Articles

247 thoughts on “Chiropractic Neurology

  1. Intraneural says:

    @ NMS-DC

    “Well, MDs generally don’t perform spinal manipulation, and generally aren’t interested in conservative therapies.”

    Absolutely false statement. Regarding back pain in specific one never immediately jumps to laminectomy, diskectomy, fusion, etc. You may find some neurosurgeons or orthopedic surgeons that may jump the gun on spinal surgery, any surgery for that matter but most will consult PT for treatment, utilize NSAIDS and acetaminophen, recommend excercise and weight loss. Most physicians realize that low back pain is a self-limited disease/symptom that will eventually resolve on its own. If a patient develops chronic low back pain they then may be sent to Chronic pain physicians that may try some invasive techniques to avoid spine surgery. If all of that fails then if the surgeon feels the problem may be treated successfully with spine surgery (by using RCT’s and science based medicine) then they may operate. There may be some conditions-spinal trauma, severe scoliosis, or discs impinging nerve roots causing neurologic deficits, that must be treated with surgery to minimize neurologic deficit. If you as a DC ever recommend against surgery in spinal trauma, scoliosis, etc then you are fooling yourself and commiting malpractice my friend.

    It is nonsense that physicians never try the conservative therapies first. Smoking cessation, weight loss, excercise, healthy diet is always reccomended to prevent risk of COPD/Lung CA, CAD, PVD, etc. Many patients will not make these adjustments and treating the diseases with medications would be the next on the list.

    One more thing, I occasionally see “RTFA” or “RTFB” pop up in your posts. I am assuming you are saying “REad the fucking article” and “read the fucking blog” as I googled these abbreviations and they seem to fit in context. If I am misinterpreting I apologize but if I am correct is derogatory language really necessary?

  2. NMS-DC says:

    @Harriet

    I will see if I can comb through the archives. Would be interesting to see. As far as chiropractic becoming scientific you and I have divergent views and contexts. What I mean by that is there are only 2 Canadian chiropractic schools, both of whom make no reference to the VSC and whose educational curricula is centred around neuromusculoskeletal practice. Both these institutions I would argue are “scientific chiropractic” as both are either in universities or have affiliations with universities and have a conducting scientific research into manual therapy, SMT and things there are pertinent to chiropractic clinical practice. These schools do not promote DCs as a PCP, and the professors there have PhDs and are from health related disciplines. For example, my neuroscience course was taught by a PhD in neuroscience and not a DC. Same goes for anatomy, neuroanatomy, immunology, microbiology and all the other basic sciences courses I took at my time of study (2002-2006). I had previously received my Honors Bachelor of Science degree. I feel very comfortable in discussing the literature and know had research methods courses in both my chiropractic and undergraduate degrees. I will always cite peer-reviewed literature in debating here. It’s a standard I hold myself up to and expect the same from others here that I debating with. Bottom line is I want you to feel like you can communicate with me in an honest and open manner and I won’t be a mindless chiropractic defender. I acknowledge the limitations of my profession in certain domains and am not a “true believer” which implies that I am a mindless drone who is part of cult and am unable to critically think. I would hope that you could extend me that courtesy until proven otherwise.

    I also understand, however, your context, where there are schools in the US such as Sherman and Life who are promoting a subluxation-based, philosophy-heavy, straight/Palmer view of chiropractic which is rightfully the target of skeptics and critics. I realize that my post is anecdotal, but if you would indulge me and visit the CMCC and UQTR websites, you could give me your impression of the research occurring at these schools and the limitations that you see and perhaps what specific evidence you require as a chiropractic skeptic that might make you “accept” that, in some limited form, perhaps, there is a scientific “branch” of the profession that strives for genuine integration in the “conventional” health care system.

    http://www.cmcc.ca/Page.aspx?pid=355
    https://oraprdnt.uqtr.uquebec.ca/pls/public/gscw031?owa_no_site=722&owa_no_fiche=1&owa_apercu=N&owa_imprimable=N&owa_bottin=

    Unfortunately the second school is in Quebec and it’s in French (I am bilingual but assume that you are not fluent in French). I was hoping that they would have a page in English. Anyways, if you would indulge me and perhaps make quick list of specific scientific criticisms of chiropractic I might be able to gain a better understanding of your POV. Is your main critique regarding the concept of joint dysfunction/subluxation or is it broader than that? I’d like us to focus, if we can, on spinal manipulation and not debate paradigms which are philosophy-driven which is not really the purpose of your website.

    A long winded reply, but I’m just trying to clarify certain things so we can have productive discussions.

    Regards,
    NMS-DC

    Regards,
    NMS-DC

  3. Harriet Hall says:

    @NMS-DC,

    I have always agreed that SMT is effective for certain types of musculoskeletal pain: I have seen it work, and the literature confirms that it is effective for LBP (although not more effective than other treatments). It is unfortunate that the effective contributions of chiropractic have been discredited by association with all the nonsense that the majority of chiropractors have engaged in. I would love to know what happens on an anatomical and physiological level during a chiropractic adjustment. After a century of practice, it is far past the time when chiropractors should be figuring out just what it is they have been doing. I acknowledge that there are scientific-minded people in chiropractic who are trying to figure that out. I strongly support good scientific research on SMT, but the quality of research so far has varied wildly. Carrick’s study that I critiqued was not good science and should never have been published. We need more solid science, preferably published in mainstream (not chiropractic) journals and verified independently by different groups of researchers.

    By the way, you assume wrong. I read French fluently, although I do not speak it well.

  4. jhawk says:

    @ harriet hall

    “Why is it that chiropractors doing these studies have not defined what kind of LBP they can treat successfully?”

    I am not sure as I was not involved in designing these studies.

    “After over a century of study? This really highlights the difference between the scientific approach and the chiropractic approach.”

    RCT outcome studies are extremely expensive and need funding of which mostly comes from NCCAM. NCCAM didn’t break a 10 million budget until the late 1980′s. So, it is more like 30 to 40 years of study not a century.
    Also, it seems as though you are implying allopathic medicine has been engraved in EBM since its beginnings and we both know this is not true. I will be generous and give you since the 1950′s.

  5. Harriet Hall says:

    @jhawk,

    The fact remains that chiropractors have been doing something they don’t understand for over a century without any attempt to discriminate who should be treated and which treatments to use. The selection of patients for appendectomy and the choice of surgical procedure were established long before the term EBM was coined, although research has continued and diagnosis and treatment have been refined. The diagnosis and treatment of “subluxation” has not made any significant progress, and chiropractic has never given up on anything except perhaps the nerve tracing nonsense of BJ Palmer. And chiropractors did not have to wait for NCCAM to do research. RCT outcome studies may be expensive, but other less expensive kinds of studies were possible.

  6. @jhawk

    Thank you for the response. I took a little time to check these out, and had the following comments jotted down on my notepad:

    http://www.ncbi.nlm.nih.gov/pubmed/20053720

    I often am skeptical of studies that utilize subjective responses from patients only (IE: a visual pain scale, word of mouth reporting, etc.) because the subjective sensation of pain can differ vastly between people in a wide variety of ways.

    That being said however, I could see the results of this study being plausible, since I did mention before that the Cochrane Collaboration did find SMT for lower back pain to be at least equal to other interventions.

    http://www.ncbi.nlm.nih.gov/pubmed/21334541

    For this study, the limitations you suggested are there, yes. However, it would be interesting to see follow up to this with more stringent methodology. I wonder if they are planning on doing so? I’d imagine one would just have to wait and watch the website of the facility to see if any research is in the works.

    http://www.ncbi.nlm.nih.gov/pubmed/21407100

    For this one, I couldn’t find out whom was reporting the outcomes of each patient and how they were measured. Perhaps one of you guys could help me out here?

    http://www.ncbi.nlm.nih.gov/pubmed/20889389

    This study is one of the ones I had looked at above when NMS-DC responded to me. The issue I had with this study is that SMT was being delivered along with conventional treatments. Therefore, it would be difficult to attribute results to any one of those treatments alone. Also, they compare that treatment grouping to “family physician directed-usual care”, but I was unable to find exactly what that means.

    I agree with you concerning LBP. It’s going to be very tricky, as there are so many different possible underlying causes. It will be interesting to see how research proceeds once more headway is made into the exact specifics concerning LBP.

  7. jhawk says:

    @ Harriet Hall

    “The fact remains that chiropractors have been doing something they don’t understand for over a century without any attempt to discriminate who should be treated and which treatments to use.”

    I disagree as many chiro’s are discriminating who should be treated and which treatments to use everyday in practice by taking a history, perfroming a physical exam, arriving at a diagnosis and then performing any number of manual therapy procedures. Hopefully the research will catch up.

    “And chiropractors did not have to wait for NCCAM to do research. RCT outcome studies may be expensive, but other less expensive kinds of studies were possible.”

    Yes, but would you even consider these less expensive studies evidence? If responses to posts of non RCT on this website are any hint, then I would have to say no.

  8. JPZ says:

    @NMS-DC

    I’ll give you credit for refining your argument over time as I read your posts.

    And when Steven Novella says,

    “…science-based, you have to already have the evidence to support your claims, not use science to back fill in claims and practices you already have. Classic pseudoscience.”

    Don’t take him seriously. By this definition, the evolution of alchemy to chemistry and the evolution of astrology to astronomy could both be dismissed by prior biases. Classic SBM bias. I think science can overwrite beliefs in a profession over time and with a willful minority.

    I hate speaking up here, but this seemed an unusually unscientific dismissal even for this forum.

  9. Harriet Hall says:

    @jhawk,
    “many chiro’s are discriminating who should be treated and which treatments to use everyday in practice by taking a history, perfroming a physical exam, arriving at a diagnosis and then performing any number of manual therapy procedures. Hopefully the research will catch up.” You believe they can discriminate, but many chiros are diagnosing subluxations in every patient and treating every patient with their preferred modality: for instance NUCCA. “The research will catch up” sounds like “we are right and the science will prove that what we are doing works” which is a pseudoscientific approach rather than the scientific “Maybe some of what we are doing doesn’t work, let’s find out what works.”

