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Causation and Hill’s Criteria

Causation is not so simple to determine as one would think. A mantra at SBM is ‘association is not causation’ and much of the belief in the efficacy of a variety of quack nostrums occurs because improvement occurs after use of a nostrum, therefore improvement occurs because of use of a nostrum. It is why vaccines as a cause of autism are so compelling to some. Vaccines are given at the same time autism starts to manifest. It would require more intellectual power than I have not to conclude, wrongly, that vaccines caused the autism. Concluding causation from sequential events is how the human mind works, and reality, as we know and ignore, constantly conspires to fool us into making false causal connections. In Infectious Diseases I see the error almost daily. The patient had a fever, patient was given antibiotics, fever went away. Therefore the antibiotics treated an infection. Well, maybe, maybe not. One of my mantras is ‘antibiotics are not antipyretics’ and you must be very careful before concluding that the fever went away because of the penacephalone.

I blog and podcast in large part to educate myself. It is amazing how much I learn in the process of preparing for one of the entries in my multimedia medical empire. Areas of knowledge that I had no idea existed can be revealed for exploration. I do not have formal training in epidemiology, although part of my job is hospital epidemiology. Like much of medicine, I acquired what I do know from on-the-job training and lots of reading. So imagine my surprise and delight to discover Hill’s Criteria of Causation, thanks to its application to chiropractic subluxation.

In 1965, Austin Bradford Hill published “The Environment and Disease: Association or Causation?” Dr. Hill, an occupational physician, sought to answer the questions (another discussion of the paper here):

How in the first place do we detect these relationships between sickness, injury and conditions of work? How do we determine what are physical, chemical and psychological hazards of occupation, and in particular those that are rare and not easily recognized?…In other words we see that the event B is associated with the environmental feature A, that, to take a specific example, some form of respiratory illness is associated with a dust in the environment. In what circumstances can we pass from this observed association to a verdict of causation? Upon what basis should be proceed to do so?

He then proceeds to list criteria (he refers to them as viewpoints) that help in determining causation. I like frameworks for thinking about processes. They provide a starting point for considering problems. Becoming a doctor is, in part, internalizing frameworks. Early in training you carry lists and papers that remind you how to evaluate acidosis, or the physiology of heart failure or suspected meningitis. After time and repetition these lists are internalized and you can evaluate the problems without resorting to lists. As an intern one of the papers I carried around was The New England Journal of Medicine article on the physiology of the Swan-Ganz catheter, and I would refer to it with each patient who had a Swan. One day I did not need to refer to the paper. I had internalized the information, and tossed the paper into the trash. Frameworks are not the be all and end all, but do serve as foundation upon which to build ideas. Part of being a specialist is to recognize when the framework doesn’t apply. However, I never had a formal framework for thinking about what constitutes causality in medicine. It is worth reading in the original if no other reason as an appreciation of a time when the medical literature was not dry as dust and devoid of humor and style. Current medical journal writing is often an excellent replacement for Ambien, even when you are fascinated by the topic. To call it the medical ‘literature’ is to refer to the phone book as literature.

The viewpoints to consider in determining if association is due to causation:

1) Strength. How strong is the association between the cause and the effect? Hill uses the example of chimney sweeps, who died of scrotal cancer at rates 400 times the normal population. It killed Bert, or so I was lead to believe. He points out that a strong association like scrotal cancer and chimney sweeps is good evidence in favor of causality from an environmental exposure. He also points to that small effects in a population can still be considered strong associations and uses the death rates from Snows evaluation of the 1855 cholera outbreak, where the death rates from the contaminated water were 17/10,000 vs. 5/10,000 in the general population. Not a huge increase in mortality, but a strong association none the less.

The strength of ‘alternative’ therapies usually hovers around background noise, usually at the level of personal experience. If acupuncture or homeopathy were 400 times superior to placebo, there would no discussion of its validity. Many medical therapies are not 400 times as effective as placebo, but the strength of the association between cause and effect is well above background noise.

2) Consistency. Almost every study should support the association for there to be causation. He uses the example of cigarettes as a cause of lung cancer, “The Advisory Committee to the Surgeon-General of the United States Public Health Service found the association of smoking with cancer of the lung in 29 retrospective and 7 prospective inquiries.” From the vantage point of 2009, where the carcinogenic effects of cigarettes are well established, this example is amusing, but instructive. Over time, as studies progressed, there was a consistent association between smoking and cancer.

He also warns about the importance of a good control group, the inclusion of which often spells the death of ‘alternative’ therapy efficacy, as the recent studies in acupuncture have demonstrated:

Patients admitted to hospital for operation for peptic ulcer are questioned about recent domestic anxieties or crises that may have precipitated the acute illness. As controls, patients admitted for operation for a simple hernia are similarly quizzed. But, as Heady points out, the two groups may not be in pari materia. If your wife ran off with the lodger last week you still have to take your perforated ulcer to hospital without delay. But with a hernia you might prefer to stay at home for a while‚ to mourn (or celebrate) the event. No number of exact repetitions would remove or necessarily reveal that fallacy.

As readers of this blog are probably aware, there is one consistent result in ‘alternative’ therapies: increasing the quality of the study decreases the efficacy until the best studies show no effect.

3) Specificity. Since diseases can have multiple etiologies and therapies can have multiple effects, this is a weaker criteria. However, given the knowledge of physiology and biochemistry since 1965, we have more sophisticated techniques for measuring and determining specificity. From the perspective of opportunistic infections, with no knowledge of viral pathophysiology, HIV is hardly a specific cause of disease. GIven the ability to measure HIV viral load and an understanding of the consequences of HIV depletion of CD4 cells, HIV has high specificity for causing AIDS.

“In short, if specificity exists we may be able to draw conclusions without hesitation; if it is not apparent, we are not thereby necessarily left sitting irresolutely on the fence.”

As Dr Hall has discussed, many ‘alternative’ medical paradigms completely lack specificity and are the one true cause or treatment of all diseases, be it subluxation, a liver fluke, or colonic toxin build up. Fools all; infections are the one true cause of all disease.

4) Temporality. The order should be exposure, disease, treatment, resolution. Cause should proceed effect.

Does a particular diet lead to disease or do the early stages of the disease lead to those particular dietetic habits? Does a particular occupation or occupational environment promote infection by the tubercle bacillus or are the men and women who select that kind of work more liable to contract tuberculosis whatever the environment‚ or, indeed, have they already contracted it? This temporal problem may not arise often, but it certainly needs to be remembered

5) Biological gradient. Also known as dose-response. A little exposure should result in a little effect, a large exposure should cause a large effect. Certainly well known to anyone who drinks alcohol; I suppose all homeopaths must be teetotallers.

