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Chiropractic Defense: Tempest in a Teapot

When Forbes.com published Steven Salzberg’s article “New Medicare Data Reveal Startling $496 million wasted on Chiropractors” (April 20, 2014), a flood of mail (more than 300 comments) from chiropractors and their patients provided a wealth of evidence that subluxation-based chiropractic is alive and well despite rejection by the scientific community. Pro-chiropractic comments laced with anti-medical rhetoric and ad hominem attacks, expressed with religious fervor, failed to distinguish between generic spinal manipulation (that can be useful in the treatment of mechanical-type back and spinal problems) and chiropractic adjustments used in an attempt to restore and maintain health by correcting vertebral subluxations. No distinction was made between a real, symptomatic orthopedic subluxation and an imaginary, asymptomatic chiropractic “vertebral subluxation complex,” neither of which has been shown to be a cause of bad health. While the chiropractic profession may have some justification for objecting to any suggestion that chiropractic treatment has no value whatsoever, especially in the case of mechanical-type back pain and other musculoskeletal problems, the tone and content of many of the comments by chiropractors provide good examples of why chiropractic is so often criticized by the scientific community.

A quote in the Forbes article, from my Science-Based Medicine article “Chiropractic: A Summary of Concerns,” brought this comment from a prominent chiropractor:

…Harriet Hall, Edzard Ernst, Jann Bellamy, and other current renowned medical bigots who attack all CAM providers but turn a blind eye to the dangers of the medical profession….Steven, your chiro critics are invalid—none of them are researchers or educators, but they are just disgruntled practitioners from yesteryear. Don’t get me started on the Science-Based guys who are just haters like you—Harriet Hall, Edzard Ernst, Jann Bellamy are renown medical bigots.

Chiropractors who subscribe to the current chiropractic paradigm (which proposes that a subluxation complex will “compromise neural integrity and may influence organ system function and general health”) often attempt to equate use of chiropractic adjustments to treat health problems with spinal manipulation used in the treatment of back pain. Subluxation-based chiropractors might also refer to medical literature describing an orthopedic subluxation to support the existence of a putative chiropractic subluxation. While a case can be made for treatment to relieve musculoskeletal symptoms caused by an orthopedic subluxation, which is not a common occurrence, there is good reason to question why Medicare (or anyone) would pay for treatment of an undetectable “chiropractic subluxation” that is alleged (by chiropractors) to be so common that it is routinely entered as a diagnosis on chiropractic Medicare claims. Since Medicare coverage of chiropractic service is specifically limited to use of manual manipulation of the spine to correct a subluxation that can be demonstrated by x-ray or physical examination, it seems logical to assume that a diagnosis of “subluxation” on a chiropractic Medicare claim is rarely appropriate.

Until consensus forces chiropractic associations to publicly renounce the implausible chiropractic vertebral subluxation theory, requiring changes in state laws and the curriculum of chiropractic colleges across the board, chiropractic will continue to be defined by pseudoscience that keeps the profession marginal and isolated. In the meantime, science-based chiropractors who use manipulation appropriately will have to make an effort to separate their work from the stigma associated with inappropriate use of manipulation based on chiropractic subluxation theory.

The conflict between chiropractic and medical science won’t change until all concerned are able to meet on common ground governed by the laws of anatomy, physiology, and other basic sciences. Unfortunately, groups guided by a belief system do not often yield to facts that are contrary to a self-perpetuating dogma, making it necessary to speak out on the side of science in the best interest of persons who might become victims of such dogma.

Facts as proof vs dogma as proof

There are many legitimate studies published in peer-reviewed scientific journals supporting use of spinal manipulation as an appropriate form of manual therapy in the treatment of back pain. There is also a plethora of journals published and reviewed by chiropractors who are dedicated to promoting chiropractic subluxation theory as an approach for treating a great variety of ailments in all age groups, e.g., Journal of Vertebral Subluxation Research and Journal of Clinical Chiropractic Pediatrics. Articles in such journals are often offered as proof that treatment based on subluxation theory is effective, but few are able to withstand the scrutiny of scientific review. When Simon Singh, a British science journalist, said in a 2008 Guardian article (“Beware the Spinal Trap”) that chiropractic treatment of certain childhood ailments, endorsed by the British Chiropractic Association (BCA), was “bogus,” the BCA sued Singh for libel and presented 29 cherry-picked studies purported to support chiropractic treatment for such ailments as colic, nocturnal enuresis, otitis media, and asthma. Few of the articles were scientifically acceptable; all were of poor quality, with the totality of evidence actually negative. (See “The British Chiropractic Association Responds to Simon Singh,” Novella, Science-Based Medicine, July 8, 2009.) The BCA lost its suit against Singh.

In 2010, following the Singh suit, the General Chiropractic Council of the United Kingdom issued a declaration stating that “The chiropractic vertebral subluxation complex is an historical concept but it remains a theoretical model. It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.” The British Chiropractic Association responded by advising its members that the advice of the General Council had no bearing on scope of practice.

