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369 thoughts on “Chiropractic – A Brief Overview, Part I

  1. nobs says:

    HH->>”Thermography has its uses, but there is no evidence that it can locate chiropractic “subluxations.”

    mojo- >>”Is there any evidence that chiropractic subluxations exist to be located?

    Please provide YOUR definition of “subluxation” as used in the above.

  2. Citizen Deux says:

    Keep up the banter, folks. Apparently the fact that even within the North American Chiro Education community there is admission of the teaching of non-scientific, non-evidenced based modalities and theories. That the same group also identified significant specious claims made in chiropractic advertising and that the number of chiro’s in the US is less than their advocacy bodies claim and concentrated in areas of chiropractic density can only lead me to the following conclusions;

    1) There is no science supporting chirpractic as it is taught in the United States

    2) The public is wasting money on chiropractic treatments

    3) Any benefit from chiropractic treatments is likely from either the placebo effect, “white coat” effect or a well understood aspect of physical therapy

    4) Studies and papers which exist only serve to extend the debating society struggle within the medical field, an area long abandoned by the American consumer.

    Since Dagg, nwtk, wieng and INNATE have no refutation for the articles cited in my last post – I will assume that they concur by fiat.

  3. weing says:

    CD,
    I concur.

  4. nobs says:

    RE: Citizen Deux -

    WOW! Anyone here confused as I? WHAT was that about?

  5. daedalus2u says:

    CD, I concur too.

    Nobs, yes, the more expensive and elaborate a “treatment” is, the stronger a placebo effect it induces.

    Adding fancy high tech bells and whistles to chiropractic doesn’t change its fundamental nature, that of a placebo.

    Differential testing is only useful for differential diagnosis which is only useful for differential treatment. If the only “treatment” being given is some kind of neck manipulation, why do you do bother testing with MRIs CTs, EMG, NCV, Reflex hammer, pinwheel, etc.

    How does a specific finding on MRIs CTs, EMG, NCV, Reflex hammer, pinwheel, etc. change treatment? If you can’t articulate how a differential test result will result in a differential treatment, why are you doing the tests?

    If it doesn’t inform treatment, then it is a useless waste. Unless it causes an increased placebo effect.

  6. nobs says:

    You have cleverly obfuscated your original declaration——

    You accused Innate of: >>>>>”and you use the thermography machine to diagnose diseases.”<<<<<

    He never said that, the evidence clearly validates that, yet you insist upon revisionally recreating a non-existant declaration.

    WOW! Incredible!!

  7. Citizen Deux says:

    nobs, it was about the chiro advocates unwillingness to look themselves in the mirror via their own educational periodical. The Journal of Chiropractic Education found several significant gaps among chiro schools, advertising practices and unsubstantiated claims supported by the governing agencies in chiro.

    This is not some hatchet job by an angry doc, but a reasoned, well researched analysis by chirpractors and educators.

    Unsubstantied Claims from Chiro Colleges

    As none of the advocates took the time to look at them, clearly, I consider their statements unrefuted. Thus if the chiro educational community doubts its own curriculum, how can we give credence to any of these technical arguments, much less the whole discipline.

    Journal Link

    A brief reading of the archived issues of this journal will reveal a program which is bereft of scholarship, lacking in scientific underpinnings and divided over its own direction.

    It is the hallmark of a critical thinker, and good scientist, to first admit that their idea could be wrong. Hence the whole of statistical analysis starts with the assumption that your idea is incorrect.

  8. healthnut says:

    I initially looked at this site expecting it to more a far more honest interpretation than presented here. As an APNP I have to say that the chiropractic attack on this site is obviously unfair. The willingness to look at the material presented is done so with a pre-determined eye and the references that I looked up that I foubd valid were dismissed in a manner that would never have been done by the opposing view. I practive family medicine with much more of a view in reality. I know the limits of physical therapy, I see them daily. I see what chiropractic does and does not do. Though it is a profession of vastly differing techniques and opinions there are a few facts that cannot be overlooked. Many people have increased range of motion and decreased pain. Now for those who have made a very strong reach of an argument as to why that is, it fails to represent why many of these same patient’s fail with PT and succeed with chiropractic. I defended Insights earlier comments because as a primary care provider I can see he is being truthful on both sides of the issue. There are pro’s and cons. Many on this site are not open and that is too bad. I refer to Chiropractors that I trust and have established protocols with and will continue to do so. When Insight said his IVD injury patient’s do not improve with PT but do with Cox manipulations I can personally atest to the same outcomes in my practice. Until PT can prove otherwise to me, I will continue to refer my disc injuey patient’s accordingly.

  9. Calli Arcale says:

    healthnut — the whole point of this place is to *question* and require *science*. Do not, therefore, be surprised when we ask for science rather than anecdotes. It is acknowledged that sometimes decisions about patient care have to be made with inadequate information — but people posting here are not in that position. With the luxury of time, why not ask for science? Why not question? Why not test to see if the treatment is really working? What might you fear?

    whitecoattales:

    The “one disease, one cure” model is therefore fundamentally flawed because it’s apparently impossible to interfere with one system without affecting others.

    Who even talks about this “one disease, one cure” model? I’ve never heard the term in medical school.

    Well, straight chiropractors, for one. The one disease is spinal misalignments, and the one cure is chiropractic adjustments. (Why, Palmer even claimed to cure blindness!)

    What’s happened is that the gentleman was using a strawman — the ancient idea of “one disease one cure” was found lacking when people started to apply science to medical practice. Unfortunately, not all medical practitioners have bought into the idea of science, and so today we have chiropractors, homeopaths, and so forth. Granted, some chiropractors have noticed that there is science that they can learn from, and have started to realize the limits of their practice. Unfortunately, they are in the minority. Their profession will never move out of that 19th Century mindset until it rises up, as a whole, and starts doing what scientists are supposed to do — ask questions.

  10. nobs says:

    >>>”Well, straight chiropractors, for one. The one disease is spinal misalignments, and the one cure is chiropractic adjustments. (Why, Palmer even claimed to cure blindness!)

    REALLY?? Please direct me to your source for this assertion. (btw- although you are most likely parroting something you read on Chirobase or similar chiro-trash site, it is not a valid source.) Produce a source in the objective literature.

  11. Harriet Hall says:

    Palmer claimed that all disease was caused by subluxation; 95% from subluxation of the spine, 5% from subluxations of other bones.
    Originally chiropractic stressed that it did not “cure” anything. All it did was align the spine to prevent nerve interference and allow Innate to keep the body in health.

  12. Dacks says:

    Healthnut,
    Non-medico here – what does APNP stand for?

  13. pmoran says:

    Healthnut, you are clearly referring to the use of manipulation for back problems. Most skeptical contributors have allowed that this may help some sufferers — even though the evidence from controlled clinical studies remains somewhat equivocal in terms of any intrinsic activity of spinal manipulation i.e. beyond placebo.

    What is unfair about that?

    The problem with “chiropractic” is that it now encompasses a lot of practices that definitely qualify as quackery i.e. exaggerated or unsupported medical claims. INNATE’s version of chiropractic is one such. I suspect you would agree with us on that if you looked at it more closely..

  14. Fred Dagg says:

    Harriet,

    you are doing your normal cherry picking. Compare what Palmer said, to what was common “medical theory” of the time (1900), please.
    What you have written is otherwise garbage and irrelevant.
    You take no cognisance of the Flexner report. What is interesting is that the first “pupils” Palmer (DD) taught were “medical practitioners”.

  15. INNATE says:

    First of all, please accept my sincere apologies for my accusation as it was clearly out of line. I will say that it was out of frustration from all the attacks and judgments I’ve had to incur from all of you thus far; judgments based on obvious misconceptions as to what exactly it is that I do. It is obvious from your comments that you really have no clue as to what chiropractic is and I feel it is my responsibility to clear up these misconceptions.

    Regarding thermography: thermography simply tells me if there’s a problem in the ANS. It also allows me to monitor and track improvements and tells me if an adjustment is needed or not. It is not the diagnosis, nor does it “locate” the “subluxation”. Allow me to clear up any misconceptions by explaining my initial exam:

    -Patient comes in and gets acclimated in my waiting room for about 10 mins. I greet them and have them put on a gown. I then run a full-spine scan using the device as well as a cervical scan (T1 to occipital shelf)(scan #1).

    -I then take the patient’s history which takes about 20 mins (sometimes more) after which I run another full-spine and cervical scan (scan #2).