The comparison would be weakened, though not necessarily destroyed, if it depended upon, say, a much heavier death rate in light smokers and a lower rate in heavier smokers. We should then need to envisage some much more complex relationship to satisfy the cause and effect hypothesis. The clear dose-response curve admits of a simple explanation and obviously puts the case in a clearer light.

Most ‘alternative’ therapies are binary and have no gradient of effect. I suppose that a chiropractor could say your spine is partly unsubluxed as a result of half a spinal manipulation or an acupuncturist saying, your chi is partly unblocked as I used too few needles. I suppose. I assume a reader will comment on the validity of this observation.

6) Plausibility. The effect must have biologic plausibility. I would take it a slightly differently: not only should it be biologically plausible, but should not violate well known laws of the universe. Hill points out “but this is a feature I am convinced we cannot demand. What is biologically plausible depends upon the biological knowledge of the day.”

Yet there is a difference between what is not yet known but possible — for example Helicobacter as a cause of gastric ulcers, which is odd but not impossible — and what almost certainly will never known because it cannot exist without a radical rewrite of all of science: meridians or water memory, which are odd and impossible. I know that there are more things in heaven and earth than are dreamt of in my philosophy. But you have to prove it to me.

In short, the association we observe may be one new to science or medicine and we must not dismiss it too light-heartedly as just too odd. As Sherlock Holmes advised Dr. Watson, “when you have eliminated the impossible, whatever remains, however improbable, must be the truth.” A nice quote, but not necessarily the case. Sometimes what remains is, however improbable, still nonsense. Which leads to:

7) Coherence. “On the other hand the cause-and-effect interpretation of our data should not seriously conflict with the generally known facts of the natural history and biology of the disease.”

I have discussed in prior entries that those who call themselves ‘holistic’ rarely are and a good physician understands a disease from the microscopic to the entire world. I know cholera, for example, from the level of the effect of the toxin on cellular receptors to the world wide changes in potable water that lead to the spread of disease and much in between. There is a coherence of understanding of the disease.

In a wider field John Snow‚ epidemiological observations on the conveyance of cholera by water from the Broad Street Pump would have been put almost beyond dispute if Robert Koch had been then around to isolate the vibrio from the baby nappies, the well itself and the gentleman in delicate health from Brighton. Yet the fact that Koch‚ work was to be awaited another thirty years did not really weaken the epidemiological case though it made it more difficult to establish against the criticisms of the day.

Ignoring most anatomy or physiology or other biologic understanding, most ‘alternative’ therapies have no coherence when placed in the context of the known universe. Homeopathy is, above all, totally incoherent.

8) Experiment. Always nice. Written in 1965, before the massive increase in biomedical research funding, experiments were not as vital in understanding diseases and treatments as they are today.

Unfortunately for most ‘alternative’ medicine, experiments rarely support their theory or efficacy. Not that it ever matters to the practitioners. I think about how my practice has changed over the last 25 years: adding, subtracting and modifying what I do as the data comes in. Consider the 44,000 articles in Pubmed in infectious disease that are published last year. I wonder how much chiropractic (233 articles on 2009) or acupuncture (1000 articles in 2009) or naturopathy (19 articles in 2009) or homeopathy (162 articles in 2009) practice changed as a result of published studies. It cannot be all that hard to keep up and, so, change accordingly.

9) Analogy. If one virus, for example, can cause a disease, then it is reasonable to suggest that a second virus could be responsible for a similar disease. Analogy is not the same as metaphor: both are the preferred methods of understanding ‘alternative’ therapies, but with little comparison to objective reality. He clearly states these are guidelines, and not to be followed blindly.

What I do not believe‚ and this has been suggested, that we can usefully lay down some hard-and-fast rules of evidence that must be obeyed before we can accept cause and effect. None of my nine viewpoints can bring indisputable evidence for or against the cause-and-effect hypothesis and none can be required as a sine qua non. What they can do, with greater or less strength, is to help us to make up our minds on the fundamental question, is there any other way of explaining the set of facts before us, is there any other answer equally, or more, likely than cause and effect?

The importance of considering all the data, the preponderance of information, in deciding cause and effect.

Hill is also not enthusiastic about statistics, the dreaded p-value:

No formal tests of significance can answer those questions. Such tests can, and should, remind us of the effects that the play of chance can create, and they will instruct us in the likely magnitude of those effects. Beyond that they contribute nothing to the, proof‚ of our hypothesis … Between the two world wars there was a strong case for emphasizing to the clinician and other research workers the importance of not overlooking the effects of the play of chance upon their data. Perhaps too often generalities were based upon two men and a laboratory dog while the treatment of choice was deducted from a difference between two bedfuls of patients and might easily have no true meaning. It was therefore a useful corrective for statisticians to stress, and to teach the needs for, tests of significance merely to serve as guides to caution before drawing a conclusion, before inflating the particular to the general… Yet there are innumerable situations in which (tests of significance) are totally unnecessary‚ because the difference is grotesquely obvious, because it is negligible, or because, whether it be formally significant or not, it is too small to be of any practical importance… What is worse the glitter of the t table diverts attention from the inadequacies of the fare.

Statistically significant nonsense is still nonsense. The article puts into perspective the ongoing problem of the meta-analysis. I always say that the meta-analysis is good for a general understanding of an intervention but rarely provides definitive answers. When meta-analyses are compared to subsequent randomized controlled trials, the meta-analyses got it wrong 35% of the time. As a result, I think meta-analyses are great if they support your prior beliefs and can be safely ignored if they contradict them. That is the problem with meta-analyses, they are good at the mathematics/statistics of multiple studies but fail to take into consideration the other viewpoints as enumerated by Dr. Hill. Far be it from me to suggest that the Cochrane reviews may be wanting as they are often considered the be all end all of analysis, but their reviews in the few areas I know a little about always leave me unsatisfied.

Dr Hill ends with a discussion on the importance of then using the information of when association merges into causation and to consider at what point we need to act on the information. Stopping a nausea medication because it may cause birth defects has a different impact than stopping the burning of fuels in the home as cause of lung disease. In the end we have to act on our information, even if it is always incomplete.

All scientific work is incomplete, whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand at a given time.

Who knows, asked Robert Browning, but the world may end tonight? True, but on available evidence most of us make ready to commute on 8:30 the next day.

8:30. It was a more leisurely era.

The explicit application of Hill’s criteria is uncommon, at least if ‘Hill’s criteria’ is used as search criteria on Pubmed. There are areas on medicine that are not clearcut as to causality. Do some therapies work? And if so, in what populations? Is X the cause of disease Y?