To date, I have seen only one credible study that has objectively examined chiropractic subluxation theory. In 2009, Timothy A. Mirtz, et al, using Hill’s criteria of causation, reported in Chiropractic and Manual Therapies (17:13) that “No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention.” Unfortunately, questions about the validity or the plausibility of chiropractic subluxation theory have not had any influence on the politics and policies of major chiropractic associations. Chiropractic associations usually respond to criticism of chiropractic care by comparing conservative care of back pain with medical care of back pain, presenting chiropractic as the superior treatment method without renouncing chiropractic subluxation theory that embraces a broad scope of health problems.

Journalism in the public interest

Few among us in the general public are able to evaluate the research published by chiropractic organizations and journals, often distributed by “press releases” and provided as a “public service” to newspapers and television stations. When there is a negative response to news that chiropractic is effective in treating a variety of health problems, chiropractors may respond by providing a long list of articles providing “facts about chiropractic,” published in chiropractic journals, offering “proof” that chiropractic can treat more than just back trouble. As in the case of the BCA-Singh suit dealing with childhood ailments, however, few of these articles would withstand scientific analysis, despite being viewed favorably by the public.

Judging from the increasing popularity of alternative medicine, science seems to be losing its battle against scams, quackery, and pseudoscience. The simple explanations offered by alternative medicine practitioners who offer anecdotes and testimonials as proof that their treatments are effective are appealing to persons who are unable to recognize the signs of pseudoscience and to entrepreneurs and health-care providers who can benefit financially from integration of questionable but popular treatment methods. Until the public as a whole is more well-informed and better educated in science and critical thinking, it will be necessary for science journalists to make every effort to protect the public by speaking out about the methods of charlatans, vendors, and well-meaning but misinformed practitioners and groups who offer inappropriate treatment to persons who are sick, in pain, or disabled.

When I write articles critical of chiropractic subluxation theory and inappropriate use of manipulation by subluxation-based chiropractors, I always make an effort to support the use of spinal manipulation as a form of manual therapy in the treatment of back trouble and related neuromusculoskeletal problems, no matter who uses such treatment. Unfortunately, chiropractic subluxation theory continues to be supported by a significant number of chiropractors, making it difficult to find a chiropractor who uses manipulation appropriately. Few chiropractors openly criticize subluxation-based chiropractic; those who do may claim that chiropractors who subscribe to subluxation theory are in the minority. The response of chiropractors to criticism of subluxation-based chiropractic, however, appears to indicate that the majority of chiropractors have not abandoned subluxation theory.

Despite the condemnation proffered by colleagues who view me as a hostile critic of chiropractic, I have always felt compelled to speak out against harmful or useless treatment methods used by practitioners who represent my profession. I have no objections to the work of science-based chiropractors who limit their treatment to care of musculoskeletal problems. I simply want to see spinal manipulation used appropriately by chiropractors and others who use manual therapy. I have always made an effort to be truthful to the best of my ability when people came to me for help or advice. When I published Bonesetting, Chiropractic, and Cultism in 1963, renouncing subluxation theory, I stood alone, knowing that publication of the book placed me in jeopardy of losing my license and my livelihood. Chiropractic journals refused to publish my articles. When the National Association for Chiropractic Medicine (NACM) was formed in 1983, members were required to renounce subluxation theory. The NACM provided opportunity for reform of the chiropractic profession and a safe haven for scientifically-oriented chiropractors. The association was able to attract only about one hundred members, however, and has since disbanded. I suspect that such an association today would not be any more successful than the NACM was in 1986 when I was a member.

Reviewing the first copy of my book Bonesetting, Chiropractic, and Cultism, with my wife, Martha, in 1963.

Reviewing the first copy of my book Bonesetting, Chiropractic, and Cultism, with my wife, Martha, in 1963.

The paper trail of a “chiropractic heretic”

Although my Bonesetting the book was reviewed by the Library Journal in 1964, it was never reviewed by a chiropractic association. When it was reviewed by Joe Keating, Ph.D., in 1990, he concluded with this statement:

Although chiropractors may take exception to Dr. Homola’s over-estimation of the scientific status of medicine, the historical value of his review of the state of chiropractic in 1963 is unmistakable. The good doctor has since authored and co-authored a number of widely read books on diet, exercise and nutrition, and continues in private practice (limited to “neuromusculoskeletal” disorders) in northern Florida. Perhaps the profession will finally seek out this seer before his most dire predictions come to pass.
Dynamic Chiropractic, January 3, 1990

Today, many members of the chiropractic profession still view me as “the turncoat” who wrote Bonesetting, Chiropractic, and Cultism. I suspect that my demise will be celebrated by subluxation-based chiropractors who have contributed to my file of hate mail over the years. Hopefully, the paper trail I leave behind will show that I always acted in the best interest of the public and my patients by following the guidelines of science. I will rest in peace knowing that my views were well received by the scientific community and that much of the criticism I endured came from persons who felt threatened by scientific scrutiny of a belief system that governed their lives and their livelihood. A collection of letters in my file (Letters to a Chiropractic Heretic) contains notes from chiropractors who harbored views similar to mine and who were encouraged by my work but were reluctant to speak out for fear of ostracism.