    -I then do the physical exam: vital signs, ortho/neuro, and I palpate their spines for pain/tenderness/abnormalities/restricted motion. If it’s indicated, I’ll do ab/thorax exams. After the physical I run another scan (scan #3).

    -I then take the x-rays of their upper cervical spine: 1 lateral, 1 base-posterior (analogous to the vertex view), and 3 nasium films: one is with the patient in neutral head posture; one is with the patient in left lateral flexion; and one in right lateral flexion. The goal of these three is to isolate lateral flexion; I ensure that the patient does not rotate or extend the head in the process. Let me clarify that positioning the patient for these films requires lost of training and skill to get quality films. After the x-rays, I run another scan (scan #4).

    -I then make an appointment for their report of findings and have them go home. This is when I go to work.

    The thermography computer display shows three vertical lines; the length of the lines is the length of the scan from bottom to top: the line on the right is the absolute heat measured by the right channel; the line on the left is that of the left channel; and the center line is based on a calculation of the difference in these absolute temperatures. Ideally the center line should be straight and centered indicating no difference (what we call “symmetry” and “balance”). However, undulations in this line are seen which indicate that there’s a problem. Furthermore, the characteristic pattern of undulation will repeat across all four scans that I take. Every patient’s pattern is different and so the software allows me to store their scans in a filing system so that I can keep track of them. Based on the four scans, I use my expertise to select one that is the most representative of all four. Again, taking the scans, reading the scans, selecting pattern all take skill and training.

    Next I do the x-ray analysis: I look at all the films and assess if there is any form of pathology (we are excessively trained and tested in chiropractic college to do this). I then use the three nasium films to determine adherence to normal biomechanical coupled motion as defined by White, Panjabi, and others. BTW, I used to take APOMs but I get far better information from the nasium films (I can adapt my practices too!). In the neutral film, I look at head tilt and determine if C1 and C2 displacements are appropriate for that head tilt direction. I then look at the right-lateral flexion film and do the same thing (did C1 move right? did C2 move left? Did C2 spinous move left?) I repeat for the left lateral flexion film. Based on this, I can determine where and in what direction the fixation exists (because, as pmoran points out, using palpation doesn’t really work). This tells me the appropriate segment and direction I need to take with the adjustment. Again, this takes a lot of training and skill to do.

    The above is and excessively simplified explanation of how I locate the “subluxation”. I diagnose the patient with “biomechanical dysfunction of the upper cervical spine” as well as their presenting complaint and anything else I may find in the history, physical, and /or x-rays.

    Patient care involves the patient first acclimating in my waiting room. I then run a cervical scan and compare it to the pattern I’ve established for that patient. If the scan is identical to their pattern then I adjust them; if it’s “clear” (a strait line) then they go home; if it’s something funny looking (not strait, and not pattern), I have them rest for 10 minutes and re-scan—the second scan will be either clear or pattern and I proceed as above. If they need an adjustment, I adjust and have them rest afterwards; I then take a post-adjustment scan to see if I’ve cleared it. My goal is to make that line straight and keep it there. In time, the patient will start to hold their adjustments for longer and longer periods of time as indicated by consecutive visits with clear initial scans. I base the frequency of their visits on the length of time that they hold their adjustment. Eventually, they’ll need to come in only once per month and I have several patients that come in once every 2 months or more. Making the adjustment, BTW, takes by far the most training and skill…it is an art. And if I get it wrong, it will be evident by the post-scan.

    I invite REAL questions about this. I’m tired of the attacks and it would be nice if we could take this discussion in a direction that tries to eliminate pre-conceived notions about each other in an effort to shed light on the areas that need further study. In this way I can make efforts to guide the research in the right direction.

    Here’s a thought experiment, though, and it deals with the placebo effect. If positive outcomes can be attributed to the placebo effect, how (what is the exact physiological mechanism) does the placebo effect produce these results? And if you don’t know how, isn’t this an indication that there are mechanisms in the body that are unexplainable yet obviously present?

  16. healthnut says:

    Dacks, I am an APNP – Advanced Practice Nurse Practitioner.

    pmoran, the statement you make about benefits of manipulation beyond placebo is also not accurate. Although you may think to the contrary if you refute the studies stated. Some of the studies mentioned earlier are quite interesting and complimentary to the opposite of your views.

    Also let us not scoff at possible organ related changes from nervous system input although I will not argue the possibilites on this site. It would be futile.

  17. weing says:

    Why does the same wine with a vintage label on the bottle and high price taste better than the wine from a cheap bottle and price? Functional MRIs show that people actually experience greater pleasure, in the former situation, drinking the same wine.

  18. weing says:

    “Also let us not scoff at possible organ related changes from nervous system input although I will not argue the possibilites on this site. It would be futile.”

    I agree, arguing the possibilities would be futile. Now if you have some studies to that effect, that would be a horse of a different color entirely.

  19. Grimreapor says:

    A few bones to pick here and there, some which may have been discussed before but I have only skim read the above as quite a lot of it was drivel… Not going to mention it as my post is adequate to figure it out.

    Innate first off, the way you defined ‘intelligence’ be it ‘innate’ or ‘universal’ is faith. Since you are counting the material evidence for its chemical interactions of oxygen with haemoglobin and the interaction of a bowling ball hitting the floor as ‘intelligence.’

    Let’s just get down to the fundamentals. First being a oxidation of the iron held in the complex, haem, part of the haemoglobin molecule if the name wasn’t obvious enough.Also I believe it can complex with the Iron in haem. (The reverse reaction of haem you can research yourselfs as I have admittedly not read on this enough. Although can safely say it is ligand substitution and reduction.) Two basic chemical reactions known to use. To say it is caused by ‘Innate Intelligence’ is just like saying God did it or the Flying Spaghetti Monster did it. Which is by definition FAITH.

    Now for the basic lesson in gravity… No I won’t go there. It’s safe to say you can refer to Newtons law of gravity, or Einstein’s equation for extreme precision. Also look up the Higgs Boson while you are there.

    Now with this fundamental principal why should we incorporate faith in evidence based/science based medicine? Faith is non falsifiable and should not be within medicine.

    Now let us have a quick look for plausibility for chiropractic. First off is that chiropractic does not deal with germ theory/disease. I’m sure you can read plenty of this by the good Doctor Novella above on this. Secondly is evidence. Anecdotes get you to see plausibility for treatment, but it only gives you a gentle poke towards an idea. And that poke has gone on too long with nothing showing in terms of research. And now I am stuck for a metaphor.

    Next is the poor studies… I really only need to say this I believe to get my point across. The inverse relationship on quality of the study to effectiveness in nearly all areas of chiropractic. Not all as I will discuss in a second. A bad study won’t get you approved as licensed treatment like a bad study on drugs won’t get that drug approved.

    And finally the crux of it all. Chiropractors do not change their treatment according to testing and observation in the grand scheme of it. They reason the bad results, and accept the good results. And at times say science cannot tell if we work or don’t work but then use BAD science based studies that were positive and shove it in our faces as it tells us something. It is a double standard at times.

    And finally a quick discussion on the positive effects. First lets start with the blood pressure stuff. I would personally say is possibly a given since blood pressure can be caused by stress. We all get it. And what can a homoeopathic sugar pill do that chiropractic can do? The placebo effect. If you believe it and get it done or even hear it may work and have some shred of hope for it, the patient may feel relieved rather than anxious etc before receiving treatment. A more plausible reason than chiropractic works as a bold statement. It only takes Occam’s Razor to get to a reasonable hypothesis to test.

    Secondly the only positive results which are reliable as far as I’ve come across from chiropractic manipulation is for uncomplicated lower back pain which I believe I have read up upon thanks to Doctor Novella again. But I believe that this area is possibly a better place for physio therapists to investigate. Which anecdotally are by far the better option as they may do some manipulation but what they do is help the person be able to move more freely or help regain function of your limbs generally by exercise and stretches. Again only from experience and anecdotes. But this is only for what I stated above, generally uncomplicated ways to help mobilise patients and help treat pain.

    *On a note by physio therapist I am strictly on about professionals who do not employ the same kind of philosophy as strict/ mixer chiropractics. Here in England there is one organisation which I believes regulated private physio therapists for approval but there are a lot of mixers still.

    Anyone who sees I made a mistake please feel free to let me know.

  20. Fred Dagg says:

    Weing, you have been given the studies, e.g. Hypertension study.
    Here is another one on the central Nervous Systems effect on the modulation of Pain.

    Man Ther. 2008 Oct;13(5):387-96. Epub 2008 Mar 3

    “An increasing number of studies hypothesise activation of the central nervous system resulting in a non-segmental hypoalgesic effect with concurrent activation of other neural pathways as a potential mechanism of action”.