    “would you even consider these less expensive studies evidence?”
    Yes, we would; preliminary evidence. If non-RCT studies had been well done and were very promising, mainstream scientists would have been spurred to do more definitive studies.

  10. Harriet Hall says:

    @JPZ, I don’t understand your point about not taking Dr. Novella seriously. Pseudoscience typically would try to prove beliefs about astrology were true; science would test those beliefs to find out if they were true. There was once a bias towards believing in astrology, but it was quickly overcome by the evidence. “Classic SBM bias”? By definition, SBM does everything possible to minimize bias.

  11. JPZ says:

    @HH

    If members of what you define as a pseudoscientific group, test their beliefs to find the scientific truth of them, that is not to “back fill in claims” as Steve claims (you could call me Dr., I could call you Col., there are titles aplenty here – and it doesn’t cut him any slack for you to call him “Dr. Novella” to defend his point of view – I suspect that “Dr.” insistance is hospital bias – I used to insist on it too when I was quite a bit younger – how about we go for science bias?).

    The people who looked at astrology and tested its tenents created the “evidence” you speak of that led to astronomy (Da Vinci notebooks I think). Do you think outsiders attacked unscientific beliefs in alchemy and astrology? I will need some evidence of that given the pervasiveness of alchemy in the 1500′s during the Royal Society’s formative period. I think I got that from the discovery of phosphorus, but I would need to check into it more. As much as I would like to, you can’t just cite everything willy-nilly here with a limit of 2.

    Science overcame belief from within, as NMS-DC is claiming for chiropractery now. I have no idea if that is true, but I read his CMCC website reference and found maybe 10% of their science directly addressing whether chiropractic principles are real. NMS-DC also called me a troll, so I am disinclined to speak up for anything s/he says.

    If you can say that SBM minimizes bias, I am going to guess that you have missed my posts in the last week. If one takes the Baysean prior and makes the SBM subjective assumption that certain kinds of scientifically-valid data (e.g. even though they are meeting Bradford-Hill criteria for example) do not meet the SBM standard of evidence due to biases against unpopular fields of study on SBM, then there is a systematic bias here, the SBM bias. The Baysean prior cannot be determined based on exclusion of relevant data; therefore, the concept of using the Baysean prior as a dismissal of any unpopular discussion on SBM is flawed based on the SBM bias. Wow, that one just came to me as I typed it. It overreaches a bit because some fields are flawed en face (homeopathy, reiki, etc.), but I am attempting to argue from a middle groud.

    You might need to read my previous posts for more details, but here is an example of a dietary supplement study that meets my standard (http://www.ncbi.nlm.nih.gov/pubmed/20434961). The subsequent JAMA study was specific to Alzheimers not cognitive decline in otherwise healthy people.

  12. JPZ says:

    So, no. I do not take Steve’s comments seriously. They are flawed, en face.

  13. Harriet Hall says:

    @JPZ,

    “the SBM subjective assumption that certain kinds of scientifically-valid data (e.g. even though they are meeting Bradford-Hill criteria for example) do not meet the SBM standard of evidence due to biases against unpopular fields of study on SBM”

    You have set up a straw man to knock down. This does not accurately represent what SBM is all about.

  14. JPZ says:

    @HH

    Not straw man. I presented evidence that Scott Gavura ignored evidence that he mis-interpreted VAS measures and misinterpreted why the drop-out rate is so high in pain studies. I also discounted his evidence that the EU has rejected probiotic supplements, and I rejected his one review based on expert evidence that it was unscientific. I mean to say to avoid further dismissal, WOO science on SBM.

    SBM reinforces what I have said. What other evidence do I need to provide?

  15. Harriet Hall says:

    @JPZ,

    Straw man. You said “What I don’t understand is the default dismissal on SBM of any case where there is some but incomplete evidence.”

    SBM does not just dismiss any case where there is some but incomplete evidence. Any of our regular readers will recall many examples where an SBM article says there is some but incomplete evidence and that accepting the claim is not justified without further evidence. That does not constitute dismissal. I think you are reading “dismissal” where we are writing “insufficient evidence for acceptance.”

  16. NMS-DC says:

    @JPZ

    Just a few things I’d like to mention before getting to bed. First, sorry for calling you a troll. I’ve come to see with your posts that you, like me, try to strive for the middle ground and I can say that you’ve approached this debate with an open mind, which all I ever wanted. Second, you stated that you “found maybe 10% of their science directly addressing whether chiropractic principles are real”. That brings up a couple of questions if you don’t mind

    1) which science are you referring to when addressing chiropractic principles? SMT? Because there is a lot of studies IMHO that may not be directly related to SMT but address neuromuscular, stabilization, and other topics pertinent to clinical chiropractic practice. Where does the 10% number come from

    2)Which principles to you personally have problems with or find to be scientifically reputable. I often hear of discussion here regarding chiropractic principles and I’m not entirely sure we are talking about the same things. It’s worth clarifying. I am not referring to the 33 principles that was part of traditional straight/subluxation-based chiropractic but underlying principles that forms the basis of contemporary chiropractic practice.

    Also, I appreciate your ability to call a spade a spade. I refer to many posters here trolls, lemmings and parrots, because they really ever challenge the editors even though, at times, like this post by Novella, there’s some egregious errors ranging from not reading the material, to not performing valid PubMed Search and then arriving at a conclusion that did not support his hypothesis then trying to pin the whole of Sidney Crosby’s recovery on placebo and cheerleader effect without knowing what specific treatment Crosby did get (I had to tell him afterwards as I have the full article and not merely a snippet online which was used in as part of this argument.

    I also agree 100% on your perceived bias at SBM and agree with your statement. But perhaps Harriet can enlighten us otherwise.

    @Harriett

    I have read your reply and will reply in kind tomorrow. I’m very impressed that you can read in French; a pleasant surprise. I was born and raised near Quebec and my mom is from there so I’ve been lucky enough to live the two cultures. I am also happy to hear you would like to read some basic science research into SMT and its effect on tissue mechanics and neurophysiology. Kawchuck, Pickar, Descarreaux, Triano, Blouin, Szerbely are all DC/PhDs studying this at the present (that I know of in Canada anyways).

    This study looks interesting: http://www.ncbi.nlm.nih.gov/pubmed/21708042

    We can finish up our discussion, there a few other topics that I’d like to get your opinion on.

    Regards,
    NMS-DC

  17. Jann Bellamy says:

    @ NMS-DC

    “I did not state that Jann. I do not think DC neuros are better at interpretation and application of neuroscience. I just think that they have a different way of looking at rehabbing neuro cases, and that their approach might broaden the spectrum of how science understands and treats neuro conditions, and specifically to this article, vestibular rehab.”

    I didn’t say you stated that, I said it appears to the basis of your argument, because you said DCs and MDs “are both using the same pool of information, we’re just applying it differently.” Dr. Novella’s post argues that the DC interpretation is not just “different,” it is, in fact, incorrect. You think the DC position is correct. So, in essence what you are arguing is that DC neurologists are better at interpreting and applying neuroscience than MD neurologists.
    However, now your comment indicates that this is not true, that MDs are in fact better than DCs in interpretation and application of neuroscience. Yet you continue to insist that the DCs just have “a different way of looking at rehabbing neuro cases.” But if an MD neurologist says it’s not just “different,” it is “incorrect,” and MD neurologists are better able to interpret and apply the neuroscience, why do you support the DC interpretation over the MD interpretation?

    As I pointed out, if the DC neurologists’ treatments had any validity MD neurologists would employ them. Your answer was that “MDs don’t generally perform spinal manipulation.” That fails to address my point: they could use any of the DC treatments they thought valid, but they don’t because they don’t think they are valid. The second part of your answer was that MDs “generally aren’t interested in conservative therapies,” an assertion that you pulled out of thin air and, again, fails to address my point. In any event, MDs neurologists don’t eschew “chiropractic neurology” because it is a “conservative treatment,” they do so because they don’t think it’s valid.

    In sum, although you deny that DC neurologists are better at interpretation of the neuroscience, you continue to support their interpretation over that of an MD neurologist.

  18. Harriet Hall says:

    @NMS-DC,
    “This study looks interesting: http://www.ncbi.nlm.nih.gov/pubmed/21708042

    The link is to a study protocol, not a completed study. It supports the claim that chiropractic is being studied. It doesn’t support anything else.

  19. Jann Bellamy says:

    @ JPZ

    “Don’t take him seriously. By this definition, the evolution of alchemy to chemistry and the evolution of astrology to astronomy could both be dismissed by prior biases.”

    Those evolutions happened several hundred years ago. This is the 21st century, and I’d like to think that society would no longer tolerate the attitude that “hopefully the research will catch up” (per jhawk). While the “research” is “catching up” millions of chiropractic patients are being diagnosed each year with joint dysfunctions/manipulable lesions/subluxations/vertebral subluxation complex, are being treated for same. This has been going on for over 100 years. It is my understanding that you are a scientist. I would hope that you are appalled at the idea of attempting to back-fill in the science, while at the same time treating patients (and charging them for it) based on (at best) woefully incomplete and (at worst) implausible “theories” of human physiology.

  20. jhawk says:

    @ Jann bellamy

    “Those evolutions happened several hundred years ago. This is the 21st century, and I’d like to think that society would no longer tolerate the attitude that “hopefully the research will catch up” (per jhawk). ”

    Yet another snipped sentence taken out of context. A commom theme on SBM. I was referring to the clinical prediciton rules being set up. The research on SMT for LBP is there. I posted some evidence previously and no one responded to the pubmed articles. Another common theme here, ignoring evidence when it doesn’t fit your belief and attacking after thought opinions.