I am comforted by the public support of a few outspoken individuals in my profession, such as Timothy A. Mirtz, Ph.D., D.C., who recently offered this response to criticism of one of my Science-Based Medicine articles:

Dr. Homola is indeed a DC himself with a long history of writing in the profession. In fact, his book, Bonesetting, Chiropractic, and Cultism was written in 1963. It is a magnificent read and if you read it today you would think he would be talking about today….I believe we owe him a debt for being the first to essentially speak out about the madness that we all find embarrassing. He is and should be honored as the Godfather of Chiropractic Reform.

Thank you, Dr. Mirtz. And thanks to all those who have supported me over the years, especially the scientific community that gave me a platform for my views. Publication of my articles on chiropractic in such peer-reviewed medical journals as Archives of Family Medicine and Clinical Orthopaedics and Related Research following my retirement from the practice of chiropractic belie the accusations of critics who say that I am simply an ignorant, disgruntled practitioner of yesteryear. In a stand diametrically opposed to the views of my chiropractic detractors, I am proud to be associated with such “medical bigots” as Harriet Hall, Edzard Ernst, and Jann Bellamy. And I am honored to be among the “haters” who write for Science-Based Medicine.


sam-bio

Sam Homola is a retired chiropractor who has been expressing his views about the benefits of appropriate use of spinal manipulation (as opposed to use of such treatment based on chiropractic subluxation theory) since publication of his book Bonesetting, Chiropractic, and Cultism in 1963. He retired from private practice in 1998. His many posts for ScienceBasedMedicine.org are archived here.

Posted in: Chiropractic, History

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51 thoughts on “Chiropractic Defense: Tempest in a Teapot

  1. FastBuckArtist says:

    When Forbes.com published Steven Salzberg’s article “New Medicare Data Reveal Startling 96 million wasted on Chiropractors” (April 20, 2014)

    $496 million actually. No wonder Steven is jealous, he didnt get any of that booty. His article is antagonistic and trollish – surely he understands that not the entire amount is wasted and many patients have received a quality service (even if its just a fancy massage). I could write an article like this claiming that “An astounding $100 billion has been wasted on allopathic medical treatments” but whats the point? It would just incite anger from the medical community and produce no meaningful reconciliation with conventional medicine.

    1. DevoutCatalyst says:

      Steven ?

      1. Sean Duggan says:

        Obviously, DBA is suffering from a chiropractic subluxation preventing blood flow to the part of the brain that processes names…

        1. Sean Duggan says:

          :-P And then I flub the abbreviation of his name… go figure.

        2. Frederick says:

          when I read the article early this morning there’s was no comment, I going to work so no time to place a the comment I wanted, Instead the first one is FBA, lol. not the best first comment to have :-)

    2. Windriven says:

      “. I could write an article like this claiming that “An astounding $100 billion has been wasted on allopathic medical treatments” but whats the point? ”

      First, your number would be too low by a breathtaking amount. Huge amounts of money are wasted on medical treatments that are ineffective and even more on treatments that are overused. The Atlas Project out of Dartmouth would be a good starting point for your research.

      Is it your fantasy that science based medicine embraces ineffective treatments or the overuse of valid medical treatments? Think again.

    3. WilliamLawrenceUtridge says:

      I could write an article like this claiming that “An astounding $100 billion has been wasted on allopathic medical treatments” but whats the point?

      Except allopathic medicine doesn’t exist (proven medicine does) and proven medicine isn’t wasted since it’s proven to work. Not always, not with all patients, but unlike CAM it does work for at least some.

      1. Andrey Pavlov says:

        “An astounding $100 billion has been wasted on allopathic medical treatments” but whats the point? It would just incite anger from the medical community and produce no meaningful reconciliation with conventional medicine.

        Precisely. Vastly more money has been spent without positive result. But that is not wasted. We could talk about how much money was “wasted” in the initial Mercury 7 program – just look at how many engine designs failed, rockets blew up, and billions of dollars literally burned to ash. But we can only say that in retrospect. We need to do tests and figure out what works. You can’t magically know which design, test, path, etc will be “the one.” So money and time must be expended in order to determine that. But it is not fruitless – which is why we so often say here that negative results are valuable! The problem is we have forgotten that in large part and feel like a negative trial becomes a waste of money.

        The difference with CAM is that it provides a much more sure way to get a negative result. In a perfect world I would be all for testing everything imaginable. With endless resources (both financial and intellectual) I could care less if someone decided to waste his or her life researching homeopathy. But we don’t live in that world (and never will). So if something has plausibilit yand a good rationale along with the legitimate potential for clinical use, then by all means do a trial. But with CAM – like the TACT trial – there are so many better ideas out there that it is almost criminal to spend that kind of money on something as low yield and ideologically driven as chelation. Particularly when the NIH funding line keeps dropping and (last I heard) was at 7% putting the likes of Dr. Gorski’s lab in jeopardy. It’s not so much a question of whether TACT had absolutely zero chance of any positive results, but more a question of which other lab/study/trial isn’t being funded that has a higher chance of results.