Recently, Hill’s Criteria were applied to chiropractic subluxation, and subluxation was found wanting. In Chiropractic theory, spinal subluxation is considered to be the cause of nearly all disease. As readers of this blog know, subluxation was made up by DD Palmer and

The Association of Chiropractic Colleges paradigm statement (ACC Paradigm) suggested that, chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. It also defined a subluxation as “a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.

Subluxation is the basis of the practice of chiropractic. It there is no subluxation, the raison d’etre for chiropractic disappears with a pop or perhaps a crack.

So when Timothy A Mirtz et. al searched the literature looking for support for the most fundamental support for the practice of chiropractic and came up with bupkis, well, imagine if the literature search for germs as a cause of infection or atherosclerosis as a cause of heart attack and found nothing. Zip. Nil. Nada. Diddley squat.

What would happen to Infectious Diseases or Cardiology? I would hope they would disappear as specialty. If there is no basis for the practice, it should be abandoned. Right?

What is the support for subluxation, using Hills ever so helpful viewpoints? I will summarize with the table from article

hills and sublux

As the conclusion states,

There is a significant lack of evidence in the literature to fulfill Hill’s criteria of causation as regards chiropractic subluxation. No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability.

So why continue with chiropractic, at least based on the treatment of subluxation? Got me. And pay for it with tax dollars or insurance premiums? If chiropractic is based entirely on nothing substantial, then nothing is what should reasonably be paid.

One wonders about other alternative therapies: homeopathy, acupuncture, various energy therapies etc. Even if a meta-analysis demonstrated marginal statistical benefit, when Hills viewpoints are considered, I doubt any would hold up.

Posted in: Science and Medicine

Leave a Comment (63) ↓

63 thoughts on “Causation and Hill’s Criteria

  1. windriven says:

    “There is a significant lack of evidence in the literature to fulfill Hill’s criteria of causation as regards chiropractic subluxation. No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention.”

    Hah. That just goes to show what bunk all this science nonsense is. My aunt Mary had a goiter the size of a pelican and she went to this chiropractor and he superluxed her subluxation and now she can play Chopin an a kazoo. So there.

  2. windriven says:

    I couldn’t get Dr. Crislip’s link to the original to work.

    It is however also available (and free!) here:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1898525/pdf/procrsmed00196-0010.pdf

  3. Deetee says:

    Nice overview Mark. Definitely one I must use myself.

    “imagine if the literature search for germs as a cause of infection or atherosclerosis as a cause of heart attack and found nothing.”

    I skimmed that too fast, and read it as “germs as a cause of infection or atherosclerosis/heart attack”.
    But I know you know about such things too, being such a good ID doc!
    ;)

    [PS. sp is "consistent" (not "consistant")]

  4. nitpicking says:

    Drs. Crislip and Novella share several attributes, including great writing skill, deep medical knowledge, and terrible spelling. I don’t see the value of correcting spelling errors in a blog entry, especially since when I did once Dr. Gorski was infuriated.

    Dr. Crislip: According to this AP story, Norway has solved the problem of MRSA by simply reducing antibiotic prescription rates. This seems to fall squarely into your specialty–is it worth turning your skeptical eye on it for a future entry?

  5. Harriet Hall says:

    Thanks, Mark, for an excellent article.
    This will serve as a permanent reference. Now when I encounter someone who confuses correlation with causation I can send him here instead of trying to explain it myself.

  6. nitpicking says:

    OK, the link above is totally irrelevant unless you have a Chinese-only copy of the movie Zu: Warriors of the Magic Mountain. Here is the AP story:

    http://www.examiner.com/x-11270-Hartford-Wellness-Examiner~y2010m1d1-Norway-the-most-infection-free-country-in-the-world

  7. Mark Crislip says:

    I run the damn things through TWO spell checkers. Mac and WordPress.

    I am always happy to have my nits picked; makes for a better post, but perhaps and email rather than clutter the comments with my multitudinous spelling and grammar mistakes.

    Hippy Newb Beer to everyone

  8. windriven says:

    @ nitpicking

    This from the article you link:

    “Because Norwegian doctors prescribe fewer antibotics than anywhere else in the world, their patients “do not have a chance to develop resistance to them.”

    I don’t have to be a pus whisperer to know that patients don’t develop resistance to antibiotics – bacteria develop resistance.

  9. Mark Crislip says:

    The decrease in antibiotics use and prescriptions will decrease some resistance in the environment, but not all.

  10. nitpicking says:

    Mark,

    As I wrote, I thought that maybe you’d like to turn your caustic pen (or cursor) upon the AP and the reporting in this article. Just a thought, of course.

  11. Very nice account, but of course it isn’t just alternative medicine that suffers from poor evidence about causality.

    The best example seems to me to be the question of diet and health. There have been few randomised trials, and those that have been done usually show that diet is less important than we are told (yes, I know there are compliance problems). Almost all of the edifice of advice about diet rests on observational epidemiology with remarkably poor evidence for causility. This is a topic that I’ve taken an interest in recently. For example the evidence for causality in the rather weak association between processed meat intake and colorectal cancer is almost non-existent.

    I’d be interested to know what other people think about Gary Taubes’ book, the Diet Delusion (or, in the USA, Good Calories, Bad Calories), which I reviewed recently for the BMJ. It seems to me to be a fascinating unpicking of delusional thinking in conventional medicine (as opposed to the largely fraudulent supplements industry). Incidentally, Taubes analysis of the crucial importance of causality in the New York Times, “Do we know what makes us healthy?“, is quite brilliant in my opinion.

  12. Scottynuke says:

    Unlike the handy subway-friendly tabloids the Examiner fills with wire service articles and prints in several cities, its Web site is much more in the “citizen journalist” (read: untrained and usually self-published) tradition.

    The item nitpicking links to is not an AP piece, it’s much closer to an opinion piece. There are several red flags:

    1) Ms. Duel fails to cite any specific WHO document to support her claim about Norway

    2) She fails to clearly identify the “six month investigation conducted by the Associated Press”

    2) She fails to note why Dr. John Birger Haug is worth quoting — no position, no medical facility affiliation

    3) She fails to note any differences between Norwegian and U.S. procedures for dealing with MRSA.

    And a screamingly large red flag is found by clicking on Ms. Duel’s “bio” link:

    “Diana has led a monthly “psychic circle” since 1988, devoted to helping its members contact their higher selves and promote wellness in mind, body and spirit through meditation, as well as metaphysical study and practice.”