  21. Diane Jacobs says:

    Fred Dagg: -> “An increasing number of studies hypothesise activation of the central nervous system resulting in a non-segmental hypoalgesic effect with concurrent activation of other neural pathways as a potential mechanism of action”.

    Yeah. But the thing is, almost anything from education about pain to physical handling of the lightest skin-only sort of manual contact can do that. Anything that changes sensory-discriminative input. So, what kind of pain patient needs high velocity manipulation, in that case? Very very very few. Vanishingly few.

  22. pmoran says:

    INNATE, one of the features of pseudoscience is its failure to take simple, obvious, rigorous and NECESSARY steps to validate itself as it goes along.

    So it is almost too late for your kind of chiropractic. The siren song of patient approval has already had its way with you — one of the most powerful forces the universe.

    But here, broadly, are some of the steps that are needed.

    1. Establish inter-observer and intra-observer reliability of the observations that determine the need for treatment and how the patient is treated. If you do this properly then it is very likely none of the other steps will be found necessary.

    It is not enough in this to merely produce results of ordinary levels of statistically significance — in order to form the basis of a whole new system of medicine we would expect a very high degree of reliability with low rates of false positives and false negatives.

    2. Establish by similarly rigorous studies that the detected abnormalities are reliably corrected by the chosen manipulation.

    3. Then — more difficult — show that the presence or absence of the abnormalities observed are correlated with any form of ill health — ideally some unmistakable objective effect on a serious illness so as to provide some support for the extravagant claims often made as to the abilities of this method.

    If it is a statistical effect on more subjective and observer dependent outcomes then three independent top quality double blind controlled trials would be the minimum needed to reach pharmaceutical standards for presumption of efficacy.

    4. Ideally produce a credible mechanism whereby it could work. Before that you and your fellow chiropractors would probably have to learn a lot of physiology and neurophysiology — we already know a great deal about the autonomic nervous system and what it does and does not do.

    Speculations are not evidence.

  23. daedalus2u says:

    INNATE,

    ”Here’s a thought experiment, though, and it deals with [cervical adjustment]. If positive outcomes can be attributed to [cervical adjustment], how (what is the exact physiological mechanism) does [cervical adjustment] produce these results? And if you don’t know how, isn’t this an indication that there are mechanisms in the body that are unexplainable yet obviously present?”

    The physiological placebo effect is mediated through the neurogenic control of physiology. The allocating of metabolic resources is done continuously by physiology to ensure survival of the organism. When the organism anticipates needing resources for “fight or flight”, those resources are diverted away from other things, such as healing. When the organisms no longer needs to be in the “fight or flight” state, that state is terminated by the physiologic placebo effect. It is a neurogenic mechanism which diverts metabolic resources back to long term pathways such as healing.

    Many (if not most) of these pathways are mediated through NO, with low NO being the “fight or flight” state and high NO being the opposite of that state, the at rest state.

    The placebo effect of chiropractic is not triggered by subluxations or other mumbo-jumbo, it is as Diane said, “simple human primate social grooming, one nervous system with its hands on another.” It is an effect mediated by communication, by the message being communicated that “everything is ok”, that there is no need to be in the “fight or flight” state, and that the individual can relax and divert resources back to maintenance, back to healing. It is the equivalent of a mother’s “kiss it and make it better”. What is being communicated is a sense of safety. When a sense of safety is effectively communicated, organisms respond by switching from a “fight or flight” state to a state of rest. There are many degrees of “fight or flight” and many degrees of “rest”. Those states are as complicated as the rest of physiology. They may appear to be “the same” but that may be an artifact of our inability to measure what is different.

    Pain is a signal. It signals insufficient resources to do the task that the tissue compartment is being called on to perform. There are 3 ways to resolve pain of insufficient resources. Reduce the demand for resources, increase the availability of resources, or block the pain signals with anesthetics. Stress relief and the physiological placebo effect reduce the demand for resources by turning off the “fight or flight” systems. That frees up resources to be used for the physiological systems activated in the “at rest” state.

    The placebo effect can reduce pain by endorphins, but I think that is a minor part of it. Extreme stress in the “fight or flight” state can completely eliminate pain, but that is not a “placebo” effect, it is a stress response. I think it is more precise to call pain relief due to a stress response something other than a placebo effect.

  24. INNATE says:

    pmoran…THANK YOU!!

    so basically,
    1. demonstrate iner/intra-observer reliability of:

    a) the thermography assessment,
    b) the x-ray analysis, and
    c) the determination of when and when not to adjust based on theremographic assessment.

    2. prove that biomechanical dysfunction is corrected by the adjustment.

    3. Monitor some (or several) parameter(s) of health throughout care and show that it improves as a result of care (and also that it doesn’t improve if care is not given–control).

    –Repeat this three independent times.

    Q: do you (or any of you) have any suggestion as to these heath parameters? what can be monitored reliably that will serve this purpose (in your opinion)?

    4. Propose a physiological/neurophysiological mechanism for why the parameter changed for those that received care and why it didn’t change for those that didn’t receive care.

    you forgot 5. Have HH comb through it with her fine-toothed bomb!!

    did I understand your instructions?

  25. INNATE says:

    daedalus2u

    Thank you for taking the time to explain that to me. Very insightful! It actually makes a lot of sense. You seem like an expert on the topic. Question, though: at what point do you start considering that there are other factors at work besides the placebo effect. In other words, if I adjust the patient in the opposite direction as is indicated by the x-ray analysis and the patient gets worse (and their thermography scans never clear) yet I do everything else the same, would it be an indication that it is not the placebo effect that gets the patient better when I adjust him/her in the direction that IS indicated?

    Or:

    Placebo effect at work:
    Adjust in the right direction->patient gets better
    Adjust in the wrong direction->patient gets better

    Placebo effect not at work:

    Adjust in the wrong direcrtion->patient gets worse

    Then:

    Adjust in the right direction->patient gets better

    Do I understand?

  26. INNATE says:

    “…fine-toothed bomb!!” should have read “…comb!!”

  27. pmoran says:

    “Q: do you (or any of you) have any suggestion as to these heath parameters? what can be monitored reliably that will serve this purpose (in your opinion)?”

    It is interesting that you should have to ask —- presumably symptomatic of the “we don’t treat disease, we enable healing” thing.

    That ploy helps you to dodge making specific claims and then having to back them up. But it also begs the question “how, then, do you know you are doing anything at all to ease medical suffering?”. I mean, something must be being “healed”.

    Most healers get to think that they are particularly good at relieving some conditions, and they become their preferred arena for testing..

    What are you good at? Enabling healing is not an answer.

  28. OZDigger says:

    Grimreapor
    “A bad study won’t get you approved as licensed treatment like a bad study on drugs won’t get that drug approved.”

    I wonder what Vioxx was, a good study of a bad drug, or a bad study of a bad drug, or even a bad study of a good drug or even a good study of a good drug?

    Harriet, you are the expert in research, you have done so much, perhaps you could help with this dilemma?

  29. Grimreapor says:

    I think Vioxx was removed from the market volentartily due as it did cause problems with long term high dosage usage.

    But it did have quite a bit of use as an NSAID as it was pretty effective.

    I would say that it was a bad study of a good drug.

    The unfortunate thing I believe was they ignored their one, own small trial about it being not as safe as they imagined at first, until they did stage four clinical trials. Which showed much higher statistical significance.

    And I agree that maybe I took a little too much liberty with what I said. I’m sure there are a few drugs that have been proven to be unsafe after being licence. Well nothing is full proof I suppose.

  30. Mojo says:

    @nobs:

    mojo- >>”Is there any evidence that chiropractic subluxations exist to be located?

    Please provide YOUR definition of “subluxation” as used in the above.

    How about the one from the article published in the Chiropractic Journal of Australia and discussed here: “an entity that is yet to be shown to exist”.

  31. daedalus2u says:

    Innate, when you do something that makes it worse, it is called the nocebo effect.

    You are confusing association with causation. You are doing all of these very impressive tests and manipulations, which you believe in your heart of hearts will “help” the patient and the patient can see that. The patient sees your belief that you are doing positive things, so the patient adopts these beliefs too. That triggers the physiological placebo effect in the patient.

    When you say “adjust in the right direction”, what do you actually mean? Could you give instructions to someone else as to which “direction” the adjustment is appropriate and how to do it?

    If you adjust” someone without doing the scans and x-rays does their condition get better?