        Now that’s in a vacuum of course. There are ethical considerations added on to that, but it plays into the same premise – the confidence in positive results is directly related to clinical equipoise. Which is why Dr. Atwood very correctly stated that a trial like this should have gone through appropriate animal modeling and bench work first. That is where we can be much more lax in our prior probabilities because we both expect a higher rate of failure and can tolerate a higher rate of failure because actual human lives are not in play.

    4. Stephen H says:

      FBA, why should “a fancy massage” be labelled as a medical treatment and paid for out of taxpayer money? If I pay for a fancy massage with quality service, I expect to receive that massage (I wonder, is “quality service” a euphemism for a “happy ending” (yes, another euphemism)?).

      Of course, your comparison of money wasted on quackery with money used to provide proven treatments for injury and illness is ridiculous. That said, I look forward to reading your properly researched and referenced article when it becomes available. I am keen to see the studies you use to prove your point, and the basis you use in deciding what treatments are appropriate.

      1. Andrey Pavlov says:

        Stephen H:

        I, for one, would actually like to have some insurance coverage for actual massage. I can’t speak to the economics of it, so perhaps it is too pie-in-the-sky, but in an ideal world I would love to be able to prescribe my patient a massage or a spa day and have it at least subsidized by insurance. We here view that as nothing but decadent luxury. The French, for example, do not and do exactly that – doctor’s scripts and insurance coverage for massage and spa. Perhaps our cultural outlook on it will make it a tougher sell or less effective (for myriad reasons I can think of but won’t belabor), but there are many benefits to massage including decreasing anxiety. And we have data to show that people who are less anxious and more relaxed are better capable of taking better care of themselves and their loved ones.

        But of course, that is distinctly different to doing quackery and calling it massage.

        1. WilliamLawrenceUtridge says:

          Massage, yes. Spa? You lose me.

          1. Andrey Pavlov says:

            Massage, yes. Spa? You lose me.

            Besides the fact that spas can also help relax muscles and reduce pain, there is a psychosocial component at play here as well. Facilitating a better psyche in your patient has salubrious effects on myriad facets of their lives.

            1. Science is about data, observation and facts.

              Politic, finances, cost and person topic should not be mixed into the debate of the methods of science.

              Massage is a valuable therapy when used correctly!

              If you wish to understand why read Gunn/Cannon’s Law. With this insight you can begin to understand why it can be therapeutic and even curative. If you know the mechanics of action of a therapy you can apply it a whole lot better.

              1. WilliamLawrenceUtridge says:

                Politic, finances, cost and person topic should not be mixed into the debate of the methods of science.

                Politics, finance and cost will always be a part of medicine because resources are not infinite – which is why it is incumbent on lawmakers to emphasize proven interventions, not quacky, improbable, disproven or placebo-based interventions. In fact, one must use politics and cost to inform the decisions made about service delivery because science cannot make value judgements.

                If you wish to understand why read Gunn/Cannon’s Law.

                What peer-reviewed literature supports these laws? Not books published by Gunn/Cannon, I mean pubmed-indexed articles? Because without such testing, it’s not a law – it’s a hypothesis.

                If you know the mechanics of action of a therapy you can apply it a whole lot better.

                “Knowing” really isn’t the point – “testing” is. Has the therapy been tested? If not – then you’re wasting time and money, and are unethical if you offer it to patients.

      2. fastbuckartist says:

        The minor abuse Mr Taxpayer receives from chiropractice is a drop in the ocean of abuse he receives from conventional medicine. The more “ethical” physicians fabricate bullshit billings for treatments that were never performed. The more evil, malicious crooks actually perform these treatments on live patients. Unneeded surgery on healthy patients for example. Or prescribing extremely toxic chemotherapy to patients who dont have a cancer to treat. Strictly science-based, of course :)

        The sickcare fraud is so lucrative that mafia families have abandoned their traditional protection racket activities to focus entirely on Medicare fraud.

        I would write an article you are a looking for, but Gorski wont publish what I have to say on this topic.

        1. WilliamLawrenceUtridge says:

          So…chiropractors get to rip people off and bill for useless services because the mafia does it to? What kind of bizarre world is that?

          Say, you could always submit a guest post. I would genuinely read an article that discussed the myriad ways the health care system has distorted billings. Of course, I would see this as an impetus for improvement, not as an opportunity to make a, ahahaha, fast buck.

          Perhaps consider that medicine doesn’t have to be perfect in order for chiropractors to be ethical.

        2. Richard Abbott says:

          One common trend of those, they have all been prosecuted for fraud.

          Where are the convictions of Chiroprators for fraud ?

          1. There will be none prosecuted for the discipline of the effective CAMs.
            The business practices of all segments of Traditional and CAM healthcare needs a thorough cleaning.

            This site is promoting mostly personal, biased and unscientific conclusions. Some have a personal vendetta with the world and this is the place they can find refuge.

            It is so blatantly one sided, it seems that there is actually a “front” to bash CAMs in an attempt to promote the failed Traditional Medical Concepts.

            1. WilliamLawrenceUtridge says:

              There will be none prosecuted for the discipline of the effective CAMs.