    While the “research” is “catching up” millions of chiropractic patients are being diagnosed each year with joint dysfunctions/manipulable lesions/subluxations/vertebral subluxation complex, are being treated for same.

    Yes, we are a MSK specialty. We see people with MSK problems including but not limited to joint dysfunction.

    This has been going on for over 100 years. It is my understanding that you are a scientist. I would hope that you are appalled at the idea of attempting to back-fill in the science, while at the same time treating patients (and charging them for it) based on (at best) woefully incomplete and (at worst) implausible “theories” of human physiology.

    Are you implying that the medical profession does not back fill in science? Please tell me why one of the most common analgesic and antipyretics used today, acetaminophen, still has a mechanism of action that is not completely understood. Here in lies your bias.

  21. Harriet Hall says:

    @jhawk,

    “one of the most common analgesic and antipyretics used today, acetaminophen, still has a mechanism of action that is not completely understood.”

    You’re missing the important difference. We have overwhelming evidence that acetaminophen is effective. We don’t have that for chiropractic.

  22. jhawk says:

    @ Harriet Hall

    “You’re missing the important difference. We have overwhelming evidence that acetaminophen is effective. We don’t have that for chiropractic.”

    In a previous post you said “I have always agreed that SMT is effective for certain types of musculoskeletal pain: I have seen it work, and the literature confirms that it is effective for LBP (although not more effective than other treatments). ”

    So SMT is effective for LBP and now research is being done to find out the exact mechanism of action. This is not back filling in science.

  23. Harriet Hall says:

    @jhawk,

    SMT has only been shown to have a limited degree of effectiveness for certain types of LBP, and research is justified to figure out who benefits and how it works. “Chiropractic” includes SMT with a lot of other baggage. If either SMT or other aspects of chiropractic care had the same level of evidence for efficacy that acetaminophen does, science-based physicians would have adopted them just as enthusiastically as they adopted acetaminophen.

  24. Intraneural says:

    @jhawk

    studies showing the efficacy of IV APAP in perioperative and inpatients, I can provide many more for you.

    http://www.ncbi.nlm.nih.gov/pubmed/22008309

    http://www.ncbi.nlm.nih.gov/pubmed/21975764

    http://www.ncbi.nlm.nih.gov/pubmed/21353105

    http://www.ncbi.nlm.nih.gov/pubmed/21296248

    http://www.ncbi.nlm.nih.gov/pubmed/21134123

    This interesting study included in its Chiro treatment arm Acetaminophen. The family practice guided arm did not specify and there was no statistically significant difference between the groups. Whose to say the effectiveness in the SMT arm was not just APAP. >>>

    http://www.thespinejournalonline.com/article/S1529-9430%2810%2901114-9/abstract

    IN all the studies above supporting chiro for low back pain they show no better than other therapies. Though acetaminophen does not yet have a clear mechanism of action discovered yet there are a plethora of studies supporting it for all types of pain-perioperative, low back pain, chronic pain, and inpatient pain. It also has a very well defined opioid sparing effect ranging from 30-50% depending on the study (mostly perioperative pain). I have not found any studies demonstrating an opioid sparing effect of chiropractic manipulation. If you have any please point me in the right direction, I will then promptly add it to my acute perioperative pain toolbox like I did acupuncture (tongue implanted in cheek).

  25. I posted some evidence previously and no one responded to the pubmed articles. Another common theme here, ignoring evidence when it doesn’t fit your belief and attacking after thought opinions.

    I responded to you with some of my thoughts above. Sorry, for some reason every time I post, my comment sits with “pending moderation” and loads of other comments jump in front of it. I don’t know why this is the case.

  26. jhawk says:

    @ Chris Repetsky

    Thanks for responding. Sorry it took me so long to get back to you but somehow I missed your response when I was reading the thread earlier.

    “I often am skeptical of studies that utilize subjective responses from patients only (IE: a visual pain scale, word of mouth reporting, etc.) because the subjective sensation of pain can differ vastly between people in a wide variety of ways.”

    I agree that the sensation of pain can vary widely but they used the Roland Morris Disability questionnare which has been shown to be a reliable way to measure progress of functional improvement.

    “For this study, the limitations you suggested are there, yes. However, it would be interesting to see follow up to this with more stringent methodology. I wonder if they are planning on doing so? I’d imagine one would just have to wait and watch the website of the facility to see if any research is in the works.”

    I was listening to an interview with the director of this clinic some time ago and if memory serves me right they are planning on more studies or at least hoping other sources will build on their model.

    “For this one, I couldn’t find out whom was reporting the outcomes of each patient and how they were measured. Perhaps one of you guys could help me out here?”

    They used work comp disability claims data. I would assume they used standard disability ratings but I could not find it either. Not sure if this answers your question?

    “This study is one of the ones I had looked at above when NMS-DC responded to me. The issue I had with this study is that SMT was being delivered along with conventional treatments. Therefore, it would be difficult to attribute results to any one of those treatments alone.”

    Agreed.

    “Also, they compare that treatment grouping to “family physician directed-usual care”, but I was unable to find exactly what that means.”

    Patients assigned to the UC group were referred back to a PCP who then treated at his/her own discretion. So opiates, nsaids, advice, physical therapy, massage, etc.

    Hope this helps.

  27. jhawk says:

    @ chris repetsky

    “I responded to you with some of my thoughts above. Sorry, for some reason every time I post, my comment sits with “pending moderation” and loads of other comments jump in front of it. I don’t know why this is the case.”

    I hear ya. I think it happens when you post more than one or two links.

  28. Intraneural says:

    Chris–It appears I have the same issue as you…my comments are always pending moderation! It appears that one of the studies I found was discussed. I think it is still interesting that the chiro arm included APAP since that topic was mentioned.

    I think pain is a very difficult thing to study. It is very subjective and experienced very differently by different patients. One good method is to use opioid consumption as a gauge of pain instead of a VAS score – but this still has problems. Some people do not push PCA buttons bc it makes them feel nauseated or drowsy and they find those symptoms more unpleasant. I deal everyday with trying to get an adequete measure of pain from patients. A very difficult to assess symptom indeed.

  29. jhawk says:

    @ Harriet Hall

    “Chiropractic” includes SMT with a lot of other baggage.”

    Somewhat true but this baggage is getting smaller and smaller via research.

    “If either SMT or other aspects of chiropractic care had the same level of evidence for efficacy that acetaminophen does, science-based physicians would have adopted them just as enthusiastically as they adopted acetaminophen.”

    Once again in a previous post you said “I have always agreed that SMT is effective for certain types of musculoskeletal pain: I have seen it work, and the literature confirms that it is effective for LBP (although not more effective than other treatments). ”

    Acetaminophen is one of these other treatments. So SMT for LBP has at least the level of effectiveness of acetaminophen for LBP.

  30. Harriet Hall says:

    @jhawk,

    Acetaminophen has been proven effective for relieving all kinds of pain. SMT has limited effectiveness for one kind of pain, and we don’t even know how to predict which patients are likely to respond. It is unfair to compare them.

  31. Harriet Hall says:

    @jhawk,

    “Somewhat true but this baggage is getting smaller and smaller via research.”
    Really? What practices has chiropractic eliminated because of research?

  32. Jann Bellamy says:

    @jhawk:

    “Yet another snipped sentence taken out of context. A commom theme on SBM. I was referring to the clinical prediciton rules being set up.”

    Actually, from the “context” you were referring to “who should be treated and which treatments to use in everyday in practice:” Here’s what you said: “I disagree as many chiro’s are discriminating who should be treated and which treatments to use everyday in practice by taking a history, perfroming a physical exam, arriving at a diagnosis and then performing any number of manual therapy procedures. Hopefully the research will catch up.”

    “The research on SMT for LBP is there.”

    The fact that there is some moderate evidence for SMT for LBP does not justify chiropractors diagnosing and treating “joint dysfunctions/manipulable lesions/subluxations/vertebral subluxation complex” a putative condition that you cannot demonstrate even exists. The effectiveness of a single therapy for a particular symptom does not validate your assumption as to the cause of that symptom nor does it validate the diagnostic techniques you are using to determine what you think might be the cause. Likewise, it does not justify extrapolating from the effectiveness of this single therapy that many other symptoms share this putative cause or that you are therefore able to find this putative cause with your diagnostic techniques.

    “Are you implying that the medical profession does not back fill in science?”

    I have no idea whether they are or are not, but it is not relevant to my point. My background is not in science and I find discussions about medicine difficult to follow. However, since you raise the point, I note that it is not hard to spot the deficiencies in many of the chiropractors’ arguments on SBM even without a background in science.

  33. Intraneural says:

    @ jhawk, HH

    I posted some links about 8 posts back regarding APAP but it took forever to post b/c it was “awating moderation”

    It reinforces your Comment Dr. Hall->

    “Acetaminophen has been proven effective for relieving all kinds of pain. SMT has limited effectiveness for one kind of pain, and we don’t even know how to predict which patients are likely to respond. It is unfair to compare them.”

  34. jhawk says:

    @ intraneural

    Thanks for posting those studies. I did not mean to imply that acetaminophen is not effective. I was just pointing out the exact mechanism of action is not fully understood.

    “Whose to say the effectiveness in the SMT arm was not just APAP. >>>”

    Maybe but not the point of the study. The point was to see if CPG based care including SMT was more effective than family physician usual care and they found it (CPG) to be superior. Whose to say every physician in the UC group did not prescribe acetaminophen? This is a preliminary study with limitations as I mentioned earlier.

  35. jhawk says:

    @ Harriet Hall

    “Really? What practices has chiropractic eliminated because of research?”

    I was thinking of the old vitalistic concepts that I guess used to be taught at chiropractic schools and might still be at Sherman or Life college. This concept is very foreign to me as I was never taught anything about it at my school. These chiro’s (vitalistic) seem to be in the minority though.