    I would tend to say Ms. Duel is not in a position to make the claims she does.

  13. Galadriel says:

    You know, most skeptical-type arguments I see against what they call “woo” tend to assume that these treatments are being pursued by people who are stupid, credulous, and simply have lots of excess money. The scorn is palpable.

    You know, a lot of people who seek chiropractic or acupuncture treatment are people who’ve been treated as fully as possible by a doctor, and eventually the doctor(s) involved simply say, “There’s nothing more we can do for you.” What does one do then, when one has intractable pain and the M.D.’s have nothing to offer?

    I note also that if one searches this very site for chiropractic (http://www.sciencebasedmedicine.org/?cat=4), one finds an article POSTED by a chiropractor; apparently this article and poster were valid enough to pass muster. But every other article seems to vilify /all/ practice of chiropractic as fraud.

    I’m quite enthusiastic about pursuing medicine as far as medicine can help a person. I think it should be the first thing anyone considers. But I also think that it’s a bit harsh to be so scornful of anyone who tries “alternative medicine” if a doctor simply can’t help–and I also think that it’s a bit hypocritical of the posters (or possibly the editors, for not saying anything) on this site to openly abominate all chiropractic, when you’ve got a poster who IS a chiropractor.

  14. zen_arcade says:

    Galadriel – You are confusing contempt for bad ideas with contempt for people who hold bad ideas. Charlatans who are clearly deceiving people to rob them of their money deserve our contempt. Earnestly ignorant, credulous people who make poor decisions without much thought deserve our pity. I can’t make out what exactly you are arguing in favor of other than “Hey, gee, guys, can’t be all just get along?”

    If some of the SBM writers seem upset or aggressive it might be because these matters are of crucial importance: cranks offering cancer “cures”, anti-vaccine loons distorting experimental evidence, homeopaths denying the elementary laws of chemistry and physics, etc. translates into preventable harm and suffering in the world. Should we not be angry about that? Should we just agree that all opinions are valid and equal even though one side has all of the evidence and reasoning on its side and the other just has shrill insistence, fear-mongering, and conspiracy theorizing? Does evidence and logic matter or not?

    You linked to an index of all SBM posts related to chiropractic. Which article were you referring to?

  15. Galadriel says:

    This poster is a chiropractor, with two posts made:
    http://www.sciencebasedmedicine.org/?author=1430

    The editor’s note one one of his articles says, “Samuel Homola, D.C., a retired chiropractor who limited his practice to science-based methods and spoke out against the irrational and abusive practices of his colleagues.” So apparently *somebody* here thinks that chiropractors can use “science-based methods” and aren’t all “woo.”

    My point was not “can’t we all just get along?” but rather “what does one do when science-based medicine has failed?”

    If a person has exhausted science-based medical treatment for their problems, what should they do? Just give up and suffer? So many people I know with chronic pain problem have reached a point where the doctors/specialists eventually say, “there’s nothing else we can do for you.” What does one do then? Even when one is skeptical, one has doubts that methods unproven by science can help, one knows that established science certainly can’t.

  16. windriven says:

    Galadriel

    So you are suggesting that when medicine is bereft of answers it is appropriate to summon the tooth fairy? One might understand a frightened patient or family member grasping at illusory straws. But this blog is about science based medicine not about providing moral support to the hopeless. Will their outcome be somehow improved by medical professionals claiming to believe in subluxations?

    And speaking of straws, your argument about dire situations where medicine ‘has nothing to offer’ is something of a straw man. There are certainly a few cases where that may be the case. But the quack industry does not thrive on the misfortune of these few alone. Chiropractors, naturopaths, acupuncturists and other purveyors of woo and nonsense prey on a much larger subset of humanity.

  17. Harriet Hall says:

    I don’t have any problem with desperate patients grasping at even the most improbable straws as long as they can give informed consent. My problem is with health care providers who make claims for those treatments that go beyond the evidence.

    “This treatment is not supported by any good scientific evidence but some patients think it has helped them and it might be worth trying if only for chance of a placebo response.” is OK in my book.
    “This treatment will correct your subluxation/flow of qi/whatever and cure you” is not.

  18. Galadriel says:

    If there are people who think the tooth fairy is helping them–and science absolutely can not–who are you to tell them they can’t even try? If they’re adults making the decision for themselves, what’s the problem? There may not be science behind it, but can you really say no one should be able to use it?

    Perhaps the industry “doesn’t thrive on” those who can’t be helped in any other way, but everyone I know who’s tried “alternative medicine” in some way has only done so because they couldn’t get relief from science-based medicine. So there are a number out there.

    And again, this very site has a guest poster who is a chiropractor, described as a user of science-based methods, but frequently articles and posters refer to all chiropractic as quackery.

  19. Joe says:

    @Galadriel on 02 Jan 2010 at 1:36 am “If there are people who think the tooth fairy is helping them–and science absolutely can not–who are you to tell them they can’t even try?”

    That is a Straw Man, nobody says they can’t try anything. Desperate people should, however, be informed about quackery they might be driven to try.

    You are mistaken to think that only desperate people go to quacks. There are many people who take their healthy children to chiropractors for regular check-ups and adjustments; which is ridiculous. And, yes, chiro is rotten to the core. See http://www.quackwatch.org and its subsidiary, chirobase. Why does it bother you that there is one chiropractor who has risen above it who posts here?

  20. kill3rTcell says:

    Galadriel – “everyone I know who’s tried “alternative medicine” in some way has only done so because they couldn’t get relief from science-based medicine”

    Your anecdote is not compelling.

    It does not counter windriven’s point that more than the hopeless go to alt med practitioners. Since you consider your own anecdote compelling I shall counter with my own (those of you familiar with logic ignore this part): My mother took me (and herself) to a chiropractor weekly for years to maintain good spinal health despite neither of us having actual back problems (other than regular subluxations), and none of the other ‘patients’ in the waiting rooms showed outward signs of back problems. She also regularly went to (and goes) to a naturopath whenever she seems to be coming down with something.

    The fact of the matter is that people go to Alt Med practitioners even when not struck down with some incurable disease. That nullifies your whole point.

    I did not mind my girlfriend going to an acupuncturist for a year for pain relief because her sinuses required an operation – for that period of time science was not helping her, however the regular, uninformed, patronage of alt med by those with no real illness (as illustrated by the example with my mother) still occurs, and this is exactly what these people are unhappy with, and which you seem to consider nonexistent.

  21. Welcome to the discussion, Galadriel. Here are some answers to your questions:

    “If there are people who think the tooth fairy is helping them–and science absolutely can not–who are you to tell them they can’t even try?”