  32. weing says:

    Vioxx was a good drug that originally was aimed at patients who were anticoagulated. If the company didn’t market it for the wider population, it would probably be still on the market. I have patients who admit to still using it, they hoarded it when it was being pulled off the shelves. I wonder if the number of MIs allegedly caused by it, as a fraction of patients using it, is equivalent to the adverse outcomes from chiropractic manipulation?

  33. nobs says:

    weing queries:
    ..” I wonder if the number of MIs allegedly caused by it, as a fraction of patients using it, is equivalent to the adverse outcomes from chiropractic manipulation?

    It is impossible to answer such a poorly constructed, ambiguous, question.

    “adverse outcomes”? While MI is a very specific event, “adverse outcomes” is ambiguous. Can you please reconstruct your question into something less ambiguous?

  34. Harriet Hall says:

    A clarification on Vioxx:

    “In 2005, advisory panels in both the U.S. and Canada encouraged the return of rofecoxib to the market, stating that rofecoxib’s benefits outweighed the risks for some patients. The FDA advisory panel voted 17-15 to allow the drug to return to the market despite being found to increase heart risk. The vote in Canada was 12-1, and the Canadian panel noted that the cardiovascular risks from rofecoxib seemed to be no worse than those from ibuprofen — though the panel recommended that further study was needed for all NSAIDs to fully understand their risk profiles. Notwithstanding these recommendations, Merck has not returned rofecoxib to the market.”

  35. nwtk2007 says:

    From my point of view that says it all about the medical community about risks and benefits.

    How does one calculate acceptable risk to benefit ratio when they see the risks of a previously banned drug as no different than ibuprofen which, of course, will never be banned.

    How many deaths per year will this acceptable risk result in if it were to be returned to use?

    I guess for Merck, the finacial risk outweighs the benefits at least.

  36. Scott says:

    “How does one calculate acceptable risk to benefit ratio when they see the risks of a previously banned drug as no different than ibuprofen which, of course, will never be banned.”

    You do realize that you’re criticizing the risk/benefit calculation by pointing out that the risks are comparable but completely disregarding the relative benefits? You have to look at both to be able to say anything at all.

  37. weing says:

    nobs,

    I guess you can compare the alleged incidence of strokes and paralysis due to chiropractic to the incidence of alleged MIs due to Vioxx. I say alleged, because I’ve never seen either. All I’ve heard is reports of both.

  38. Harriet Hall says:

    Vioxx is mainly a problem for patients who have cardiovascular disease or who are at high risk. It could be marketed with a black box warning to guide prescribing. The drug appears to be safe for people with low cardiovascular risk, and it is highly effective. Patients who had tried many other treatments and only got relief from Vioxx were denied the only effective treatment they had found.

  39. nobs says:

    HH->> “The drug appears to be safe for people with low cardiovascular risk

    Please cite the evidence supporting this assertion.

  40. nobs says:

    weing->>”I guess you can compare the alleged incidence of strokes and paralysis due to chiropractic to the incidence of alleged MIs due to Vioxx. I say alleged, because I’ve never seen either. All I’ve heard is reports of both.

    “due to chiropractic”———”chiropractic”what?

    All of SMT and “chiropractic” a subgroup?

    All of SMT with cervical manipulation(I am assuming you are referring to) as a subgroup of that and “chiropractic” a subgroup of that? and licensed chiropractors a subgroup of that?

  41. Harriet Hall says:

    The evidence was evaluated by the US and Canadian advisory panels that recommended returning Vioxx to the market.

    Black box warnings are recommended re cardiovascular risk. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm103420.htm
    Risks are cumulative, so obviously it is safer for someone with a low risk of cardiovascular disease to take it than someone with a higher risk.

    Of course, safety is relative. There are significant risks for anyone taking any NSAID that must be balanced against the benefits.

  42. healthnut says:

    I have to make one more comment after seeing where this thread has gone. Now I prescribe medication, it saves lives and makes people have better quality of life in many situations. With that being said, many drugs are over prescribed, have side effects which are far more dangerous than the conditions they are prescribed to treat. If you want an honest assessment, read Rakel’s work. An MD who wrote the alternative medicine text. He lists the statistics on morbidity and mortality for drugs in non life threatening conditions. Also lets look at the most prescribed drugs in out country. SSRI’s and PPI’s and statins. Necessity versus reliability in these medications is not proportionate to need vs risk. I welcome any argument in these cases. You will not find an honest PCP who will refute the risk or the over usage. If PCPs were better in nutritional understanding and recommendations as well as that of special testing, this would not be happening.

  43. INNATE says:

    daedalus2u,
    “When you say “adjust in the right direction”, what do you actually mean?”

    –Again, we do A-P lateral flexion x-ray studies of the UC spine and determine if normal biomechanical coupled motion (as described by White, Panjabi, and various other authors regarding spinal biomechanics) is being followed. When we do this study, the *directionlality* of restricted motion is evident. As I’ve stated, performing this analysis takes skill and training as well as an understanding of what normal should look like in order to recognize not-normal. The “right” direction would then mean: a direction that frees the restriction and restores normal biomechanics.

    “Could you give instructions to someone else as to which “direction” the adjustment is appropriate and how to do it?”

    yes!

    “If you adjust” someone without doing the scans and x-rays does their condition get better?

    NO! This is why we take the time to do these things…in my circle of UC chiros, we don’t buy “palpation”. there’s no way of characterizing (reliably and reproducibly) altered biomechanics using your fingers, especially in a region of the spine as complex as the upper cervical spine.

    Another thing I forgot to mention is that all patients present with some degree of marked head tilt and decreased range of motion in the direction opposite the head tilt. After the correct adjustment, the head tilt normalizes and ROM increases to the previously restriced direction. the incorrect adjustment creates more head tilt (it also makes the scan go “berzerk”, if you will–significant undulations in the DeltaT graph).

    pmoran: so what you are saying is that a marker of a *specific* disease process needs to be tracked (by a blinded evaluator). I was more asking for a general marker of health, like daedalus2u explains that increased [NO] is associated with the “at rest” state. Are there other markers such as [NO] that can reliably be monitored? or is it more important/significant that a specific disease marker be monitored to demonstrate efectiveness?

    Thank you for your input.

  44. nobs says:

    HH->>”The evidence was evaluated by the US and Canadian advisory panels that recommended returning Vioxx to the market.

    Perhaps my request was unclear. This is essentially an edited restatement of your prior post. I am interested in your cites supporting your assertion.

  45. “due to chiropractic”———”chiropractic”what?

    The phrasing here leads one to believe that chiropractic is an adjective that requires a noun. This is incorrect. Chiropractic is the noun referring to the system of spinal manipulation practiced by chiropractors.
    In other words, the question is wrong.

  46. nobs says:

    wcts->>”The phrasing here leads one to believe that chiropractic is an adjective that requires a noun. This is incorrect. Chiropractic is the noun referring to the system of spinal manipulation practiced by chiropractors.
    In other words, the question is wrong.”

    The question is indeed accurate and correct.
    See:

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

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

  47. tmac57 says:

    Wow! 246 comments so far and this is just Part I! Way to stir it up Dr N . Can’t wait for Part II.

  48. Harriet Hall says:

    “If you adjust” someone without doing the scans and x-rays does their condition get better?

    Innate says “NO!”

    This amounts to a condemnation of chiropractic. Essentially, he is saying that chiropractors don’t help patients unless they use his specific upper cervical techniques. The great majority of chiropractors would disagree.

  49. INNATE says:

    “If you adjust” someone without doing the scans and x-rays does their condition get better?

    Innate says “NO!”

    Let me rephrase the “NO”…you COULD get lucky and and get the adjustment right, but we don’t like to take that chance.

    HH->”This amounts to a condemnation of chiropractic. Essentially, he is saying that chiropractors don’t help patients unless they use his specific upper cervical techniques. The great majority of chiropractors would disagree.”

    That’s right, HH, you are starting to get it!! In specific chiroporactic, we try to be as objective as possible: we use an objective test to determine the “listing” as we call it (the directionality of the restriction) and we use an objective test to determine if the patient needs an adjustment or not! you can, at least *loosely*, call this science-based although, admittedly, A LOT more science is required (as you and pmoran have so graciously pointed out-thank you!).

    Full-spine chiropractors help a lot of people,especially folks with acute MS conditions; but their method of adjusting doesn’t clear the scan (no studies on this, that I know of, but we’ve proved this among our own circles.)