  36. Harriet Hall says:

    @jhawk,
    “These chiro’s (vitalistic) seem to be in the minority though.”
    A much larger minority than medical doctors who practice bloodletting to balance the humors. :-)
    Scientific medicine has given up many practices when they were proven not to work; chiropractic and the rest of CAM seldom if ever give up doing anything.

  37. jhawk says:

    @ Jann Bellamy

    “The fact that there is some moderate evidence for SMT for LBP does not justify chiropractors diagnosing and treating “joint dysfunctions/manipulable lesions/subluxations/vertebral subluxation complex” a putative condition that you cannot demonstrate even exists. The effectiveness of a single therapy for a particular symptom does not validate your assumption as to the cause of that symptom nor does it validate the diagnostic techniques you are using to determine what you think might be the cause. Likewise, it does not justify extrapolating from the effectiveness of this single therapy that many other symptoms share this putative cause or that you are therefore able to find this putative cause with your diagnostic techniques. ”

    First of all, I never said any of this. Obviously not all LBP is due to joint dysfunction. This is why you take a history, perfrom a physical exam and arrive at a diagnosis. Joint dysfunction is not a chiropractors only diagnosis and SMT is not the only therapy as you imply.

  38. jhawk says:

    @ Harriet Hall

    “Scientific medicine has given up many practices when they were proven not to work; chiropractic and the rest of CAM seldom if ever give up doing anything.”

    The majority in chiropractic have given this vitalistic theory up and hopefully the minority will soon follow. It is ashame they have not already.

    “A much larger minority than medical doctors who practice bloodletting to balance the humors.”

    Harriet Hall, not only a medical doctor but a comedian as well!!

  39. GLaDOS says:

    Here’s a chiropractic neurologist who helps personal injury attorneys win big after someone gets a bonk on the head with or without loss of consciousness. Now, these are legitimate cases. And remember, you must get an MRI which will show where the lesion is or evidence of shearing forces upon the brain.

    http://www.youtube.com/watch?v=Azn5-NRBe5w

    I would like to know:

    1) How come chiropractors are allowed to order MRIs?

    2) Why does that chiro in the video need a stethoscope around his neck?

  40. GLaDOS says:

    lizditz,

    In 2004 several VA hospitals began offering chiropractic services (West Haven VA is one; maybe Steve knows how this is working out?). For veterans not near these facilities, the VA insurance plan will pay for a certain number of visits per year with a chiropractor of the patient’s choice.

    The past couple of years I’ve seen chiros networking through organizations like the Wounded Warrior Project and a few chiropractic neurologists promoting themselves as TBI experts with an interest in vets returning from Iraq and Afghanistan.

    I Googled to find some examples for you. My first result isn’t what I was looking for but it’s so precious that I must use it:

    http://www.ehow.com/how_8155371_treat-tbi-chiropractor.html

    Just a taste:

    Tips & Warnings

    While there is no scientific proof of TBI treatment by chiropractors, decreases in symptoms and pain medications and an increase in function are common results following chiropractic care in those who have suffered from TBIs.

    If a TBI is expected, seek a diagnosis from a neurologist.

  41. Jann Bellamy says:

    @jhawk:
    “First of all, I never said any of this. Obviously not all LBP is due to joint dysfunction. This is why you take a history, perfrom a physical exam and arrive at a diagnosis. Joint dysfunction is not a chiropractors only diagnosis and SMT is not the only therapy as you imply.

    I imply neither. Let’s review the chronology of the comments: In response to Dr. Hall’s criticism that “chiropractors have been doing something they don’t understand for over a century without any attempt to discriminate who should be treated and which treatments to use,” you disagreed, saying that “taking a history, perfroming a physical exam, arriving at a diagnosis and then performing any number of manual therapy procedures. Hopefully the research will catch up.” I then pointed out (in a comment to JPZ) that “this is the 21st century, and I’d like to think that society would no longer tolerate the attitude that ‘hopefully the research will catch up’ (per jhawk). While the ‘research’ is ‘catching up’ millions of chiropractic patients are being diagnosed each year with joint dysfunctions/manipulable lesions/subluxations/vertebral subluxation complex, are being treated for same. This has been going on for over 100 years.” Next, you claimed that you were referring only to the clinical prediction rules being set up, and that I had taken your comments out of context, a mischaracterization we’ve previously cleared up. In any event, you also criticized the veracity of my comment by stating, “the research on SMT for LBP is there” the only research you reference in your response. I followed up by pointing out that chiropractors can’t legitimately use the fact that SMT is moderately effective for LBP as a justification for the existence of the dysfunction/manipulable lesion/subluxation/vertebral subluxation complex.

    But, since you bring it up, as to the assertion that “not all LBP is due to joint dysfunction” let’s be clear: there is no evidence that any LBP is due to “joint dysfunction” as the term (synonymous with subluxation, manipulable lesion, etc.) is defined (to the extent it has been defined) by chiropractors.

  42. JPZ says:

    @Jann Bellamy

    “I would hope that you are appalled at the idea of attempting to back-fill in the science, while at the same time treating patients (and charging them for it) based on (at best) woefully incomplete and (at worst) implausible “theories” of human physiology.”

    I think your particular characterization is just a matter of perspective. I don’t think chiropracters should be making money by claiming to treat health conditions they have no evidence they can treat, if your proposed legislation can stop them from doing that – more power to you. What you call back-fill science could also be seen as building an evidence base for the limited portion of chiropractery that someone feels actually works. If that is what they are actually doing (like discovering chemical principles that work in the midst of alchemical principles that don’t), more power to them.

    But, I could try to make a joke about why it took chiropracters 100′s of years to get to their own scientific evolution… but I don’t think funny is the way to go right now.

  43. ConspicuousCarl says:

    NMS-DC said:
    I looked back at my posts on chirotalk circa 2005-2006 and they actually proved to be prophetic. The same will happen here in 5-10 years when the research accrues and many of the fundamental principles of chiropractic have been validated by scientific investigation.

    So just to be clear: You are, right now, in the year 2011, saying many things which have not yet been validated by scientific investigation… and those things are fundamental principles of chiropractic?

  44. JPZ says:

    @HH

    I said, “What I don’t understand is the default dismissal on SBM of any case where there is some but incomplete evidence.”

    You said, “SBM does not just dismiss any case where there is some but incomplete evidence.”

    Ah, my use of “any” may be the problem. Let me rephrase to more accurately convey my opinion and correct my error. In my experience, if a valid scientific case is presented here in favor of an unpopular subject, many SBM commentators and contributors will not accept evidence short of two RCTs (even if they fulfill Bradford-Hill criteria to provide supporting evidence for a scientific case, for example). This is a pervasive bias on SBM, and this bias impairs the group’s ability to reach scientifically sound conclusions.

    Example 1 (This thread):

    When Steve says,

    “To be science-based, you have to already have the evidence to support your claims, not use science to back fill in claims and practices you already have. Classic pseudoscience.”

    Which means what? That chiropractors should not try to test the tenants of their profession because they are already doing it wrong? There are a lot of bad things I hear about chiropractic practices, but “don’t even try to do science” seems pretty dismissive to me.

    Example 2 (Alpha Brain – What’s Wrong with the Supplement Industry? thread)

    Steve says,

    “Usually the claim is implied in the name of the product itself – sleepwell, or brainboost.”

    “The popular product Airborne fits this mold. It is essentially a multivitamin with the unfounded claim that it will prevent infection by boosting the immune system.”

    “In the US, regulations (under DSHEA) specifically allow “structure/function” claims without any requirement for evidence to back up the claims.”

    To which I replied that these were illegal names for products, a fraudulent product prosecuted by the FTC, and an outright false statement (I provided links there). I think this could be called dismissal of the whole dietary supplement industry (regardless of ANY evidence) based on three false examples.

    Example 3 (Constipation Myths and Facts thread)

    Scott says,

    “For constipation, their effectiveness hasn’t been demonstrated though. A systematic review published in 2010 examined the data supporting their use in adults and children. Five high quality trials were identified and the results were unimpressive:”

    These were five trials on five different genuses or species of probiotic organisms. Professional groups and EFSA have all said that data from different organisms cannot be combined in determining efficacy (links in that thread), but this review did. It is an invalid basis for dismissal of probiotic efficacy.

    Scott also says,

    “…little reason to recommend their use. That’s the opinion of some regulators, too. The European Food Safety Authority has largely rejected general health claims for probiotics.”

    As I pointed out to Scott in that thread, they rejected 170 of 180 requests for probiotic health claims due to incomplete paperwork. So, this is not an opinion of the regulators, and Scott has no remaining basis for dismissing the efficacy of probiotics in constipation.

    Example 4 (Collagen: An implausible supplement for joint pain thread)

    Scott says,

    “The body doesn’t treat amino acids derived from collagen any differently than any other protein source. For this reason, the idea that collagen supplementation can be an effective treatment for joint pain, osteoarthritis, or any other condition, is highly implausible, if not impossible in principle.”

    There is data supporting selective uptake of radiolabeled oral collagen into mouse cartilage (PMID 10498764) and a human imaging technique can detect increases in knee cartilage after collagen hydrolysate feeding (PMID 21251991). Proof? No. Proof enough to counter a claim of impossible? Easily.

    Scott says,

    “Setting aside the grandiose claims, statistical significance isn’t enough — we want clinical significance. A tiny change in pain may be enough to be statistically significant — but is it relevant in the real world?”

    Dismissal by moving the goal posts? I walked him through why VAS scales don’t pick up “tiny change[s] in pain” (details in that thread) – especially when physician and patient scores agree like in the Penn State study. And, unless clinical significance is coming from a practice guideline, clinical significance is an opinion that differs between physicians.