    Actually, no one’s telling them they can’t.

    “If they’re adults making the decision for themselves, what’s the problem?”

    Some alt-med treatments are “experimental” while many others have been proven to be ineffective but practitioners carry on offering them anyway. Considering the latter case only for the moment, selling such a treatment is obviously ethically wrong. Just because someone will buy false hope doesn’t mean that it should be sold.

    Also, see whatstheharm.net. I’m afraid many therapies labelled as “alternative” are actually quite dangerous, even lethal, especially the experimental cancer cures.

    “… this very site has a guest poster who is a chiropractor, described as a user of science-based methods, but frequently articles and posters refer to all chiropractic as quackery.”

    That’s true, but it’s not actually a contradiction. A profession can be generally characterized by ineffective therapies and anti-scientific beliefs, while individual practitioners oppose it. Evidence-based and science-based medicine are approaches to the difficult problem trying to figure out what “really works,” not exclusive clubs.

  22. Plonit says:

    A profession can be generally characterized by ineffective therapies and anti-scientific beliefs, while individual practitioners oppose it.

    +++++++++++++

    Actually, I’m not completely sure that’s true. Can we imagine a professional homeopath who opposes ineffective therapies and anti-scientific beliefs? Surely they would be an ex-homeopath? And similarly for chiropractic (insofar as we differentiate chiropractic, with its beliefs about subluxations, from other physical therapies).

  23. Sam Homola says:

    I don’t know of anything offered by homeopathy that has a plausible basis, other than a placebo effect. Spinal manipulation, however, as used by science-based chiropractors, has value and plausiblity as opposed to spinal adjustments used by subluxation-based chiropractors. Thus, it’s possible for a science-based chiropractor to oppose subluxation-based chiropractic while recommending use of generic manipulation by science-based chiropractors.

  24. Hey, Plonit. I generally agree with you, but I can’t go quite as far as agreeing that it’s impossible, due to present company if nothing else: myself, Dr. Homola … and, well, dang, not many others! But we are the black swans that prove that black swans exist.

    Professionals sometimes start out in alternative medicine and then discover, along the way, that they disagree with many common beliefs in their profession. For an alt-med practitioner to discover this is not necessarily equivalent with quitting — there’s some tough economics involved.

    Dr. Hall put this extremely well recently: “I have sympathy for the rational chiropractors who are victims of their education and who are trapped in an unfortunate situation. Samuel Homola was one. He couldn’t afford to start over in a new profession, and he managed to separate the wheat from the chaff and help patients who otherwise would have resorted to a less scrupulous chiropractor. I’m in favor of trying to leave people like Sam a means of livelihood.”

    Instead of quitting, some alt-med professionals then go to extraordinary lengths to try to promote the application of EBM within their profession, as Dr. Homola has certainly done (and for which he probably deserves a medal).

    That said, I grant you that some professions are (much) farther out on a limb than others, and it is basically impossible to imagine a skeptical homeopath who would stay in the profession. While a massage therapist or chiropractor can pick and choose from a variety of interventions, a few of which are evidence-based or at least plausible and promising and perfectly acceptable services when offered with appropriate informed consent, a homeopath who doesn’t believe in homeopathy is … a paradox. You cannot “modernize” that profession or it would “promptly vanish in a puff of logic.”

    Skeptics are perpetually proving what decent and actually open-minded folks they are by offering me the flattering benefit of the doubt that massage therapists “aren’t that bad.” Unfortunately, my professional experience in massage therapy has been that there are only a tiny minority of practitioners earnestly keen on EBM — barely enough to even be called a “faction,” really. Collectively, the profession is more or less completely rotten with ignorance of science and overy anti-scientific sentiment.

  25. Plonit says:

    Professionals sometimes start out in alternative medicine and then discover, along the way, that they disagree with many common beliefs in their profession.

    +++++++++++++

    Many common beliefs? Or foundational beliefs? What is the reason for a chiropractor who comes to belief that subluxation is bunk continuing to describe him or herself as a chiropractor?

    The unwillingness to take the financial penalty of retraining or alternatively redescribing one’s practice strikes me as understandable but far from heroic.

  26. Perhaps “heroic” was hyperbolic, and it would have been sufficient to simply say that I deeply respect Dr. Homola’s work, and his book, Inside Chiropractic, was one of the most important steps in my own education as a critical thinker.

    The beliefs I referred to are both incidental and/or foundational. Massage therapists have a lot of non-foundational beliefs. When I was in school, for instance, there was a group of jock-therapists that were angrily critical of the “woo” components of the curriculum. They were angry a lot, as you might imagine. It wasn’t so much that they were skeptics or interested in EBM, though some probably were: they simply weren’t interested in reflexology and therapeutic touch and didn’t think those “skills” would help them become the team therapist for the Canucks.

    I didn’t understand or sympathize with their point, at the time, but I came to eventually … thanks to the example of critical thinkers like Dr. Homola.

    There is quite a lot of variety of belief in massage therapy, and considerable argument within the profession about what massage therapy does and does not include. Does skepticism about reflexology inexorably lead to rejection of ALL massage-esque modalities? Not hardly.

  27. Plonit says:

    The incidental and/or foundational beliefs amongst massage therapists is not particularly relevant to the foundational beliefs of chiropractic.

    That’s the issue – can a chiropractor renounce sublux and still remain a chiropractor in any meaningful sense of the term?

    If a homeopathist renounces the principle of dilution, are they still a homeopathist? Or have they become some variety of herbalist?

  28. You’ve argued me into the ground, Plonit! Uncle! I tap out! Agreed, massage therapy is quite a different case, and I (still) have no significant objection to your main point.

    That same point was made and discussed extensively and recently in Dr. Hall’s post, The End of Chiropractic. Dr. Hall effectively argued that, without subluxation, chiropractic has “no justifiable place in modern medical care except as competitors of physical therapists in providing treatment of certain musculoskeletal conditions.” Dr. Homola, myself and many other skeptics all agreed on the substance of this in the extensive comments, as we duked it out with some chiro trolls. Unless I missed you, I’m surprised you weren’t there! Check it out: hours of fun for the whole family.

  29. Lawrence C. says:

    Excellent post and summary of the topics presented, although it can’t quite quash George Carlin’s observation: “Death is caused by swallowing small amounts of saliva over a long period of time.”

    So I’m off to my recycled-fiber-board-certified ayurvedihomeochiromultimodalitist for a 100% recycled post-consumer, waste-recovered, copper-banded Drool Diverter to prevent death and live forever! (And by also going for some accuvitalized rectal-palatal hydrotherapy I won’t have to get any of those Big Floss vaccines, brush my teeth or wash in anything but triple-filtered homeopathic Ohgoshittasteslikesucrose(tm), otherwise known as the Waters of Life made by Moiron-Walletdrainer PLC.)

