advocates of science-based medicine due to the broad scope of practice granted chiropractors, naturopaths, homeopaths, acupuncturists and direct-entry midwives under state law, as well as their over-confident view of themselves and their abilities. As we have previously discussed, for example, both naturopaths and chiropractors fancy themselves as primary care physicians able to differentially diagnose any patient with any disease or condition and, in many cases, treat or “co-manage” these patients.

As might be expected, a brouhaha is brewing over just what Section 2607 means. And there is one attempt to repeal it outright.

In all cases of statutory interpretation, the proper starting point is the statutory language itself.

SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.

(a) PROVIDERS.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary [of Health and Human Services] from establishing varying reimbursement rates based on quality or performance measures.

In short, while broadly prohibiting discrimination, there are two important limitations. This is not an “any willing provider law” requiring an insurance company to contract with any provider agreeing to the insurer’s contract. And insurers can pay different rates to different providers as long as these rates are “based on quality or performance measures.” (more…)

Posted in: Chiropractic, Legal, Politics and Regulation

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