              Which CAMs are effective? And, of course, if it’s genuinely effective then it will become part of routine care anyway – which is why CAM is inherently unethical to charge for.

              The business practices of all segments of Traditional and CAM healthcare needs a thorough cleaning.

              I agree, though we might disagree over implementation. I think these quacks should be prohibited from being funded by taxpayer money, should be excluded from insurance packages, and should be prohibited from treating any serious medical condition. Quacks and CAM charlatans are perfectly willing to take advantage of desperate patients to fleece them into a pauper’s grave and it’s sickening.

              This site is promoting mostly personal, biased and unscientific conclusions. Some have a personal vendetta with the world and this is the place they can find refuge.

              You say such things Steve, but all that has ever been asked of you is some reasonable measure of proof that the services you offer are science-based. You have never been able to clear that bar. It’s not a vendetta to ask “what proof do you have”, then rightly point out that “my patients get better” is inadequate. You don’t have to keep posting nonsense and empty claims here, but as long as you do – I will keep pointing out that your CAM practices are unethical and you don’t know what you are talking about.

              It is so blatantly one sided, it seems that there is actually a “front” to bash CAMs in an attempt to promote the failed Traditional Medical Concepts.

              You might have a point if SBM didn’t also have articles criticizing the pharmaceutical industry and happily pointing out when they are forced to pay massive fines.

              It’s not one-sided, quite the opposite – it’s a single standard. All we want is that CAM is required to prove that its modalities work before they are sold. Why do you consider that unreasonable?

          2. n brownlee says:

            Here’s a start. I mean, you just run a raw search on the terms ‘chiropractor fraud convictions’ and you’ll get beaucoup listings. I got a list of forty; mail fraud, medicare fraud, common or garden fraud fraud. Then you can refine, to your taste

            http://www.justice.gov/opa/pr/2014/February/14-tax-130.html

        3. Windriven says:

          “I would write an article you are a looking for, but Gorski wont publish what I have to say on this topic.”

          Why would he? What have you ever uttered in these pages that has anything to do with science based medicine?

        4. Rickinnocal says:

          You are missing the major point.

          Yes, *some* medical providers *sometimes* commit fraud – they bill for services that were not provided, or over-diagnose or over-prescribe for financial reasons. The difference between that and Medicare billings for chiropractic is that in the case of real medicine, fraudulent billings are the outlying minority. In the case of chiropractic, virtually EVERY billing is fraudulent by definition, because chiropractic itself – except for a very small number of cases involving back pain and other directly related issues.

          Your claim is like saying that we should tolerate car theft because some auto-mechanics overcharge their customers. The difference – like the difference between medicine and chiropractic – is that a mechanic “usually” fixes your car, while you NEVER get any benefit from having it stolen.

          Richard

  2. Shane says:

    Fastbuck you really dont seem to understand. There is just medicine, medicine that is plausible and has credible proof of a real world effect. Be it holding bones together untill they heal as the ancient Egyptians did or finding out which was the active ingredient in a herbal remedy for dropsy. Nothing alternative nor allopathic just real world proof, tested and proven to work. As is acute PCI and allthe other modern science based treatments. There is no difference.

    As a radiographer I see chiropractors requesting examinations far outside their scope of practice i see them misdiagnosing colles fractures and irradiating children for no good reason other than dogma. I have helped save an elderly lady’s life after having her intercostal arteties torn off by a chiropractors incompetence. The only proven benifit as far as I have read is symptomatic relief with a similar success rate to physiotherapy. And no evidence of effect for any other conditions as the Simon Singh case so eloquently showed.

    Unless we have actual evidence of a benefit it is just misleading and not serving our patients. I dont understand how you can misunderstand this simple conept. If it doesn’t work we should discard it unless you think that laudable pus still has merit.

    1. FastBuckArtist says:

      Well Shane I see your point of view as a radiologist that works with chiropractors. I dont work with chiropractors myself, but what the market is telling me is there is a demand for their services. Chiropractic has been around for a long time, and tried by millions of people, The market already figured out if its a valuable service and what that value is.

      That service may be worthless to you or me, but for a segment of the population, its a service they value and are willing to pay for and that’s what matters. Whether that benefit is medical or emotional or entertainment is a point of endless discussion on these pages by people who think they know more than the market does.

      In the end though, a dollar earned on the chiropractic table is just as real as the dollar earned on the physiotherapy chair.

      1. WilliamLawrenceUtridge says:

        there is a demand for their services

        There is a demand for the services of child prostitutes, astrologers and palm readers, that doesn’t make their lies, deceptions and exploitation any more palatable to me. Perhaps you’re different.

        Chiropractic has been around for a long time, and tried by millions of people, The market already figured out if its a valuable service and what that value is.

        Bloodletting has been around for about 20-30 times longer, and the market was tremendously in favour of leeches. Oh, and the burning of witches. Perhaps we should bring back lancets, stake-burnings and pillories, because the market is never wrong.

        Whether that benefit is medical or emotional or entertainment is a point of endless discussion on these pages by people who think they know more than the market does.