    Life is so much simpler when one knows the True Cause. :-)

  30. Mark Crislip says:

    Smoking: stupid.
    Smokers: not.

    Driving without seatbelt: stupid
    Driver: not.

    Unprotected sex with a stranger: stupid.
    The person having sex: not.

    Having 14 affairs while your swedish wife is having your kids: stupid.
    Oops. Example fail.

    Alternative medicine, well, you get the picture.

    We all do stupid things, that does not make us stupid. And for those times, there is mastercard

  31. wales says:

    Dr. Crislip says “The explicit application of Hill’s criteria is uncommon” It appears that there are good reasons for this 1) Hill’s “criteria” were never intended to be criteria (even by Hill) and 2) Hill’s “criteria” applied as a checklist is a simplification of the complex process of causal inference. As stated in the 2004 Phillips/Goodman paper to which Dr. Crislip linked, one should use caution when applying Hill’s “criteria” as a checklist for causality:

    “Despite widely distributed and clearly elaborated advice to the contrary, Hill’s nine considerations are still frequently taught to students of epidemiology and referred to in the literature as “causal criteria.”

    “Hill never used the term “criteria” and he explicitly stated that he did not believe any hard-and-fast rules of evidence could be laid down, emphasizing that his nine “viewpoints” were neither necessary nor sufficient for causation. His suggestions about how to intuitively assess causation are almost completely lost when his address is distilled into a checklist.”

    The paper concludes with “The uncritical repetition of Hill’s “causal criteria” is probably counterproductive in promoting sophisticated understanding of causal inference. But a different list of considerations in his address is worthy of repeating….” Five considerations are listed, the last one being “Uncertainty about whether there is a causal relationship (or even an association) is not sufficient to suggest action should not be taken.” The authors state that “The last point may be the most important unlearned lesson in health decision making.”

    This caution is echoed by a 2005 paper titled “Association or Causation: Evaluating Links Between “Environment and Disease” (RM Lucas & AJ McMichael, The Royal Society of Medicine Press) which states: “Bradford Hill’s criteria provide a framework against which exposures can be tested as component causes, but they are not absolute. As with statistical P-tests, the criteria of causality must be viewed as aids to judgment, not as arbiters of reality.”

  32. Lawrence C. says:

    Regarding what has become of Hill’s work, it is a commonplace that a paper or idea goes on to have a life of its own, regardless of authorial intention. It is good to note intent (when such is directly expressed or otherwise discernible) but whether or not that intent has any bearing on the work in question is a separate issue that doesn’t necessarily undermine or support subsequent uses or interpretations.

    In this age when causal inferences savaged from sequential events is the rampant norm, anything that causes one to stop for a moment and think differently is probably a very good thing. It seems to me Dr. Crislip is working towards that sort of thing.

  33. Phillips/Goodman as quoted by Wales: “….repetition of Hill’s ‘causal criteria’ is probably counterproductive in promoting sophisticated understanding of causal inference.”

    How can repeating an interesting list of considerations — “criteria” or otherwise — possibly be “counter-productive”? It’s a list of things to think about, not the ten commandments. Perhaps the reasoning would be clear to me if I bothered to read the paper, but it seems a rather pointless conclusion out of context. Hill’s criteria thingamies are all worth thinking about, and I don’t know how they’re stopping me from acquiring a deeper understanding of casual inference. I didn’t read them and think, “Well, shoot, I guess that’s the last word on that! What a relief that I never need to think about causal inference again!”

  34. Scottynuke says:

    Having now seen the full AP article about Norway and MRSA, I take back what I said about Ms. Duel.

    I now conclude she’s just a plagiarist.

    Oh, and the final screaming red flag is still valid. :-)

  35. wales says:

    Paul, if you had read the paper you would see that the accurate quote is “uncritical repetition”. It makes a difference. The point is that causal inference is complex and a checklist is not enough. For those who don’t want to bother with the complexity of the matter or read the critique, I suppose a checklist is as good as it gets.

    As the cited paper states “…… Hill’s list seems to have been a useful contribution to a young science that surely needed systematic thinking, but it long since should have been relegated to part of the historical foundation, as an early rough cut.”

  36. rosemary says:

    nitpickingon, “Drs. Crislip and Novella share several attributes, including great writing skill, deep medical knowledge, and terrible spelling.”

    How do you define “great writing skill” or more to the point are you familiar with any studies that indicate the most effective ways to educate and communicate with the general public using the written word?

  37. windriven says:

    @rosemary

    Huh?

    I would define great writing skill – at least in terms of expository prose – as concise, compelling, accurate, clear and entertaining or at least engaging.

    Concise: Novella, check Crislip, check
    Compelling: Novella, check Crislip, check
    Accurate: Novella, check Crislip, check
    Clear: Novella, check Crislip, check
    Entertaining: Novella, check Crislip, check plus

    So WTF?

    What is your point in asking such an open-ended question?

    No, I am not familiar “with any studies that indicate the most effective ways to educate and communicate with the general public using the written word,” are you?

  38. nitpicking says:

    Rosemary, I’d prefer if you stated a specific objection rather than casting vague, implied aspersions. Speaking as an educator and professional writer.

  39. drmark says:

    I’d like to add, as an individual with a PhD in Neuroscience and a practicing massage therapist, that I fully agree that most massage therapists are drowning in woo, despite the best efforts to educate them scientifically otherwise. It constantly drives me crazy how fellow therapists will say things that are not coherent or plausible or even possible to test, and how frequently their belief in x makes x true in their minds. I used to run a massage school, and I didn’t hesitate to explain why reflexology is absurd and ridiculous. But a majority of woowoo therapists doesn’t change the value of some forms of massage to address musculoskeletal concerns as well as reducing stress, the importance of which can’t be over….um…..stressed. :)

    I do find it very odd that there is so much anti-chiropractic in this discussion. I also agree that it’s absurd to claim that subluxations are the root of disease, but it’s not difficult to see in an xray that they exist. I’ve spent most of my life being very thankful that chiropractors were around to quickly change me from a state in which my neck can’t rotate to one side, into a state in which it can. If ya’ll haven’t had such a life, you can be very thankful. I’m not going to chiropractors to treat disease. I go so I can turn my head and reduce pain. Does this group find it incoherent or implausible that two vertebrae could be subluxated in such a way so as to reduce range of motion? Numbness and weakness from spinal impingement of nerve roots is pretty basic science, so why does this group not seem open to a Gradient of diseases caused by subluxations?