    Scott says,

    “…but there’s certainly no persuasive evidence to suggest that’s the case. Based on what collagen is, how it’s absorbed, and how we know collagen is actually synthesized in the body, it’s highly implausible that 1200mg of additional protein consumed daily will have any meaningful therapeutic effects.”

    I have said many times, there is not enough evidence to recommend collagen hydrolysate as a treatment for OA. Are there human clinical efficacy trials? Yes, a few, (PMID 18416885) and (PMID 19212858), but some junk trials too. Is calling this small amount of evidence “highly implausible” or “impossible” a dismissal due to SBM bias?

    Those are four recent examples where I spoke up and supported my contention with evidence and data. The lack of scientifically engaged replies might also fall into the realm of dismissal of counter evidence.

    So, when you said,

    “SBM does not just dismiss any case where there is some but incomplete evidence. Any of our regular readers will recall many examples where an SBM article says there is some but incomplete evidence and that accepting the claim is not justified without further evidence. That does not constitute dismissal. I think you are reading “dismissal” where we are writing “insufficient evidence for acceptance.”

    In reply, I cite the four most recent examples of SBM bias in posts where I have participated in the comment thread. Actually, your hoodia post was the most science and fact focused dietary supplement post I have seen here recently. If you can find something other than SBM dismissal in what I presented, I am more than open to finding where the golden mean may lie.

  45. nybgrus says:

    Whilst I have not (and will not) be my usual prolifically logorrheic self, I have been following my usual fora and these comments as well.

    First, I would also like to commend NMS-DC on his change of tone and tack (well, save the RTFA comments which I was also puzzled about but didn’t look up). Now if only his understanding of science can make a commensurate shift….

    Second, it is edifying to see that completely without my input, the chiro argumentation is exactly the same and the other science based commentators are all chiming in similarly as well. Makes me feel like I wasn’t crazy, despite NMS-DC’s insistence. Also, my creationist analogy is still very much apt at this point.

    Jann said it very well:

    However, since you raise the point, I note that it is not hard to spot the deficiencies in many of the chiropractors’ arguments on SBM even without a background in science.

    Lastly, it seems that mon ami JPZ is still stuck on the basic sciences/clinical sciences issue.

    What you call back-fill science could also be seen as building an evidence base for the limited portion of chiropractery that someone feels actually works.

    As a scientist, JPZ, I find it strange you would say such a thing. You don’t “feel [something] actually works.” You have evidence for it or you don’t. The only aspect of chiro that has any evidence of actual efficacy is for chronic LBP – not any other kind. The mechanism for that is actually fairly straightforward and has to to with massage, expectancy effects, motivational encounters, and placebo responses to pain. That is why it is no more effective than any other treatment, including sham acupuncture. To try and hang the hat of chiropractic on that tiny of a nail is simply a fail.

    The rest of chiropractic has extremely limited, if any, evidence for efficacy. Trying to find a mechanism by which such chiro interventions might have putative effects, without having first proven that they even have effects in the first place is precisely the back-fill bad science I had spent much time explaining in the very first thread where NMS-DC made an appearance.

    To try and make a sort of tu coque argument wherein we as SB medical practitioners use acetominophen with knowing the precise MOA is a complete straw man. Doing the basic science to demonstrate why tylenol works is not bad science because there is robust evidence for and a good Bayesian as well – the subsequent science is not seeking to justify the use of it but merely to explain why it works. Chiropractic “science” does not seek to determine mechanisms for why something works, since they have no evidence that any of it works. They are seeking basic science mechanisms to string together a “just-so” type story in order to justify their continued use of what they already think works. There is a vast difference, that is entirely lost upon the chiro contingent here.

    If that is what they are actually doing (like discovering chemical principles that work in the midst of alchemical principles that don’t), more power to them.

    So no, that is not what they are actually doing, no matter how vehemently they try and assert it.

    As for your criticsm of SBM – I agree with Dr. Hall that it is misplaced. You aren’t wrong but the sum of your arguments does not, IMO, add up to what SBM is looking for. You claim that SBM has moved goalposts on you and that your references to basic science were dismissed and that we need at least two RCTs for everything. That really is not true. As Dr. Gorksi pointed out in his FSU talk, the point of SBM was to add to the facet of EBM that led to the increase of methodolatry – taking into account basic sciences. But from an SBM perspective, basic sciences are very good at disproving things but not proving them (i.e. lowering the Bayesian prior, but not increasing it). The reason for this is that highly improbable priors, like homeopathy and reiki, are much more easy to identify than more probable priors (like collagen for OA). As I had said in our previous discussion, the post has always been the clinical application of any treatment. SBM observes that even the best bench research has a very limited clinical application and actually very rarely pans out into something clinically useful. So when you cite the bench science demonstrating collagen peptide uptake, that (from our perspective as clinical medical scientists/practitioners) actually doesn’t really change the prior all that much. We could be wrong, but to the best of knowledge as we have it today, that is a valid assessment. If bench and clinical research continues, and demonstrates that our assessment of the Bayesian prior was incorrectly low, then we here would be the first to accept that, admit our error, and correspondingly change our view. But, once again IMO, nothing you presented in the OA discussion offered cause to change that assessment. Nobody said further research shouldn’t be done (like we do for homeopathy). From a basic science perspective it looks very interesting and promising. But from a clinical medicine perspective it is still genuinely unimpressive.

    If you can find something other than SBM dismissal in what I presented, I am more than open to finding where the golden mean may lie.

    So it wasn’t dismissal of evidence – it was an SBM perspective assessment of the magnitude of said evidence. Not a changing a goalposts but an explicit statement as to where the goalposts are, which indeed are very different from a bench sciences perspective (I don’t like calling them “basic” sciences, since they really are not very basic, even though that is the common parlance and I fall into it frequently).

    At least, that is my opinion on the matter. I’d be happy to have Drs. Novella and/or Hall offer any corrections.

    (oh, and BTW, at least for me, referring to them by title is a sign of respect for the level of knowledge and education they have. It absolutely dwarfs mine and was very hard earned. I don’t feel it is demanded of me, but I do it because I feel they deserve it. I do the same IRL, even with physicians that I worked with extensively and have had drinks with. It depends on the situation, of course, but I do not know these physicians well enough to feel comfortable calling them by first name – it was mentioned somewhere up on the thread, so I thought I’d kick in my two cents on the matter).

    I’ll check back on this at some point, but I am actually quite busy running errands and seeing family and whatnot, but had some time and desire to chime in.

  46. Harriet Hall says:

    Thanks, nybgrus. You have explained it very nicely. As I said, he was reading “dismissal” where we are writing “insufficient evidence for acceptance.”

    As for using titles, I do know my colleagues well enough to call them by their first names, but I think it is a courtesy to use their titles when referring to them in a discussion with third parties. It’s a cultural thing, and I am not always consistent. It really is unimportant and irrelevant to the discussion. Our critics frequently use diversions like that when they can’t find anything more substantive to say about the topic under discussion.

    For future reference, I don’t care what people call me as long as it is polite and is not intended as a subtle put-down. I have been called “Ms. Hall” by people who didn’t know any better and didn’t intend any disrespect and also by those who wanted to insult me.

  47. jhawk says:

    @ Jann Bellamy

    “But, since you bring it up, as to the assertion that “not all LBP is due to joint dysfunction” let’s be clear: there is no evidence that any LBP is due to “joint dysfunction” as the term (synonymous with subluxation, manipulable lesion, etc.) is defined (to the extent it has been defined) by chiropractors”

    Actually, two of the known pain generators in LBP are the facet joints (http://www.ncbi.nlm.nih.gov/pubmed/8059268) and the SI joints (http://www.ncbi.nlm.nih.gov/pubmed/7709277). These two structures can be painful due to irritation or scar tissue lay down. Either way these structures can have limited motion due to this irritation or scar tissue and this equals joint dysfunction.

  48. Harriet Hall says:

    You could justify calling LBP “joint dysfunction” because there are joints in the back and if a patient is in pain, something is obviously not functioning normally. “Joint dysfunction” can be used as a replacement for “subluxation” to justify manipulating anything a chiropractor wants to manipulate. Like subluxation, it is not meaningfully defined.

  49. GLaDOS says:

    Awr, I feel a little bad now that I called Steve, “Steve” instead of “Dr. Novella” a few comments up. But I have to blame too many hours spent listening to The Skeptic’s Guide to the Universe,” which is awesome btw.

    Speaking of podcasts, Brian Dunning did a really good job on this one, which you all should listen to:

    http://skeptoid.com/episodes/4283

    JPZ, don’t be sad that nobody cares about rat level evidence –and by “nobody” I mean working physicians.

    It is good that researchers care and invest a lot of time into sorting out potential novel treatments. Keep at it. More power to ya. Just don’t expect busy doctors to pay any attention to the rat stuff.

    Kinda cool about the mice eating Jello and having bits of it getting into their cartilage. I wonder what percentage of the gelatin placed in the mouse gut is getting absorbed as amino acids verses small peptides.

    I eat a lot of Trolli worms but my nails are crap. What is up with that?

  50. jhawk says:

    @ Harriet Hall

    “You could justify calling LBP “joint dysfunction” because there are joints in the back and if a patient is in pain, something is obviously not functioning normally. “Joint dysfunction” can be used as a replacement for “subluxation” to justify manipulating anything a chiropractor wants to manipulate. Like subluxation, it is not meaningfully defined.”

    ACA’s definiton of subluxation:
    A motion segment, in which alignment, movement integrity, and/or physiological function are altered although contact between joint surfaces remains intact.

    Before joint dysfunction is diagnosed you must have ruled out sinister pathology as well as other causes of LBP (instability, disc herniation, internal disc derangement, sprain /strain, etc.). Then you must also have tenderness/pain, range of motion abnormality, assymetry and or tissue texture change. This is how it is taught in chiro school not LBP equals jont dysfunction equals adjust.