    Here’s a youtube video of BJ scanning, adjusting, and clearing the scan (you may find it interesting, or you may fall to the floor laughing):

    http://www.youtube.com/watch?v=1zfZM3QpGY8

  50. Fred Dagg says:

    In the latest edition of the Lancet, two U.K. experts, Sir Iain Chalmers and Prof Paul Glasziou lament on the tens of billions of dollars wasted on medical research each year. The money is wasted because of badly designed studies and poor reporting. They say that biased reporting is common, and researchers do not focus on the issues that doctors and patients most want to know about.
    For example, a survey found that although 9% of patients with osteoarthritis of the knee wanted further research into drug treatments, – the rest would have preferred rigorous evaluations of physiotherapy and surgery.
    However, according to the article, more than 80% of private and publically funded trials into the condition (Osteoarthritis) were drug evaluations.

    Harriet, you blather on about “science”, but when it is pointed out to you a few areas where “science” in healthcare is so one sided, you seem to be amazingly quiet. This is just one example of your silence.

    Also it has been pointed out to you on numerous occassions where the use of the term “chiropractor” has been used innappropriately when discussing accidents and incidents as a result of spinal manual therapy. I do not think this point has sunk in yet.

  51. tmac57 says:

    “Sir Iain Chalmers and Prof Paul Glasziou lament on the tens of billions of dollars wasted on medical research each year. The money is wasted because of badly designed studies and poor reporting.”
    Sounds like they could be talking about CAM research.

  52. Fred Dagg says:

    Yes, but they were not. They were talking about “medical research”. Read the article instead of trying to negate it.

  53. Harriet Hall says:

    Innate,
    How can you expect to convince the rest of us if you can’t even convince the majority of chiropractors?

    “no studies on this, that I know of, but we’ve proved this among our own circles”

    What does that mean? What do you call proof?

  54. Harriet Hall says:

    Fred Dagg said,

    “it has been pointed out to you on numerous occassions where the use of the term “chiropractor” has been used innappropriately when discussing accidents and incidents as a result of spinal manual therapy. I do not think this point has sunk in yet.”

    Yes, it has sunk in. But it is irrelevant. SMT is associated with risks. Chiropractors are associated with SMT. SMT is their whole raison d’etre. So anything that worries us about SMT should worry us about chiropractic.

  55. weing says:

    “Now I prescribe medication, it saves lives and makes people have better quality of life in many situations. With that being said, many drugs are over prescribed, have side effects which are far more dangerous than the conditions they are prescribed to treat.”

    By this do you mean that you are over prescribing? Are you also saying that your understanding of nutrition is inadequate?

  56. pmoran says:

    INNATE “pmoran: so what you are saying is that a marker of a *specific* disease process needs to be tracked (by a blinded evaluator). I was more asking for a general marker of health, like daedalus2u explains that increased [NO] is associated with the “at rest” state. Are there other markers such as [NO] that can reliably be monitored? or is it more important/significant that a specific disease marker be monitored to demonstrate efectiveness?”

    I know of no suitable marker and that you have to ask hints at the lack of substance to the “upper cervical” brand of chiropractic.

    For we are talking about YOUR claims. Remember those, the ones that supposedly make your approach so superior to the crude activities of ordinary doctors — the pluripotent benefits– on health, better organ function, stronger immune systems, and improving the ability to heal from (implied) ANY illness?

    How on earth did such claims ever arise in the first place, if you are unaware of suitable markers for them, or any other way in which you can prove that your methods do what you claim?

    “But, but, but,” — (this dialogue usually goes) —”it is difficult to get down to those specifics because we are mainly involved in preventing illness, and the ability to heal future illness.”

    Well, yes, it is true that this is more difficult to test out because it would require very large prospective long-term RCTs showing that patients under upper cervical care just don’t get as sick as those without. And such studies don’t exist either, do they?

    So again, WTF provided the basis for such claims in the first place? As I suggested once before, it is not based upon science but upon the interaction of commonplace clinical outcomes with a highly susceptible chiropractic psyche.

    It was always predictable that the instant you started putting patients through your elaborate “healing” ritual, many of them would find ways it which it was making them feel better. That, unfortunately, proves nothing.

  57. INNATE says:

    HH->”How can you expect to convince the rest of us if you can’t even convince the majority of chiropractors?”

    First, I’m not trying to convince any of you; I’m mearly trying to clear up misconceptions (honestly, have you ever had anyone explain to you the methods that I use? you never knew those existed, did you?). second, the majority of chiropractors do what they do out of choice; we have a choice of whether we want to do full-spine or upper-cervical. all full-spiners will give credence to upper-cervical methods (ask them) and upper-cervical chiros give credence to theirs. It’s simply a matter of how we want to spend our day. I’d rather spend my day doing the methods I expained because I resonate with the specificity and objectivity of it; and also because this is the method BJ did for the last few decades of his life.

    ““no studies on this, that I know of, but we’ve proved this among our own circles”

    What does that mean? What do you call proof?”

    well…several instances of pre- and post scans related to the “rotary-break” or “Gonstead cervical” adjustments (the kind of cervical adjustment all of you associate with chiroporactic) indicating that the post scan does not clear as it does with the adjusment that I do (the one on the youtube video). This is admetedly anecdotal but it is know and accepted among our circles. It would be interesting to conduct an actual study and one may even exist but to us it’s a non-issue. in fact, full-spiners don’t use thermography BECAUSE they know they can’t clear it and also because it’s specific to upper cervical techniques. They DO restore movement to the full-spine and extremities and that has value on other levels…people feel like they can go out and do stuff like exercise and sports and even labor when their spines have unrestriced motion in them.

  58. INNATE says:

    pmoran–I’m aware of suitable markers; I was just asking for your insight into other’s out of respect for your knowledge…I thought you would have been kind enough to oblige by providing a creative way to monitor overall health, but I guess not. thanks for the steps you outlined last night, that really helped (more than you know). I won’t bother you anymore.

  59. NMS-DC says:

    What a thread. It’s basically like reading a Democrat vs. Republican argument, no one is going to change anyone’s underlying biases and philosophies although let’s hope both sides get educated.

    Comment #1 directed to Dr. Novella:

    Your brief overview is not very reliable and misses a large amount of chiropractic history that is essential to understand the true dichotomy of the profession. Were you aware for example, that in 1898 the first graduating class of chiropractors immediately set-up a ‘competing’ chiropractic curriculum, one that had MDs and DOs on staff and essentially ‘merged’ chiropractic, osteopathy and medicine? The resulting college was National College of Chiropractic, now NUHS. If you don’t know the significance of NCC and Joseph Janse to the profession, then you are missing a large chunk of the development of the profession and your article is invalidated and not reliable.

    Comment #2 directed to Dr. Hall:

    Do you consider the CCGPP (www.ccgpp.org) a credible organization, and if so, have you read the evidence-based literature syntheses documents produced? If so, what is your opinion on them?

    Skeptics here (and there are plenty) you need to attack the BEST of chiropractic research and literature and the BEST practitioners for they are the standard bearer. You judge the profession by it’s research and contributions to science. Chiropractic medicine has had a very late start to it (and who blames them, the profession was ostracized by organized medicine since the beginning and couldn’t get any research dollars) but in the last 25 years a lot of good research has been published that supports the use of SMT for MSK conditions. So, it the very least chiropractic medicine is legitimate for MSK management.

    Subluxation is just another word for segmental dysfunction, somatic lesion, manipulable lesion, joint fixation/restriciton/dysfunciton. Research is being done to understand the effects of SMT on the ANS and the next 5-10 years will demonstrate whether or not is has a beneficial clinical effect for non MSK conditions. The Eisenberg data from the joint chiropractic/allopathic (not used in a deragatory sense) study yielded very favourable results. Physical medicine with pharmaceutical medicine each has their proper role in management of mechanical pain and wellness.

  60. NMS-DC says:

    Harriet,

    “Yes, it has sunk in. But it is irrelevant. SMT is associated with risks. Chiropractors are associated with SMT. SMT is their whole raison d’etre. So anything that worries us about SMT should worry us about chiropractic.”

    SMT used inappropriately or incompetently is dangerous. Is the clinical reasoning and skill of the practitioner and not the act itself. That’s why it’s important that any profession that wishes to use SMT regularly have proper skill, education and oversight. So, even though MDs are “licensed” to perform SMT, I wouldn’t trust my physician to give me an adjustment, anywhere. Same with PTs who think that 1 month of training in undergrad makes them the equivalent in skill.

    Put in another way, if I got my knee “butchered” by a surgeon I wouldn’t throw the whole orthopedic surgeon profession into disrepute I would blame the individual who had poor skills. IMHO, it’s the same thing with individual DCs who perform a) inappropriate or b) poorly executed manipulation.