    I don’t know whether acupuncture is valid or not, but I do think the statement that it’s not possible is unfortunate. I’ve read of a discovery of something called bonghan ducts–extremely tiny tubes carrying fluid that thread the body much like meridians are described. I’m certainly not saying these ‘are’ meridians or that the fluid is ‘chi’, but I am saying that something like this could be found that make the impossible possible. One should say it doesn’t fit into our current anatomical understanding, rather than say it’s not possible.

  40. nitpicking says:

    I also agree that it’s absurd to claim that subluxations are the root of disease, but it’s not difficult to see in an xray that they exist.

    So why can’t anyone actually do it, if it’s so simple? Really, no one in actual controlled trials has ever shown this ability. Or do you know of a study you can post a link to, which I haven’t heard of?

  41. Diane Jacobs says:

    @drmark
    “a majority of woowoo therapists doesn’t change the value of some forms of massage to address musculoskeletal concerns as well as reducing stress, the importance of which can’t be over….um…..stressed.”

    I treat with manual handling also, and your statement doesn’t make sense to me. IMO manual handling does not “reduce stress”… I think that’s a perceptual fantasy. Or a conceptual hallucination. Not sure. Maybe both.

    Are you thinking of pain reduction?

    Stress and pain are two very different but often intertwined critters.

    Pain is endogenously produced and sometimes maladaptively maintained, as response to a threat, whereas stress is a type of threat, perceived consciously or non-consciously, to which the brain can/must adapt, usually favorably, but not always.

    I’ve come to consider manual therapy as yet another type of stressor; one that can/i> (often does) help the brain learn to not produce persisting pain… however, only when applied strategically and minimally.

    If you actually believe you can reduce “stress” by providing the brain of your patient still more stress in the form of manual handling, adding yet more sensory-discriminative input for it to deal with, then I think your treatment construct is wrong.

  42. Sam Homola says:

    No one denies that vertebral misalignment or orthopedic subluxations exist. Such subluxations can cause musculoskeletal symptoms, can be verified on x-ray, and can often be relieved by manipulation. Common vertebral misalignments or more rarely occurring painful orthopedic subluxations have never been identified as a cause of organic disease. Spinal nerves are commonly compressed by bony spurs and herniated discs. Even the most severe compression of a spinal nerve which cripples the supplied musculoskeletal structures does not cause organic disease.

    Organ function is governed by the autonomic nervous system in concert with psychic, chemical, hormonal, and circulatory factors, independent of spinal nerves. What is at issue is the claim by chiropractors that vertebral misalignment or an elusive “vertebral subluxation complex” can be a cause of visceral disease and can be adjusted to “restore and maintain health.” Such subluxations have never been proven to exist.

  43. “I know that there are more things in heaven and earth than are dreamt of in my philosophy. But you have to prove it to me.”

    Added to my Random Quotes page. Am I correct in attributing it to Mark Crislip, or did somebody else think of it first?

  44. drmark

    “One should say it doesn’t fit into our current anatomical understanding, rather than say it’s not possible.”

    In science, it’s generally understood that when something is said to be impossible, it means that all our current understanding says that it is not possible or plausible, but that it is possible (however unlikely in any specific situation) that current understanding can change with new and better information- that’s the nature of science. The qualification is not really necessary.

    Homeopathy is not plausible without nearly all current knowledge of chemistry, physics, and medicine being grossly wrong; the short hand version is that homeopathy is not plausible.

  45. windriven says:

    @Karl Withakay

    Hamlet, Act I, Scene v

    There are more things in heaven and earth, Horatio,
    Than are dreamt of in your philosophy.

  46. @windriven,

    Thanks, I may be a teller of tales full of sound and fury that signify nothing, but I did already knew that was from Hamlet. :) (And yes, I know that’s Macbeth)

    I was referring to the entire quote that adds “But you have to prove it to me” and asking if that part is original Mark Crislip or not.

  47. Harriet Hall says:

    There are more things dreamed of in your philosophy, Horatio, than exist in heaven and earth.

  48. …and Harriet gives me another one for my Random Quotes page.

  49. windriven says:

    I like Dr. Hall’s better than Shakespeare’s. But then The Bard didn’t have homeopathy for inspiration.

  50. rosemary says:

    Addressing nitpicking, I wrote, “How do you define ‘great writing skill’ or more to the point are you familiar with any studies that indicate the most effective ways to educate and communicate with the general public using the written word?”

    Windriven responded, “What is your point in asking such an open-ended question?”

    My point is that I have been doing a lot of writing over the past 15 years trying very hard to educate the general public about the need to verify supplement claims with independent evidence before believing them. I am also on the board of a non-profit health organization that is in the position of constantly trying to explain very complex issues to the general public. The bloggers here and many readers are also trying very hard to do that. However, IMO we need objective evidence, good studies, showing us how to do it and the best way to do it. I myself am not aware of any such studies although I would love to see them if they exist. If they don’t, I’d love to see them done because I think that evidence rather than opinions, feelings and beliefs is the best way to evaluate things, including things like how to effectively communicate. To put it another way, I find it ironic that people would insist on evidence to support medical claims, but not even consider the fact that evidence is needed to determine whether or not we are communicating what we want to communicate and whether or not we are doing it in the most efficient manner possible.

    Nitpicking responded, “Rosemary, I’d prefer if you stated a specific objection rather than casting vague, implied aspersions. Speaking as an educator and professional writer.”

    Nitpicking, I’d prefer if you didn’t read into what I write things that are’t there. I was not implying or casting aspersions. You used a term “great writing skill” which I asked you to define. Since you are an educator and professional writer, I would expect you would either be able to do that, refer me to a link if you think the topic is too detailed to cover in a comment, or simply say, “You know I’ve never thought about that, but I recognize it when I read it.”

    I don’t have a reference but I have read that Ronald Bowers, a prosecutor with the Los Angeles DA’s office for about 40 years, was chosen by his office to start and head a division to develop visual aids for prosecutors and to learn and teach them how best to communicate complicated ideas to juries. That was done since it had been noticed that great oratory no longer convinces people the way it did in the past and because there were studies (I don’t have references) showing that people process auditory and visual input differently, visual impressions are remembered better and the best way to communicate to people is to use a combination of auditory and visual methods. In other words they found studies showing the best way to communicate in a courtroom, then developed and taught methods of communicating based on those studies.

    I think that if we had that kind of evidence about written communication that it would go a long way in helping us accomplish our goals.