  51. Harriet Hall says:

    @jhawk,

    “Before joint dysfunction is diagnosed you must have ruled out sinister pathology as well as other causes of LBP (instability, disc herniation, internal disc derangement, sprain /strain, etc.). Then you must also have tenderness/pain, range of motion abnormality, assymetry and or tissue texture change.”

    I’m not convinced that chiropractors can objectively and reliability do all that. I’m not convinced that chiropractic’s “joint dysfunction” is a valid diagnosis. I’m not convinced that making that diagnosis discriminates which patients will benefit from manipulation.

  52. nybgrus says:

    Thank you Dr. Hall. I am still very much learning, so thank you for taking the time to comment on my post.

    I really think that is the sole issue JPZ has been having – that bridge between the bench and clinical sciences. I guess a simpler way of putting it would be that even the absolute best bench science findings have a sort of “capped” upper limit for the prior – which is still relatively small. I don’t think we can reasonably assign an actual value to it, but no matter what, bench science can never be justifiably used in a clinical application (don’t misread me – that can mean that it should be quickly and robustly assessed in clinical trials, but just not rushed into clinical practice). My step father is a critical care doc and we were chatting just the two days ago and his take is that he always waits at least 12-24 months before beginning to use new drugs. Hence, his practice was little affected by the whole Xigris thing that Dr. Crislip wrote about (that and he thought the evidence was slim). I think that also reflects the SBM ethos regarding early studies and the decline effect.

    As for titles, of course – if someone doesn’t know better then why would one be offended? But it certainly CAN be used as a derogatory. I’m sure if I started calling you by first name on this forum you wouldn’t be offended, but from my end I don’t know you well enough to do so, and even if I did I probably still would use your title. As I said, your knowledge (and those of the other contributors here) absolutely dwarfs mine and I think it is a reasonable sign of respect that is hard earned and well deserved, despite not being demanded.

  53. ConspicuousCarl says:

    JPZ on 21 Nov 2011 at 12:45 am
    Steve says,

    “Usually the claim is implied in the name of the product itself – sleepwell, or brainboost.”

    “The popular product Airborne fits this mold. It is essentially a multivitamin with the unfounded claim that it will prevent infection by boosting the immune system.”

    “In the US, regulations (under DSHEA) specifically allow “structure/function” claims without any requirement for evidence to back up the claims.”

    To which I replied that these were illegal names for products, a fraudulent product prosecuted by the FTC, and an outright false statement (I provided links there).

    Hey, I remember that! Indeed, you even cited a specific law. Wasn’t I the one who pointed out that your own citation included an explanation for how a product name could get away with it so long as they played the non-disease game, and how the page you cited even provided an example for it?

    Weren’t you also informed at that time that the same product, in spite of the prosecution, is still sold under the same name and as a product which “supports the immune system” because the ruling only required them to stop referring to diseases directly?

    MEEEEEEEMMMMORY all alooOOOoone in the mooOOonlight
    I can smile at the ooOOOoold days
    I was beautiful then

  54. ConspicuousCarl says:

    I hope the singing wasn’t too much.

  55. JPZ says:

    @ConspicuousCarl

    And did you read my replies? You pointed out very pertinent aspects of the law that require cross-referencing with other laws to properly understand. I believe I provided those cross-references.

  56. JPZ says:

    @nybgrus

    “As a scientist, JPZ, I find it strange you would say such a thing. You don’t “feel [something] actually works.”

    Sure you do, it is called a “hypothesis.” You don’t start off with proof of your hypothesis, so you test it. If a chiropracter believes a procedure has real health benefits but knows that there is no proof of efficacy, what is wrong with testing the hypothesis that the procedure works? One guy is developing a sham control for a neck procedure at CMCC, which sounds like a step in the right direction for better procedure validation.

    “Trying to find a mechanism by which such chiro interventions might have putative effects, without having first proven that they even have effects in the first place is precisely the back-fill bad science I had spent much time explaining in the very first thread where NMS-DC made an appearance.”

    My assumption was that a procedure is hypothesized to have a beneficial effect, and the procedure is tested to determine if the benefit is real. If chiros don’t know how to best test a procedure but they hypothesize a potential benefit, what is the harm in looking for more sensitive biomarkers before you begin your efficacy testing? I think you are having NMC-DC’s conversation with me.

    “So no, that is not what they are actually doing, no matter how vehemently they try and assert it”

    OK, and I have always said that you know more about it than I do on this topic. Just some of the comment here against chiro science seem to violate some fundamental aspects of the scientific method.

  57. JPZ says:

    @nybgrus and HH

    “But from an SBM perspective, basic sciences are very good at disproving things but not proving them (i.e. lowering the Bayesian prior, but not increasing it). The reason for this is that highly improbable priors, like homeopathy and reiki, are much more easy to identify than more probable priors (like collagen for OA).”

    Yes! SBM citing the Baysean prior to toss out reiki and homeopathy is easy. But, the Baysean prior is only valid where all available are taken into account to set the prior. Weighing all the data would raise the prior proportionally to the amount of supporting data (I diagree that you can’t raise the prior with animal and pilot data since it may address Brandord-Hill criteria or other measures). SBM can’t seem to overcome its own bias to raise the prior. I don’t accept that pilot studies, mechanistic and animal studies have NO or infintesimal weight in the Baysean prior because that violates the assumptions of the statistic.

    “As I had said in our previous discussion, the post has always been the clinical application of any treatment.”

    But, wait a minute, a paragraph before you said,

    “You claim that SBM has moved goalposts on you and that your references to basic science were dismissed and that we need at least two RCTs for everything. That really is not true.”

    So, what are the research standards for the clinical application of any treatment if not 2 RCTs?

    “So when you cite the bench science demonstrating collagen peptide uptake, that… from a clinical medicine perspective it is still genuinely unimpressive.

    I didn’t cite it for a proof of efficacy (getting tired of repeating myself). Scott said that peptide uptake into cartilage from collagen hydrosylate after digestion is impossible. I provide direct proof in rats and indirect proof in humans that it is taken up. Don’t move the Baysean prior – toss out your assumptions!

    @HH

    And this comes back to the 500 lb. gorilla in the room, most of what I discussed in my examples above were cases of dismissive conclusions drawn by SBM commentators using false statements or examples. When data or evidence to the contrary is presented, there is no revision of the conclusion. If you are not willing to revise your opinion based on new scientific data, then you have a systematic bias (SBM+ bias?).

  58. Harriet Hall says:

    @JPZ, “When data or evidence to the contrary is presented, there is no revision of the conclusion.”

    When evidence to the contrary is presented but is insufficient to alter the conclusion, there is no reason to revise the conclusion.

    There may be some confusion when a statement intended as a provisional conclusion or an opinion is read as a dogmatic statement of fact. We need to exercise caution to distinguish between these, and our readers need to exercise caution in interpreting what we write.

  59. JPZ says:

    @HH

    The examples I listed in this thread quoted the commentators as making unqualified statements of fact or conclusion based on their own opinion or based upon a quoted piece of information. I presented data showing that the basis for their unqualified statement was either disproven, false interpretation of the law, or a fatally-flawed review. If you and I were playing ‘gothca bingo’ with words like “any” (that I misused earlier), I could somewhat better understand your soft sell of the differences. This is why I took the time to document some fairly clear-cut examples.

    ‘The hardest thing to explain is the glaringly evident which everybody had decided not to see.’ – Ayn Rand

  60. Regarding the SBM clinical vs research dispute. I’d like to add a laymen’s opinion. I’ll be clear, that I only think I understand about half the discussion (which means it’s more likely I understand a quarter,) but here goes.

    While SBM does focus on the clinical application of therapies, some articles do cover therapies that are currently being research that may be promising, but are not ready for prime time. It is suggested that patients should not participate in these therapies, since they are unproven, but they should be research further. Also, there have been occasional complaints about NCCAM wasting money on reasearching implausible treatments. In fact I think I recall some article that talked about how SBM is, in part, built to exclude researching implausible treatments that can sometime result in papers that prove the impossible (I think there was some Poe on prayer as an example.)

    So, from a laymen’s perspective it does seem important, in term of research, if SBM is claiming a particular therapeutic avenue is “implausible or impossible” rather than say…not promising or not ready for prime time (clinical application).

    As a laymen, who sometimes needs to rely on others to say whether something is scientifically impossible or not, I find it quite confusing for a SBM writer to use the word implausible to describe both homeopathy and something that has a remote possibility of working, but needs a bunch of research before we have an idea if it might work (collagen for OA).

    I would appreciate it if writers made the distinctions within the implausible to plausible spectrum clear when discussing the clinical (or research) aspects of the therapies.

    Just my two cents.

  61. Harriet Hall says:

    @JPZ,
    “I presented data showing that the basis for their unqualified statement was either disproven, false interpretation of the law, or a fatally-flawed review.”

    I’m not going to get into a fight about your examples: I’ll leave the writers to defend themselves. As for myself, if you think something I write is disproven, false interpretation or fatally flawed, I’ll gladly look at your evidence and if you can convince me, I’ll gladly correct my errors.

  62. JPZ says:

    @HH

    “I’m not going to get into a fight about your examples: I’ll leave the writers to defend themselves.”

    I agree, that would be unfair for you to defend the validity of their statements. I presented the examples as evidence that your previous statement

    “SBM does not just dismiss any case where there is some but incomplete evidence.”

    was falsifiable. Even without going into the validity of the statements (which the authors should defend), we see a pattern. If a SBMster makes a statement based on a falacious opinion or fact; a commentator replies with verifiable, appropriate, scientific evidence countering the falacious opinion or fact; and the SBMster dismisses the contrary evidence by ignoring it. I could certainly continue to collect examples of scientifically-flawed SBM-bias beyond these four, but to what end? If the SBMster won’t face the fact that they got the facts wrong, they only discredit themselves over time until they become the Mercola they hate.