        It’s funny, because lying to people about their health and whether spending money on and subjecting yourself to the risks of treatment is worthwhile or not, I consider these lies to be unethical. In circumstances where one is claiming something can give a phsyical benefit, particularly when you’re talking about cancer, or diabetes, or strokes, “proof of efficacy” strikes me as somehow important.

        But hey, maybe you pass along your beliefs about medical care at the hospital the next time you are there, maybe they’ll give you the placebo instead. Maybe mention this to the cashier when you buy vitamins, since you don’t care about something as inconvenient as a fact, it shouldn’t matter to you whether you actually get a real vitamin or not.

        In the end though, a dollar earned on the chiropractic table is just as real as the dollar earned on the physiotherapy chair.

        Sure, as long as you don’t particularly care whether that dollar acutally results in a health improvement or not. As long as you don’t care about consumer protection or the opportunity costs to the patient or health care system. As long as all you care about is a fast buck.

        1. Andrey Pavlov says:

          Now this is an example of the utter nonsense of “truth by consensus” that Hank was on about. FBA is trying to assert truth by consensus, with the votes cast by dollars. I think you lampooned that idea quite nicely WLU.

          It is always funny for me to watch when two (or more) people with fervent beliefs not based in reality duke it out (or even talk past each other like FBA and Hank). Hank and FBA are arguing mutually exclusive points. But they are both content to agree that regardless of who is right or wrong, we here at SBM are most definitely wrong. And demonstrating that takes precedence over realizing each hold mutually exclusive positions that cannot be reconciled instead of noting that the SBM view accounts for both views and why people would be misled to believe them.

          1. WilliamLawrenceUtridge says:

            That’s how creationists managed to get young-earthers, intelligent design, old-earthers and Raelians into the same tent – nothing unites like a common enemy.

      2. Windriven says:

        ” its a service they value and are willing to pay for and that’s what matters.”

        No, often they are willing to have their insurer pay for it. That means – presuming I use an insurer who covers it – that my premiums go up fractionally to cover chiropractic plus the SG&A and profit associated with it.

        I don’t object when we’re talking about therapies with demonstrated efficacy. I do object when we’re talking about quackery.

      3. Sawyer says:

        “The market already figured out if its a valuable service and what that value is.”

        In a single sentence you’ve managed to fail first year medical school classes, introductory college economics, high school civics, middle school science and what I would consider to be a second grader’s understanding of ethics. I have you give you credit FBA, you have a talent for writing very few of us possess. I would take me an entire page to introduce so many misconceptions.

        Please at least catch up to the standards of medical treatment that were being developed 2400 years ago before you post again.

  3. tgobbi says:

    First, let me say that I’m always pleased to see a column by Sam Homola on SBM. His insider’s view justifies my longstanding antipathy toward chiropractic.

    Sam states, “… science-based chiropractors who use manipulation appropriately will have to make an effort to separate their work from the stigma associated with inappropriate use of manipulation based on chiropractic subluxation theory.” Based on this, is it correct to infer that he believes that all DCs who have abrogated the subluxation theory are necessarily science-based or scientific practitioners? My skeptical nature, right or wrong, tells me that an anti- or pseudo-scientific predisposition is what drives one to become a chiropractor in the first place. In other words, I’m not so sure that anti-subluxation equals pro-science. If Sam or anyone else cares to enlighten me here, I’m interested in others’ opinions.

    1. Andrey Pavlov says:

      Based on this, is it correct to infer that he believes that all DCs who have abrogated the subluxation theory are necessarily science-based or scientific practitioners? My skeptical nature, right or wrong, tells me that an anti- or pseudo-scientific predisposition is what drives one to become a chiropractor in the first place.

      I can’t speak for Sam, but my reading is different to yours. You seem to be forcing a false false dichotomy (meaning you recognize the false dichotomy, but are inserting one that I don’t see is there).

      I think Sam is trying to say that those chiros who are actually science based need to force out the pseudoscientific ones and distance their own practice from theirs. Hence his caveat that they both use manipulation appropriately and are science based. I believe he is trying to say what many of us here have said as well – that the mainstream of medicine cannot utilize actual science based chiros effectively until there is a means by which to differentiate them.

      As I have said before I would (hypothetically) refer my patients to Sam. But I could not refer them to any chiro I don’t personally know to be science based and I cannot distinguish them based on their degree or degree granting institution. I could remove those obviously into quackery by looking at some of their webpages, but there is undoubtedly a group of them that a not quite quack-ish enough to distinguish. And the bigger issue is that if I did refer my patient to a chiro I know to be science based, my patient is unlikely to recognize or understand the distinction and thus validate any chiropractor out there.

      So it makes sense that the only way to salvage anything is to have those like Sam actually make a clear and public difference known. However, while I think that is certainly the only way forward and a laudable goal, I believe there is serious question as to whether it is possible given the current worldwide state and history of chiropractic.

  4. “science-based chiropractors who use manipulation appropriately will have to make an effort to separate their work from the stigma associated with inappropriate use of manipulation based on chiropractic subluxation theory.”