  61. pmoran says:

    INNATE I did answer your question. There is no “general marker for health” because health is the default state.

  62. Harriet Hall says:

    NMS_DC asked me “Do you consider the CCGPP (www.ccgpp.org) a credible organization, and if so, have you read the evidence-based literature syntheses documents produced? If so, what is your opinion on them?”

    I read this:
    http://www.ccgpp.org/2.pdf
    I was not impressed. It surveys the literature on chiropractic treatment of nonmusculoskeletal disorders, showing that the evidence is shaky at best and mostly negative. Others have reviewed the same evidence and have concluded that there is no credible evidence that chiropractic benefits any nonmusculoskeletal condition. These guys concluded “Evidence from
    controlled studies and usual practice supports chiropractic care (the entire clinical encounter) as providing benefit
    to patients with asthma, cervicogenic vertigo, and infantile colic. Evidence was promising for potential benefit
    of manual procedures for children with otitis media and elderly patients with pneumonia.” This is wishful thinking, not rigorous scientific judgment.

  63. Subluxation is just another word for segmental dysfunction, somatic lesion, manipulable lesion, joint fixation/restriciton/dysfunciton

    Whatever word you apply to it, one of the major barriers to the skeptics on this blog accepting chiropractic is the lack of evidence that these subluxations exist.

    The big issue in my mind is the lack of interoperator reliability in diagnosing subluxations. Please see my comment above at on 26 Jun 2009 at 8:53 pm above. It’s the one with 9 citations, multiple of which discuss this problem.

  64. NMS-DC says:

    Whitecoattales

    First, you would have to agree that the general concept of joint dysfunction exists. In any medical speciality involving musculoskeletal medicine (including chiropractic medicine itself) there is a biomechanical, functional lesion in joints. The unique relationship between chiropractic and joint dysfunction is that spinal manipulation is believed to have a NEUROLOGICAL benefits, at a minimum, at the neuromusculoskeletal level.

    That’s a given already, as Dr. Hall and Novella have already conceded.

    Given that 95% visits to chiropractors involve some form of MSK it would seem that even the most ardent of skeptics would admit in the legitimacy of the appropriate of chiropractic medicine as a speciality in manual medicine for MSK function. However, sadly, this is not the case.

    Joint dysfunction exists, period, and the semantics are just that. The idea that biomechanical dysfunction has an effect on the nervous system is well established (neuromuscular, skeletal) has been proven both directly and indirectly.

    More recent palpation studies are available Whitecoattales, your list is dated:

    http://www.ncbi.nlm.nih.gov/pubmed/16904495?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed

    http://www.ncbi.nlm.nih.gov/pubmed/18984245?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed

    http://www.ncbi.nlm.nih.gov/pubmed/19539121?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed

    Assessment of joint dysfunction is both an art and a skill and generally speaking, where there is spine pain there is joint dysfunction at some level. The astute clinician will determine whether or not it mechanical pain that can benefit from SMT and prescribe an exercise to complement it. Also, the DIAGNOSIS of subluxation, IMHO is more of a FINDING than a diagnosis in itself and is always accompanied with some kind of focal soft tissue changes. Regardless, it is a physical entity, biomechanical in nature and should be noted in at the very least an orthopaedic sense.

    Semantics are getting in the way of proper interprofessional conduct and integration. The skeptics here simply cannot reasonably explain why they would oppose the integration of chiropractic doctors for MSK. This is primarily what they treat and the research on non MSK generated from 2010-2020 will determine whether DCs are valid in their claims of managing (not spinal manipulation per se) holistically (i.e. without pharmaceuticals) non NMS.

    So, you accept then, Whitecoattales, that chiropractic medicine is valid MSK?

  65. NMS-DC says:

    Harriet,

    Ok, we’ve established that you disagree on the appropriate of ANY chiropractic management of NMS.

    However, what was your opinion of the other literature regarding chiropractic management of low back disorders, thoracic and cervical spine pain, diagnostic imaging, soft tissue injuries, upper/lower extremity pain? What is your opinion on the methodology of these guidelines?

    Confront your skepticism in a constructive manner and LEARN about MODERN developments in the profession both in North America and Europe (particularly exciting there). Saying one doesn’t ‘believe’ in subluxations is not really a valid argument because that is saying that is not merit in spinal manipulation. The subluxation, at its core, is a manipulable lesion. One that DCs, DOs, PTs, MDs adjust.

  66. OZDigger says:

    Paradigm shift in manual therapy? Evidence for a central nervous system component in the response to passive cervical joint mobilisation

    We found consistency for concurrent hypoalgesia, sympathetic nervous system excitation and changes in motor function. Pooling of data suggested that joint mobilisation improved outcomes by approximately 20% relative to controls. This specific pattern suggests that descending pathways might play a key role in manual therapy induced hypoalgesia. Our review supports the existence of an alternative neurophysiological model, in which passive joint mobilisation stimulates areas within the central nervous system.
    Man Ther. 2008 Oct;13(5):387-96. Epub 2008 Mar 3

    Something from the physiotherapists. Probably wasted on most of you, but it does talk about the neurophysiological effects of joint mobilisation.

  67. Joe says:

    @NWS

    You say we should judge chiros by the “best” in that job. No, one must judge them by their education, and by their beliefs. The education centers on a non-existent subluxation and Innate. http://www.chirocolleges.org/paradigm_scopet.html And, by your own surveys, 90% of chiros believe in subluxations http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B75KC-4F1H9GS-5&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=754fe88415cd702aa52be6484f7005b8 In addition, they can geaduate and set-up shop with no meaningful experience http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53681&MERCURYSID=9ac341fe894c032f3c98ee00405aa420

    Now you want us to give you 5-10 years to determine if your services have validity?! Please explain to me why you should be allowed to continue as if your job had validity.

  68. Joe says:

    The British Chiropractic Association is suing Simon Singh for saying there is no evidence that chiro is effective for colic, asthma, etc. The BCA has now released its list of articles supporting use of chiro for those conditions http://www.chiropractic-uk.co.uk/gfx/uploads/textbox/Singh/BCA%20Statement%20170609.pdf It is pathetic. Ten of the papers are irrelevant! The rest are some set of: uncontrolled, unblinded or have too few subjects.

  69. Diane Jacobs says:

    OZDigger-> “Evidence for a central nervous system component in the response to passive cervical joint mobilisation. We found consistency for concurrent hypoalgesia, sympathetic nervous system excitation and changes in motor function. Pooling of data suggested that joint mobilisation improved outcomes by approximately 20% relative to controls. This specific pattern suggests that descending pathways might play a key role in manual therapy induced hypoalgesia. Our review supports the existence of an alternative neurophysiological model, in which passive joint mobilisation stimulates areas within the central nervous system. Man Ther. 2008 Oct;13(5):387-96. Epub 2008 Mar 3. Something from the physiotherapists. Probably wasted on most of you, but it does talk about the neurophysiological effects of joint mobilisation.

    Diane (further up) -> “Yeah. But the thing is, almost anything from education about pain to physical handling of the lightest skin-only sort of manual contact can do that. Anything that changes sensory-discriminative input. So, what kind of pain patient needs high velocity manipulation, in that case? Very very very few. Vanishingly few.”

    I.e., any kind of manual contact (including that which was limited to skin only) would likely produce the same neurological results. It’s logically impossible IMO to rule out effects of ordinary human primate social grooming on the outer layer of the body on both the peripheral and central nervous systems.
    1. So, why do chiros (and others, like orthopaedic manipulative therapists) seem to think they have to push joints around in order to get results of the most generic neurophysiological sort? Especially when skin (most conveniently located on the outside of the body) has the densest afferent innervation recognizable at conscious levels of the brain?
    2. In their studies on joint manip effects, do they remove skin first, so that it does not end up being a confounding factor as they try to isolate neural responses from joint manipulation? I think not.
    3. In that the nervous system signals at a rate of something like 270 mph, how does one isolate effects from joints without considering possible artifact effects from skin?
    4. Wouldn’t it be more scientifically appropriate to first consider, then figure out a way to rule out afferent neural noise from skin? Why continue to hypothesize that joint afferent effect is more important than skin afferent effect? I’ve seen nothing that would ever convince me it is, in over 40 years of being a PT and manual therapist/human primate social groomer.

  70. Joe – thanks for the link. The list of 20 studies are all but worthless, and of course they did not include the well-designed studies that refute their claims. This deserves a separate analysis.