    “As for myself, if you think something I write is disproven, false interpretation or fatally flawed, I’ll gladly look at your evidence and if you can convince me, I’ll gladly correct my errors.”

    Gladly, I haven’t seen one from you. I enjoy reading your posts, and you refrain from overstepping what the science says. I may differ with your interpretations at times, but that is opinion and not any fault in the facts.

  63. Harriet Hall says:

    @JPZ,
    “SBM does not just dismiss any case where there is some but incomplete evidence.” is true in general, even if there are rare exceptions.

  64. DrRobert says:

    As simplistic as my view may be, I simply don’t trust anything a chiropractor says. Their entire practice is based on scientific nonsense. If they’ve devoted 4 years of their life to studying this nonsense, why on earth would I trust their opinion regarding anything. There’s a strange trend where people have started to believe that chiropractors know a lot about nutrition. If someone believes that all of disease comes from mystical subluxations of vertebrae why on earth would I trust their opinion on anything else?

  65. GLaDOS says:

    JPZ,

    If someone writes something that you feel is too dismissive, rather than claim that everyone at SBM is biased, I would comment on the particular author’s post. If that author doesn’t see eye to eye with you, go ahead and hate them for being unfair, if you must.

    Anyway, I think you and I might not agree on the meaning of “dismissive.” For a new drug, yes I want two clinical trials showing safety and efficacy before I start recommending it to patients. For other stuff, it depends.

    Chiropractic back rubs for adults who get something out of the experience? Fine. I don’t care. Whatever floats your boat.

    Craniosacral therapy or gluten free diet for kids with autism? GTFO and DIAF.

  66. GLaDOS says:

    “As a laymen, who sometimes needs to rely on others to say whether something is scientifically impossible or not, I find it quite confusing for a SBM writer to use the word implausible to describe both homeopathy and something that has a remote possibility of working, but needs a bunch of research before we have an idea if it might work (collagen for OA).”

    Collagen is a protein. A protein is a chain of amino acids arranged like beads on a string. There are 22 different amino acids.

    When you eat protein, your gut secretes proteases which chop the individual beads from the string. It is these beads, not the string, that gets transported from the gut lumen into your blood stream.

    So there exists a plausibility hurdle for anyone claiming that eating collagen will do more for your joints than, say, eating a steak (myosin). Myosin and collagen chopped up are the same 22 amino acids as far as your urea cycle is concerned.

    The plausibility hurdle is this: how are big assed collagen molecules nearly the size of a bus getting into someone’s blood stream? And why is that person not yet dead?

    If you say, only a little tiny bit of the collagen is getting into the blood, ok maybe that is true. But then I would guess that only a little tiny bit of one tiny little joint is noticing any benefit.

  67. JPZ says:

    @GLaDOS

    “If someone writes something that you feel is too dismissive, rather than claim that everyone at SBM is biased, I would comment on the particular author’s post. If that author doesn’t see eye to eye with you, go ahead and hate them for being unfair, if you must.”

    I addressed each individual false claim in the original thread with relevant facts but no response. Now I am up to four examples of this occurring in the last 2 weeks, I have a pattern. The two commentators who won’t face up to facts are SBM staff. If you can’t step up and discuss the science even when you are wrong, then you have a bias – the SBM bias.

    These are not differences of opinion. An exampe is that you claim oral collagen can’t get into cartilage in any significant amount (define significant) because it is completely broken down. Based on your well-educated opinion, correct? When I take your well-educated opinion and contrast it to selective uptake of macromolecular radiolabeled oral collagen into mouse cartilage (PMID 10498764) and a human imaging technique that can detect increases in knee cartilage after collagen hydrolysate feeding (PMID 21251991), do you feel your opinion still wins out over data? Do you feel you should revise your opinion – even provisionally?

    This isn’t about being “unfair” it is about the deliberate proliferation of lies by not addressing contrasting data. Scott Gavura dismisses the use of probiotics for constipation based on one review and by saying EFSA also doesn’t support probiotic claims. The review tried to compare five different genus and species of probiotic organisms to form one conclusion. EFSA and ISCAPP have both said you cannot compare efficacy studies across different organisms to draw more general conclusions – fatal study flaw. And, the only reason EFSA threw out 170 of 180 probiotic claims was due to incomplete paperwork. So, with the only two pieces of support in the posting, a fatally-flawed review and a total misinterpretation of EFSA actions, somehow the statement that probiotics don’t work in constipation still makes perfect sense? Is how chiros feel when they won’t let go of subluxations despite the evidence against it?

    GLaDOS, I appreciate the attempt to engage the softer vocabulary of “feel” and “unfair,” but this is a scientific discussion and we can occasionally separate truth and fiction based on facts.

  68. JPZ says:

    @HH

    “SBM does not just dismiss any case where there is some but incomplete evidence.” is true in general, even if there are rare exceptions.”

    Could you link me to 1-3 examples of where the SBM discussion gave a favorable impression of a potential treatment that had less than 1 full RCT completed? I think I would learn a lot by actually seeing one of those, and it might give me a better insight into the selection bias that I perceive.

    Thank you!

  69. nybgrus says:

    Sure you do, it is called a “hypothesis.” You don’t start off with proof of your hypothesis, so you test it.

    They don’t have a hypothesis. They have a claim that it works. Look at what they all write – particularly NMS-DC. They each state something to the effect that the science is finally catching up to what chiropractic has been doing all along. Very different things.

    If a chiropracter believes a procedure has real health benefits but knows that there is no proof of efficacy, what is wrong with testing the hypothesis that the procedure works? One guy is developing a sham control for a neck procedure at CMCC, which sounds like a step in the right direction for better procedure validation.

    That is a very rare exception to what we actually see from the chiros. Actually testing to see if the intervention works is fine. But to use the intervention without that evidence is questionable at best. And the evidence they have been putting up is all bench science and animal studies. As we’ve discussed, that does not explain nor justify the use of an intervention at a clinical level. Telling me that pinning a guinea pig’s knee joint is proof for the use of SMT on humans for low back pain is…. bad science.

    If chiros don’t know how to best test a procedure but they hypothesize a potential benefit, what is the harm in looking for more sensitive biomarkers before you begin your efficacy testing?

    The point is that we all agree (well, save the chiros of course) that the surrogate biomarkers and endpoints are not adequate.

    I think you are having NMC-DC’s conversation with me.

    True enough. It was to tie it all in to illustrate the SBM point.

    Just some of the comment here against chiro science seem to violate some fundamental aspects of the scientific method.

    I’m sure not everything is 100% spot on. But close enough.

    Weighing all the data would raise the prior proportionally to the amount of supporting data

    Yes, we agree it would raise the prior. We disagree as to how much.

    I diagree that you can’t raise the prior with animal and pilot data since it may address Brandord-Hill criteria or other measure

    I never said that you can’t raise the prior. I said that bench science can only raise it to a non-insignificant but small value. Having piles and piles of bench science that gives as much plausibility and Bradford-Hill as you could hope for only means that a decently powered and well designed RCT will be enough to convince me. Less than that means highly powered or repeat RCTs. But anything else is a stretch. To put it plainly, what truly excites and tittilates a bench scientist is usually quite less dramatic for a clinical scientist – and both are right to have that reaction.

    I don’t accept that pilot studies, mechanistic and animal studies have NO or infintesimal weight in the Baysean prior because that violates the assumptions of the statistic.

    Once again, I never said no weight. I never even said infinitesimal. But the one consideration you aren’t taking into your account in the Bayesian prior is that historically and with good reason the vast majority of bench science breakthroughs lead to zilch in clinical application. Even really good, very plausible, well done, super-awesome bench science. The assumptions of the statistic must take that into account as well. So the most a bench science finding(s) can do for me is make me quite interested in future work. That’s about it.

    So, what are the research standards for the clinical application of any treatment if not 2 RCTs?

    Convergence and concordance of evidence is good enough as well. We don’t have RCTs on smoking and lung cancer, but I feel pretty confident telling my patients they should quit. We don’t have RCTs on use of lidocaine and epinephrine in full arrest, but I’ll still order and push the drugs. But those require at least some good retrospective studies, maybe some case-controls, prospective cohort studies, etc and bench science to back it up. It is possible to clear those SBM goalposts without 2 RCTs, but it is certainly much tougher. But bench science alone cannot clear them.

    I provide direct proof in rats and indirect proof in humans that it is taken up. Don’t move the Baysean prior – toss out your assumptions!

    Actually, as I pointed out, you did not offer such proof. You offered plausibility that it might happen to some undefined extent. You like to cite the DHEA uptake of less than 1% being enough to effect a response in the brain – that has no bearing on this discussion. Hormones and structural peptides are inherently and vastly different in their potencies. And even then, comparing uptake and bioavailibility of similar compounds is only moderately interesting at best.

    The articles demonstrates a relative increase in radiolabeled density – that means it could have gone from .0001% to .0026% for all we know. It tells us nothing clinically useful. It also used rat gut-sac product protein electrophoresis. That tells us that in a rat gut sac some of the polypeptide gets through as a macromolecule. Besides the fact that they are using a cut piece of rat gut (as opposed to an intact human gut) it merely tells us that the macromolecule can exist outside the gut-sac to some extent. It does not inform us as to whether that is a 1:1 relationship between the radiolabel signal in the cartilage. The notion that human guts can absorb larger than just single amino acids or short oligopeptides is nothing new BTW – I knew about that from my high school days.

    The point is that this is all very interested from a bench science perspective. But has so many assumptions and leaps, plus the inherent implausibility of a relative drop in the ocean of collagen, combined with the ever present fact that bench science rarely pans out, plus the really equivocal human studies means that nothing has changed with our Bayesian prior. The goal posts didn’t move and our assumptions were not flawed (perhaps amongst some of us they were in need of some refinement) – the additional data just didn’t reach the posts is all.