    Simple solution for the “science-based chiropractors” here. Stop calling yourselves chiropractors. “Science-based chiropractors” do nothing more than a licensed physical therapist, so why cling to a name laden with such negative baggage? It’s like you’re trying to re-claim a name that was never yours to begin with. Chiropractic started as a pseudoscience, and there it shall remain.

    1. Windriven says:

      You make an excellent point. The problem is that those chiropractors who eschew subluxation and try to practice ethically have a substantial investment in their DC degrees. It is easy enough to understand their desire to she’d the subluxation fantasy rather than the name.

    2. WilliamLawrenceUtridge says:

      A “science-based chiropractor” would be a lot better than a subluxation-based chiropractor, but I would hesitate to claim they were the same as a licensed physical therapist.

  5. Windriven says:

    “Until consensus forces chiropractic associations to publicly renounce the implausible chiropractic vertebral subluxation theory,”

    The problem with renouncing subluxation is that a chiropractic limited to musculoskeletal conditions would support a smaller cohort of chiropractors. Chiropractic associations are unlikely to support such a truncation of their scope of practice.

  6. Chris Hickie says:

    I am a pediatrician who continues to see more and more parents taking their children to chiropractors for non-spinal issues such as ear infections and GERD. What bothers me even more is the almost universal undercurrent of anti-vaccinationism given to these parents by those chiropractors who think they can cure everything under the sun. I’ve also seen parents told by chiropractors that their skeletally healthy very normal infant will need frequent adjustments for many years to keep them healthy as well. In short, I’m not seeing a whole lot of anything science-based coming from the modern day chiropractors who feel they have the training to treat children. Sadly, I’m pretty sure all those chiropractors would disagree with this blog.

  7. Thinking_Chiro says:

    This is the best description I’ve seen of philosophy:
    “The presentation of opinions, theories, or advice isn’t philosophy, no matter what the content. Doing philosophy involves thinking about things in a certain (rigorous, questioning) way, offering arguments for one’s ideas, meeting arguments against them, and being prepared to change one’s mind.”
    Sam you have always had the right philosophy! Critical assessment and evaluation leading to change is called progress. Every day in practice is an opportunity to learn, reassess and grow, providing the best up to date, evidence based patient care. It is a work in progress. You care enough to push reform and make a difference and it is appreciated.

    1. tgobbi says:

      Maybe the D.C. who calls himself the “Thinking Chiro” has inadvertently answered my question about what constitutes “science-based chiropractic.” How about renaming all those chiros who’ve abrogated subluxation nonsense “thinking chiropractors” and forget about the “science-based” designation entirely?

  8. Alex, Chiro says:

    Fantastic article. My profession needs more people like Dr Homola

  9. Mike says:

    Thank you for this article.

    What is your take on the increasing evidence that Spinal Manipulation Therapy “is not associated with clinically relevant specific therapeutic effects” and may be a theatrical placebo?

    1. WilliamLawrenceUtridge says:

      The key part of Dr. Ernst’s post are the words “in normal people”; a comparable study would need to be conducted on those with back pain to say it’s genuinely useless. Spinal manipulation has supporting evidence for back pain, though I can’t speak to its quality. This looks more like a test of “maintenance adjustments”.

      But that’s just my take based on a quick reading.

    2. Andrey Pavlov says:

      WLU is on track with his comment.

      Basically this study – and Ernt’s analysis of it – basically demonstrates a large placebo component to SMT. Specifically this was in healthy subjects demonstrated that expectancy effects can lead to both placebo and nocebo responses. He ties this in with SMT as used for ridiculous indications like enuresis and asthma. He does not – nor does the study – address the use in patients with existing back pain. He also makes it a point to say that sham-controlled SMT studies are feasible and should be done in order to establish the validity of SMT for various indications, specifically back pain.

      Basically it is saying that there is indeed a robust component of placebo to SMT and that this accounts for any and all effects seen in conditions that we should realize a priori are not amenable to treatment by SMT. He then goes on further to imply that for other indications, like existing back pain, there are means by which to test for efficacy beyond placebo and that we should do that. He is indicating an absence of good evidence to support SMT for back pain and putting the onus (rightly) on those using it for that indication to demonstrate the utility while simultaneously saying he won’t accept “we can’t do sham controlled studies” as an excuse.

      From my reading of the literature in my extensive battles with chiros over the past couple of years there is compelling evidence to believe that SMT would be efficacious in treatment of chronic (but not acute) back pain. The evidence is most compelling for low back pain, but that is because it is both the most common form and the most studied. I find no reason to think that the same mechanisms and effects would be present for upper back pain, given the same sort of mechanical etiology (typically upper back pain is considered a “red flag” symptom because it is uncommon to experience it without some sort of sinister cause or trauma).