  71. First, you would have to agree that the general concept of joint dysfunction exists. In any medical speciality involving musculoskeletal medicine (including chiropractic medicine itself) there is a biomechanical, functional lesion in joints.

    Trivial point

    The unique relationship between chiropractic and joint dysfunction is that spinal manipulation is believed to have a NEUROLOGICAL benefits, at a minimum, at the neuromusculoskeletal level.

    Believed by who? Anyone who ISN’T a DC?

    Given that 95% visits to chiropractors involve some form of MSK it would seem that even the most ardent of skeptics would admit in the legitimacy of the appropriate of chiropractic medicine as a speciality in manual medicine for MSK function. However, sadly, this is not the case.

    Argumentum ad populum. This says “people use chiropractic, ergo chiropratic must be a valid speciality.” Without evidence of efficacy, and evidence that chiropractic will stop holding it’s many anti-scienctific beliefs, this is without value.

    Joint dysfunction exists, period, and the semantics are just that. The idea that biomechanical dysfunction has an effect on the nervous system is well established (neuromuscular, skeletal) has been proven both directly and indirectly.

    None of this says anything about the value of chiropractic manipulation.

    More recent palpation studies are available Whitecoattales, your list is dated:

    Let’s see about that shall we?

    http://www.ncbi.nlm.nih.gov/pubmed/16904495?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed

    Noone said that people couldn’t consistently identify osseus and soft tissue pain, which is all this paper talks about. MD’s palpate as well. We don’t claim to have found a manipulable lesion, which is the important part of the claim. Saying you can poke at someones back and consistently find where it hurts is meaningless.

    http://www.ncbi.nlm.nih.gov/pubmed/18984245?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed

    From the results:

    After removing articles that did not meet the inclusion criteria, 44 were considered relevant and appraised for quality. Fifteen studies focused on MP excursion, 24 focused on end feel, and 5 used both. Eight studies reported high levels of reproducibility (kappa = >or=0.4), although 4 were not of acceptable quality, and 2 were only marginally acceptable. When only high-quality studies were considered, 3 of 24 end-feel studies reported good reliability compared with 1 of 15 excursion studies.

    Out of 44 papers, 8 showed reliability, of which 4 were poor quality. 4 out of 44 papers showed interobserver reliability. Additionally, this paper didn’t set out to assess interoperator reliability. It was intended to compare between different methods of palpation. That’s some weak kung fu.

    http://www.ncbi.nlm.nih.gov/pubmed/19539121?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed

    From the paper:

    CONCLUSION: Reported indices of agreement were generally low. More of the pain palpation studies reported acceptable kappa levels, although no one method of palpation could be deemed clearly superior.

    So again, no validity, same basic conclusions as the paper above.

    I’m curious, did you not read the papers before you cited them? Or did you just think I wouldn’t read the papers?

    Assessment of joint dysfunction is both an art and a skill and generally speaking, where there is spine pain there is joint dysfunction at some level.

    I dispute this assertion. This is exactly the statement that I’m saying the literature disagrees with.

    The astute clinician will determine whether or not it mechanical pain that can benefit from SMT and prescribe an exercise to complement it.

    The astute clinician will look at the evidence, and see that chiropractic manipulation is not warranted in almost any case.

    Also, the DIAGNOSIS of subluxation, IMHO is more of a FINDING than a diagnosis in itself and is always accompanied with some kind of focal soft tissue changes. Regardless, it is a physical entity, biomechanical in nature and should be noted in at the very least an orthopaedic sense.

    Finding, or diagnosis, either way without a reliable way to find or diagnose it, it’s meaningless, and it’s existance is in question.

    Semantics are getting in the way of proper interprofessional conduct and integration.

    This is not semantics. If you are saying you find and treat lsions, then you should be able to consistently find the lesion. You haven’t shown that.

    The skeptics here simply cannot reasonably explain why they would oppose the integration of chiropractic doctors for MSK.

    Yes. We can.
    1. The theory of chiropractic is nonscientific, indeed, antiscientific.
    2. The studies that chiropractors cite as being “pro chiropractic” are always weak at best, and so far, disagree with the balance of the evidence.
    3. The efficacy of chiropractic has yet to be proven in any meaningful setting.

    This is primarily what they treat and the research on non MSK generated from 2010-2020 will determine whether DCs are valid in their claims of managing (not spinal manipulation per se) holistically (i.e. without pharmaceuticals) non NMS.

    If in 2020 the research shows the DCs are valid in their claims, then I’ll consider chiropractic valid then. SO far, the research shows chiropractic isnot valid.

    So, you accept then, Whitecoattales, that chiropractic medicine is valid MSK?

    Absolutely not. Why should I?

  72. healthnut says:

    weing, you asked;

    “By this do you mean that you are over prescribing? Are you also saying that your understanding of nutrition is inadequate?”

    Obviously the answer to the first question is no. I realized long ago that many PCPs used the meds I mentioned incorrectly and it had become the norm. To anwer your second question, Yes. I did have the inadequate training and lack of clinical applications for nutrition. I went back to school 6 years ago and obtained my Clinical Nutrition Certification. I went with a friend who is a IM doc and we were blown away at how much we didn’t learn and how much there is to know. I rarely if ever use statin drugs anymore. Most GERD patients respond to supplementation and diet so they don’t require PPIs. Many patients have depression issues due to a variety of deficiencies such as D3. I use far less PT and surgeons for spinal problems and utilize 2 chiropractors. All of this has increased patient satisfaction, reduced medication risks and made my patients healthier and testing such as blood and radiography has shown it.

  73. weing says:

    “I realized long ago that many PCPs used the meds I mentioned incorrectly and it had become the norm.”
    Oh, so you ran a study of the PCPs in your area. What were their reasons for over prescribing?

  74. nobs says:

    Healthnut->>”I rarely if ever use statin drugs anymore.”

    Around here, statins are prescribed like the new VIT C.
    Yet, with the script, I have never seen a concommitant(prescribed or even suggested) COQ10.

    I look forward to your comments on this.

    Thank-you

  75. weing says:

    What would be the reason for prescribing an unproven medication, one that can be bought without a prescription, and one that you have no way of knowing that it is in the pill?

  76. coryblick says:

    “The subluxation, at its core, is a manipulable lesion. One that DCs, DOs, PTs, MDs adjust.”

    Uh, no we don’t. Substituting one undefined term for another doesn’t exactly clarify the issue.

    Adjust….this term alone implies a need for continual care, whether or not you actually promote it directly, it’s there…the implication. And it also implies that the body is like a car, something that needs alignments and adjustments and so on and similar to a car is a mechanical machine. Both of these implications are wrapped up in this awful term to the detriment of the patients that so quickly identify with it (after all, most have cars) and PTs do NOT adjust “manipulable lesions.” Whatever those are. Nor do I imagine does any professional other than DCs.

  77. healthnut says:

    weing, I don’t want to be rude but you aren’t very bright are you??

    Seriously?!

    I didnt need to run a survey of docs in my area to know what is over prescribed nationally, well are all aware of the abuse. I also explained why it is happening, aren’t you able to follow along???

    In regard to prescribing supplementation for health problems, your comments are uneducated on the topic. We use medicinal grade supplements from companies that only sell to providers that have paid to bring in regulation to ensure quality. Much of Andrew Weils program outlines the current research. Are you really asking me why I choose to avoid statin drugs. Do you want to compare risk factors for patient’s with their use. Lowering cholesterol is very easy in many cases without prescribing these drugs.

    Please have a better understanding before you reply. Your arguments are uneducated from a literature and practical stand point.

  78. nobs says:

    Thank-you Healthnut-

    Your strong response is refreshing on this site of pseudoskeptics.

  79. Joe says:

    @ healthnut on 02 Jul 2009 at 11:21 am “weing, I don’t want to be rude but you aren’t very bright are you?? … Much of Andrew Weils program outlines the current research.”

    healthnut, I don’t want to be rude but you aren’t very bright are you??

    Andrew Weil is a notorious crackpot. If you cannot figure that out, what can I say? http://www.quackwatch.org/11Ind/weil.html

  80. weing says:

    healthnut,
    I guess you are correct, I must not be too bright. Your kung fu is much stronger. Who needs to study what everybody knows already? Why bother verifying efficacy and safety of Q10 since you already know it works? You don’t need to do the expensive studies like those done on statins to prove efficacy and safety. Stupid me. And it’s only about a dollar a day.

  81. OZDigger says:

    Joe,

    quoting Quackwatch destroys your argument from the start. It is a site that has no credibility. Barretts integrity has been called to question many times, especially a Royal Commission of Inquiry.