  51. windriven says:

    @rosemary

    “Addressing nitpicking, I wrote, “How do you define ‘great writing skill’…”

    You may well have been responding to nitpicking but you did so on a public blog so I feel no restraint from kibitzing.

    Expository prose is an art, not a science. I cannot begin to imagine how one would construct a meaningful RCT to define “… the most effective ways to educate and communicate with the general public using the written word?” There is an entire body of didactic theory and practice but I don’t know that much of it has solid scientific underpinning.

    Beyond that the task at hand is much more complex than choosing the best locutions. First one has to identify the target audience, find a way to get their attention, communicate and educate, and get them to internalize the lesson and incorporate it into their thought processes.

    I worry that sites like SBM attract only their choirs and the magical thinkers who stand in polar opposition and are unlikely to be convinced by any level of proof. If you will pardon the comparison, the heated argument may be between the Democrats and the Republicans but often the election is decided by the independents.

    So for me the more important question is: how do we identify those who can be convinced and how can we convince them.

    We are marketing a way of thinking and so are the other guys. Ours is a rigorous way, sometimes difficult and requiring research and effort. Their way is easy and requires only ‘feeling’ and credulity.

  52. rosemary says:

    @windriven

    “Expository prose is an art, not a science. I cannot begin to imagine how one would construct a meaningful RCT to define ‘… the most effective ways to educate and communicate with the general public using the written word?’ There is an entire body of didactic theory and practice but I don’t know that much of it has solid scientific underpinning.

    Beyond that the task at hand is much more complex than choosing the best locutions. First one has to identify the target audience, find a way to get their attention, communicate and educate, and get them to internalize the lesson and incorporate it into their thought processes.”

    There are definitely objective ways to evaluate the efficacy of different methods of educating and communicating and they are obviously very different than RCTs or methods used to evaluate drugs.

    I identified my target audience long ago. It is the group often referred to as the “mass market”, the “average consumer”, not the true believer. I also know from the media I’ve worked with that that is the same market they use me to target.

    Based on experience with this group, I believe that very often attempts by intellectuals to describe the fallacies of very slick alt medders often has the opposite effect leaving the general public with the stereotypical impression of doctors alts love to paint, one which generates distrust not trust or even an openness to listen to them.

    Val has referred to problems communicating with the general public and her efforts to find more effective ways of doing that. I think we should all be working on that or at the very least realize how important it is.

  53. EricSherman says:

    Excellent, excellent article Mark! Hoping you’ll turn this into a Quackcast episode??

  54. windriven says:

    @rosemary

    “I believe that very often attempts by intellectuals to describe the fallacies of very slick alt medders often has the opposite effect leaving the general public with the stereotypical impression of doctors alts love to paint,”

    I couldn’t agree more whole-heartedly. I said something very similar to this is in a personal communication with one of the editors. Sites like SBM are great for the choir and, perversely, great for the opposition; not so much for the great unwashed. And it is the great unwashed who we really need to reach.

  55. EricSherman says:

    Well, I am, confessedly, one of the “great unwashed” being reached.

  56. Wales: “Paul, if you had read the paper you would see that the accurate quote is ‘uncritical repetition’. It makes a difference.”

    Well, I suppose I walked into that rebuttal! Never dare to contradict the point of citing a paper you haven’t read! But the thesis that “uncritical repetition” is bad is not hard to understand from your summary, and my answer to it is: just what exactly is so “uncritical” about the repetition of Hill’s criteria here?

    I don’t think Dr. Crislip’s repetition was uncritical, and intelligent people don’t read anything uncritically, and I see no problem with contemplating an “early rough cut” … even if that is what Hill’s list is.

    If the state of the art has advanced so far beyond Hill, then, by all means, let’s discuss that. But I see no need to exclude Hill’s list or Dr. Crislip’s discussion of it.

  57. SubluxChiro says:

    Hello everyone. I am a subluxation based chiropractor.

    I am entering this new blog arena with hopes to help you in your thought processes here. I can not represent anyone other than myself, nor am I trying to defend any other professions. I did think however you may be interested in a deviation from your academic, outside in look at subluxation based chiropractors and get some real insight.

    Don´t be fooled, I know I am entering the lion´s den here and will do my best to keep to topic if you will. Let´s stay on point with conceptual models, I will not get crazy over spelling, or issues of semantics but rather offer what I can as an average day in and day out practitioner. Is that reasonable?

    There are so many points listed here before my involvement. I would rather not try and defend them all, nor want to really, not all my position.

    Where I can start are with 2 issues:
    1. Research: Let´s be real. Chiropractic is a private profession. No government grants, assistance or much benefits. Almost all the funding for education comes from tuition… 96% as apposed to the 4% from Stanford. No 3rd party grants, insurance money for studies…pharmaceutical money or the like so financially we are at a disadvantage of at least 10,000 to 1 dollar wise in that concern. So not an even playing field. We would love more research if we could get it done, and welcome it.
    2. Subluxation as the cause of disease: That is a misunderstanding. We view subluxation as an entity or dynamic process that limits the full expression of health, be it, bio-mechanical, neurologically or other wise. When the body can not function at 100% for any reason is when opportunist ¨germs¨ take play and result in disease.
    We are recognizing that germs are not the primary cause of disease, but the bodies inability to manage itself optimally and fight them off is…. no matter what the reason, we acknowledge that bio-mechanical, mechanical-neurological issues in the spine play a role in this. That´s it.

    Let me just start there. Some neutral ground, room to play and hope we can all stay constructive. I look forward to hearing from you.

  58. Harriet Hall says:

    SubluxChiro said,

    “We view subluxation as an entity or dynamic process that limits the full expression of health, be it, bio-mechanical, neurologically or other wise. When the body can not function at 100% for any reason is when opportunist ¨germs¨ take play and result in disease.
    We are recognizing that germs are not the primary cause of disease, but the bodies inability to manage itself optimally and fight them off is…. no matter what the reason, we acknowledge that bio-mechanical, mechanical-neurological issues in the spine play a role in this. That´s it.”

    This is so vague that it is meaningless. What is your basis for assuming that a biomechanical process can increase the body’s susceptibility to germs? Do you know of any evidence that a muscle strain in the back or a ruptured disk makes someone more likely to catch the flu? Is a patient with spondylolisthesis more susceptible to tuberculosis or AIDS? Do you think that a patient whose spine has been adjusted by a chiropractor could not be harmed by Ebola virus? What about illnesses that are not germ-related?

    I think you are just rationalizing to find a hypothetical excuse for manipulating any patient you want to manipulate. You are describing a belief system, nothing more.

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