      However, the true effect size is not well described because, as Ernst points out, a component of that will be placebo effect. The existing effect is also not fully robustly demonstrated. Furthermore, there is no good data to guide what type of manual therapy is indicated in which cases. Some data exist that indicate there may be no difference and that any sort of massage or manipulation which the patient finds tolerable and/or pleasurable is sufficient, with no differences between specific techniques and motions. While I would still recommend my patients to seek some sort of manual therapy, I would also like to see such data because it can help me gauge the cost-effectiveness of the therapy. I would, for example, be more willing to tell my patient with financial hardship to spend good money on manipulative therapy if I knew that the effect size was intrinsic, robust, and large enough. Alternately if the data showed something else, I would be more willing to try and find alternates while maximizing (ethically and legitimately) positive expectancy effects based on the data. Lastly, it would be helpful to establish which, if any, specific methods are effective or not so that there can be some standardization and I can refer my patients better knowing that they won’t stumble across some massage therapist or physio who does weird stuff with less efficacy just because there are no guidelines or data otherwise.

  10. Jann Bellamy says:

    And I am honored too, Dr. Homola, to be associated with someone who has been so abused by chiropractors for telling the truth, yet hung in there despite the personal consequences.

  11. Thinking_Chiro says:

    To think that Sam wrote that groungbrealing book in 1963 is astonishing. You may not hear this enough and you should. THANKYOU!
    Every profession needs critical thinkers and pioneers. They are to be treasured and emulated!

  12. Alan Smith says:

    Either Chiropractors are off the deep end or are years ahead of allopathic medicine. Quantum neurology has been on the forefront. Welcome aboard Doctors of Dentistry.

    http://www.seas.harvard.edu/news/2014/05/researchers-use-light-to-coax-stem-cells-to-repair-teeth

    Give CAM research grants that are on par with drug companies that produce toxic pharmaceutical agents, so the public has a level playing field of knowledge to decide and to make choices for their health.

    1. Andrey Pavlov says:

      Citing Mercola = instant lose.

      If you can’t figure out that Mercola is not a source to use, then you won’t find yourself having a good time here.

    2. WilliamLawrenceUtridge says:

      Drug sales of $1T – this is a fact, you are pretending it is a self-illustrating point. So what? Part of that $1T is made up of insulin for type I diabetics, asthma inhalers, chemotherapy, antiemetics, analgesics, antibiotics, antifungals, and hell – even viagra. Useful medicines that do what they are supposed to do, and provide genunie benefits – they do what they are supposed to do (but with side effects that are recognized both when the drug is licensed, and based on postmarketing surveillance).

      I’m assuming you are posting this comment here because of some link to chiropractic. While there are limited indications for spinal manipulation (low back pain), chiropractors a) do not limit themselves to merely manipulating the lumbar spine. They do not disclose the risk of cervical artery dissection. And they are not the sole profession capable of spinal manipulation – it is being adopted by physiotherapists, who manipulate only single vertebrae, not the entire spinal column. And there are also chiropractors who manipulate the spine in the vain claim of the ability to cure utterly unrelated diseases like diabetes and cancer – which is like a drug company claiming viagra cures brain tumors (which they can’t do, and would get massive penalties for trying). So yes, Big Pharma makes tons and tons of money, but they do so producing a standard, effective product that has risks that are public and acknowledged. Chiropractic grossly oversells a technique that can be learned by a better-trained, more realistic profession, often for nonsensical and impossible indications, and actively denies the risks involved.

      But yeah – Big Pharma is the Big Bad here.

      Also – why would you cite Joe Mercola, a loon who just wants you to buy his coconut oil, when you could cite the extensive scientific literature that examines iatrogenic harms in an effort to reduce them? And, of course, what happens if you try to eliminate those iatrogenic harms by eliminating medicine? You would eliminate all the benefits of medicine, which means type I diabetics would die in droves, asthmatics and the allergic would choke to death, vaccine-preventable diseases would roar back, and you would get to watch helplessly while your parents die of massive heart attacks or are slowly eaten to death by cancer. But Joe Mercola will happily sell you a jug of coconut oil that he claims will cure all disease, the unethical shit.

      So yeah – iatrogenic deaths are bad; abandoning medicine is worse.

  13. Frederick says:

    Excellent Article it was a good read with the coffee this morning,
    Congratulation on holding Science and the search for truth in high regards all this time.

    I wonder if “science-based Chiropractic” should not be rename, or become a part of physical therapy, it seem that in the end the think that do work in Chiro, are more like what physical therapist do. maybe some kind of specialty? In a one it will help people make the difference between SB-chiro and believers in the pseudo-science.
    It must have been hard to withstand all those attack from believers.
    But at Least there was things that work in what you were doing, Imagine a Acupuncturist of come to his senses, I maybe there nothing there, it is all placebo, all you knew become useless, somehow I can see why they don,t come around much, it is hard. The best is to have no beliefs.

  14. John Peter says:

    To assume that SAM wrote that groungbrealing book in 1963 is astonishing. you’ll not hear this enough and you must

  15. D Scown says:

    Most aggressive criticism of the medical profession and pharmacy comes from within their own. We on the other hand never cease to proclaim our immunity from scrutiny and as a result wild claims and absolute lies mixed with valid approaches are par for the course. If it were not the case the fatuous Big Idea and downright anatomical lie of the Spine Simulator would not only be history but our profession would have institutionalised effective self moderation instead of faith.

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