  82. Joe says:

    OZDigger on 02 Jul 2009 at 1:18 pm “Joe, quoting Quackwatch destroys your argument from the start.”

    Okay, tell me what is technically, significantly wrong with an article there. One person chose to object to Dr. Barrett’s bio there; but that is not technical. It is wishful, distorted ad hom.

    Also, the Royal Commission, to which you refer, was a joke comprised of three people (a lawyer, a school headmistress and a chemist) with not a jot of knowledge of medicine among them. Their conclusion was bogus; it reads like a Monty Python script.

    Tell me, if you don’t feel well would you consult one of those people? Really- a school teacher …

    To the cognoscenti, Quackwatch is the best, general source about sCAM on the web. sCAMmers sniffle the Dr. Barrett is “so mean;” but none of them has been able to invalidate any technical article at the site, and there are thousands of such articles. I would expect a certain error rate; but, so far, you guys cannot demonstrate it.

  83. healthnut says:

    weing, I don’t remember ever mentioning CoQ10, although it is a good supplement. Dollars per day on statins you mentioned. You are right, we should put every high cholesterol patient on a drug that has a laundry list of severe side effects instead of changing diet, exercise and using supplements because you wont accept the literature cause it wasn’t peformed in a Big Pharma study.

    Statins have been shown to be less effective and have more risk than taking red yeast rice daily. Even Big Pharma’s recent studies have not been kind to statin use.

    Joe,

    Quackwatch has zero credibility. If that is your smoking gun in defense of your stance? Andrew Weil has one of the largest residency programs in the country. Hospital systems around the world are sending their practitioner’s through his program. Are you really pinning your credibility on a doctor who was found biased and unqualified to testify objectively?

  84. nwtk2007 says:

    Statins are just another example of medicine gone overboard with something that is not welll understood and much more potentially harmful that ANY chiropractic treatment.

    The science is bad and not undertood by most doctors.

    The problem is that the harmfull effect on coronary arteries is due to oxidized LDL and the LDL levels are really not relevant or related to coronary artery disease (plaque) formation.

    Lowering LDL has no effect. Lowering oxidized LDL does. Statins apparently do not lower or reduce oxidized LDL’s to a safe level.

    Fooling patients into taking a drug that is not needed is exactly what the anti-chiro’s accuse the chiro’s of; prescribing a treatment that they feel is not effective. Two way street I’m afraid.

    Anyway, I have to get back to providing my placebo treatments for my patient’s as they seem to work so well. And no side effects.

  85. Lowering LDL has no effect. Lowering oxidized LDL does. Statins apparently do not lower or reduce oxidized LDL’s to a safe level.

    Citation?

    Anyway, I have to get back to providing my placebo treatments for my patient’s as they seem to work so well. And no side effects.

    Still no reply to my response to your question up above? You asked the question, came back, and said “no replies yet”, then when a reply came up, ignored it.

    Statins have been shown to be less effective and have more risk than taking red yeast rice daily. Even Big Pharma’s recent studies have not been kind to statin use.

    1. Citation? You make a comment on the efficacy of red yeast rice, AND the lack of efficacy of statins. The is interesting because…
    The active ingredient in red yeast rice is…. *drumroll* Lovastatin.

  86. Insight says:

    This forum has gone to Stephen Barrett as it’s validation.
    That pretty much sums up this crowd. The rational medical
    world views him as a radical, close minded crack pot. I should
    not be shocked he has a following here.

    whitecoattales,

    I think by mentioning Lovastatin you just proved her point.

  87. Joe says:

    healthnut on 02 Jul 2009 at 3:02 pm “Joe, Quackwatch has zero credibility.”

    I keep hearing that; but nobody can back it up. So- be the first to show us why.

    As far as how many disciples Weil has, that is a fallacious ad pop argument, … when you see flies swarming on road-kill are you tempted to join them?

  88. nobs says:

    Insight->>”This forum has gone to Stephen Barrett as it’s validation.

    YUP—– the one and same that the courts found, “biased and without credibility” . NO publications in peer-reviewed, indexed journals………..HMMMMMM

    Glad to see you are still here Insight. I always look forward to your posts. Keep ‘em coming! Thanks for your time.

  89. nobs says:

    Insight-

    Per your previous post……let me direct you to a site I know you will enjoy:

    Who Watches The Quackwatchers?
    http://randomjohn.wordpress.com/2005/12/29/data-please-holding-quackbusters-to-their-own-standards-part-i-prometheus-unhinged/

    Data please: holding quackbusters to their own standards, Part II
    http://randomjohn.wordpress.com/2005/12/29/data-please-holding-quackbusters-to-their-own-standards-part-ii-orac-you-know/

  90. Fred Dagg says:

    Hi Joe,

    Let me see, it is a big choice here?
    Quackwatch or Harvard University???????/
    Quackwatch or JMPT?
    Quackwatch or Royal Commission of Inquiry?

    I think that Quackwatch and all who sail in it lose.
    Sorry Joe, it is not a credible citation. Barrett is a “propagandist”, and his status to the commission was zip, none, insignificant.
    If you doubt the commissioners validity, remember that they had susmissions on behalf of the Chiropractors, Physiotherapists, Medical Practitioners and others. Any conclusions that were made, were made on the quality of the evidence given to them.
    The Royal Commission into Chiropractic was very favourable to Chiropractic. Comments to the contrary are just sour grapes.

    http://www.chiro.org/LINKS/New_Zealand_Report.shtml

    See what they said about Barrett and his cahouts. You did not have to be a rocket scientist to come to that conclusion about his integrity and motives.

  91. I think by mentioning Lovastatin you just proved her point.

    How?
    She’s criticizing statins, suggesting without reference that an anternative treatmet is better. Then it turns out, her alternative treatment’s active ingredient is a statin.

    What then, could her point have been?

  92. weing says:

    Fred,
    It’s already been established that I am definitely not a rocket scientist. So, what are Barrett’s motives? What are the motives and integrity of the Royal Commission of Inquiry? What are the qualifications of the Commission?

  93. weing says:

    whitecoattales,

    I’m not even sure about that. Check out:
    http://www.theheart.org/article/805737.do

  94. pmoran says:

    “Let me see, it is a big choice here?
    Quackwatch or Harvard University???????/
    Quackwatch or JMPT?
    Quackwatch or Royal Commission of Inquiry?”

    What specific medical claim are we considering here? Generalizations create confusion and unnecessary conflict.

    For example, many like to demonize Quackwatch. But it criticises medical activities that nearly everybody, including most “alternative” supporters, regard as fraudulent or silly, also claims that have been proved to be false and that AM itself has largely distanced itself from e.g. some extravagant claims once made for vitamin C.

    On other matters, such as chiropractic, it has more qualified opinions.

    So, what exactly is in dispute here?

    The NZ commission was utter rubbish, in my opinion. The commissioners lacked the background needed to assess primary sources of evidence. They seem to have relied upon secondary opinion and gossip. I am aghast at some of the material that they thought worth considering. The decision seems to have gone to those prepared to rely upon the character assassination of opponents.

    In my view Eisenberg’s claims regarding the use of certain manual methods for chronic back pain at Harvard hang upon whether objective and cost-effective outcomes are confirmed. Other skeptics might see the use of acupuncture, even on that basis, as risking a slippery slope into quackery. They would be divided regarding spinal manipulation, as the evidence remains somewhat equivocal as to whether it may sometimes have useful intrinsic activity in this context. .

  95. weing says:

    “You are right, we should put every high cholesterol patient on a drug that has a laundry list of severe side effects instead of changing diet, exercise and using supplements because you wont accept the literature cause it wasn’t peformed in a Big Pharma study.”

    Citations, please.

    “Statins have been shown to be less effective and have more risk than taking red yeast rice daily. Even Big Pharma’s recent studies have not been kind to statin use.”

    Really? By whom? What Big Pharma studies? Dialysis patients?

    The aim is science based medicine, not anecdote based medicine.

  96. nobs says:

    weing->>”The aim is science based medicine, not anecdote based medicine

    And off-label prescription would be ………… ?????

  97. And off-label prescription would be ………… ?????

    …generally speaking, off-label prescription is the freedom doctors require to generate grist for the science mill that makes the science mill.

    Noone is objecting to anecdotes as the start of a hypothesis. We’re objecting to anecdotes as the endpoint.

  98. generate grist for the science mill that makes the science mill.

    My that was incoherant of me

    lets render that:

    “generally speaking, off-label prescription is the freedom doctors require to generate grist for the science mill… “

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