  70. Harriet Hall says:

    @JPZ,
    You appear to be moving the goalposts. First you accused us of dismissing things and now you ask “Could you link me to 1-3 examples of where the SBM discussion gave a favorable impression of a potential treatment that had less than 1 full RCT completed?” Not giving a favorable impression does not equate to dismissing.

    It would not be good science to give favorable biases to untested treatments, and we shouldn’t be doing that. What we should do and do do is not dismiss a treatment just because it has not been tested with RCTs, and to acknowledge when a treatment seems to have promise and deserves further testing. Here are just a few of many examples:

    http://www.sciencebasedmedicine.org/index.php/hash-oil-for-gliomas-what-would-you-do/
    http://www.sciencebasedmedicine.org/index.php/protandim-another-kind-of-antioxidant/
    http://www.sciencebasedmedicine.org/index.php/amish-home-burn-treatment-bw-salve-and-burdock-leaves/

  71. GLaDOS says:

    Could you link me to 1-3 examples of where the SBM discussion gave a favorable impression of a potential treatment that had less than 1 full RCT completed?

    Wat.

    “Favorable” in the sense that further research is justified, or “favorable” in the sense that working doctors ought to promote some supplement to their patients. Cuz if you mean the latter, then no, that is not okay.

    These are not differences of opinion. An exampe is that you claim oral collagen can’t get into cartilage in any significant amount (define significant) because it is completely broken down. Based on your well-educated opinion, correct? When I take your well-educated opinion and contrast it to selective uptake of macromolecular radiolabeled oral collagen into mouse cartilage (PMID 10498764) and a human imaging technique that can detect increases in knee cartilage after collagen hydrolysate feeding (PMID 21251991), do you feel your opinion still wins out over data? Do you feel you should revise your opinion – even provisionally?

    Mouse abstract:

    Several investigations showed a positive influence of orally administered gelatin on degenerative diseases of the musculo-skeletal system. Both the therapeutic mechanism and the absorption dynamics, however, remain unclear. Therefore, this study investigated the time course of gelatin hydrolysate absorption and its subsequent distribution in various tissues in mice (C57/BL). Absorption of (14)C labeled gelatin hydrolysate was compared to control mice administered (14)C labeled proline following intragastric application. Plasma and tissue radioactivity was measured over 192 h. Additional “gut sac” experiments were conducted to quantify the MW distribution of the absorbed gelatin using SDS-electrophoresis and HPLC. Ninety-five percent of enterally applied gelatin hydrolysate was absorbed within the first 12 h. The distribution of the labeled gelatin in the various tissues was similar to that of labeled proline with the exception of cartilage, where a pronounced and long-lasting accumulation of gelatin hydrolysate was observed. In cartilage, measured radioactivity was more than twice as high following gelatin administration compared to the control group. The absorption of gelatin hydrolysate in its high molecular form, with peptides of 2.5-15kD, was detected following intestinal passage. These results demonstrate intestinal absorption and cartilage tissue accumulation of gelatin hydrolysate and suggest a potential mechanism for previously observed clinical benefits of orally administered gelatin.

    Based on this, I’m supposed to recommend collagen supplements to people with arthritis? Is this what you are saying?

    If you give a mouse just proline but no other amino acids, how is the poor thing supposed to make any new proteins to stick in its joints or wherever?

    Protein digestion involving protease and the gut barrier against the absorption of large molecules by diffusion isn’t really a personal opinion on my part.

  72. GLaDOS says:

    http://www.chicagotribune.com/health/la-heb-chronic-fatigue-syndrome-xmrv-20110922,0,6289303.story

    How much did that wild goose chase cost?

    People who say “favorable” things about some potential medical intervention based on research from one group without independent replication are bad people who should feel badly about themselves.

  73. JPZ says:

    @HH

    “First you accused us of dismissing things and now you ask “Could you link me to 1-3 examples of where the SBM discussion gave a favorable impression of a potential treatment that had less than 1 full RCT completed?”

    Goal posts didn’t move – just being open to counter-evidence. I do feel SBM dismisses certain classes of data and when I provided examples, you said it does not. I asked for examples to support your counter-claim, you gave them. I will read them with as open a mind as possible and comment favorably or unfavorably as fairly as I can as to whether I see your point of view more clearly. So far, this portion of our conversation has not tested a goal post. Actually, I fear it will be personal definitions of the words “favorable,” “dismiss,” and “untested” where goalposts are in danger of being moved.

    “It would not be good science to give favorable biases to untested treatments, and we shouldn’t be doing that.”

    I thought the discussion was about treatments supported by some data just not 2 RCTs. It sounds like negative bias to call them “untested,” unless that was unintentional. Although, It is a given that a treatment with NO data gains no favorable bias – I am totally on board with that aspect of SBM.

    “What we should do and do do is not dismiss a treatment just because it has not been tested with RCTs, and to acknowledge when a treatment seems to have promise and deserves further testing.”

    I lost you in the “do and do do”‘s typo, but it sounded like we were agreeing there.

  74. JPZ says:

    @GLaDOS

    Your patient-centric viewpoint makes perfect sense in terms of “show it to me in a practice guidline and I will see if it is worthwhile in my patients.” Nothing short of 2 RCTs is good enough for your patients. Also, you derive schadenfreude when a CAM treatment fails.

    As I have said, repeatedly, there is not enough data to support collagen as a treatment to prescibe for OA patients. Period.

    Pardon my transforming your previous comments into a wall of text. You said,

    “Collagen is a protein. A protein is a chain of amino acids arranged like beads on a string. There are 22 different amino acids. “When you eat protein, your gut secretes proteases which chop the individual beads from the string. It is these beads, not the string, that gets transported from the gut lumen into your blood stream. So there exists a plausibility hurdle for anyone claiming that eating collagen will do more for your joints than, say, eating a steak (myosin). Myosin and collagen chopped up are the same 22 amino acids as far as your urea cycle is concerned. The plausibility hurdle is this: how are big assed collagen molecules nearly the size of a bus getting into someone’s blood stream? And why is that person not yet dead? If you say, only a little tiny bit of the collagen is getting into the blood, ok maybe that is true. But then I would guess that only a little tiny bit of one tiny little joint is noticing any benefit.”

    I provided two references, one showing SELECTIVE uptake into rat cartilage (mechanism via radioisotopes) and the second showing empirical increase in human cartilage in a pilot randomized trial. nybgrus can explain the macromolecular part better than I (he put it quite well). This is not to say “go prescribe it now” this is to say that the mechanism you thought was true is not, and that you should consider revising it and your bias against other data here.

    “Mouse abstract”

    Well, I suppose we could bring you by the lab a shoot you up with C14-proline labeled collagen fragments as long as you don’t mind giving up some cartilage, liver, adipose, etc. ;)

  75. GLaDOS says:

    Some medical interventions are difficult to study using methods of blinding and randomization. But in the case of oral supplements for common conditions, I don’t really see the problem with using the same standard that we want for drugs: two RTCs. That is not dismissive. That is just practical.

    Even with the two RTCs, we still get a lot of treatments to market that turn out to be disappointing in some way. If we lower our evidential bar further, we will be up to our ears in spam medicine.

    Oh wait. We did lower our bar, thanks to DSHEA. And we are up to our ears in spam medicine.

    So back to two RTCs for little things that you put in your mouth. Is that so wrong?

  76. nybgrus says:

    JPZ:

    I thought the discussion was about treatments supported by some data just not 2 RCTs. It sounds like negative bias to call them “untested,” unless that was unintentional.

    We are clinicians (some in training ;-)) practicing on actual human beings. Bench science = untested. 1 million guinea pigs agree that testing on them means untested from an SBM perspective.

    Also, you derive schadenfreude when a CAM treatment fails.

    I do too, to be honest. If I was in a genuine scientific discussion with someone where we were both intellectually honest and I were vindicated I would not. But when people are swayed away by dishonest political and ideological tactics from actual science and those doing the swaying trip and fall, yes, I will happily derive some schadenfreude. One of my favorite words, BTW.

    nybgrus can explain the macromolecular part better than I (he put it quite well). This is not to say “go prescribe it now” this is to say that the mechanism you thought was true is not, and that you should consider revising it and your bias against other data here.

    I will actually be forced to agree here and say that GLaDOS was either misinformed or taking a shortcut for brevity. Macromolecules of decently large size can and are regularly absorbed through the gut. Not each and every single protein in chopped into mono- or oligo-peptides. However, exactly what those macromolecules are has not been determined. At best, they are in a similar size distribution as the original protein electrophoretic profile in question. That doesn’t tell us how much and where GLaDOS is right is that it is almost certainly rather small amounts. Furthermore, the rat studies you cite explicitly state that their methodology for determined said electrophoretic profile is flawed, but “the best available.”

    In other words, all the data is tenuous at best. GLaDOS is not unjustified in ignoring it as noise from a clinical perspective. From a strict scientific one, he should be compelled to change his verbiage a bit, but the overall conclusions stay the same. I can understand his shortcut though – I am in a position where I can delve into such bench science studies. He, I am sure, is much busier. And until good data comes about that demonstrates that such macro-peptide absorption is actually a clinically significant entity (and so far it only has in cases of the development of pediatric allergy, but that is a different topic altogether), then he can reasonably continue with the “bias” you ascribe to him, which, IMO, is more of a rounding error than a systematic bias. We all have to take shortcuts sometime.

  77. GLaDOS says:

    “Well, I suppose we could bring you by the lab a shoot you up with C14-proline labeled collagen fragments as long as you don’t mind giving up some cartilage, liver, adipose, etc.”

    The study mice got C14-proline labelled collagen and the control group got C14-proline only, is this correct?

    So the control mice could not manufacture cartilage using the meals they were given over the few days they participated in this study, while the study mice could.

    I don’t understand how the researchers could differentiate radiolabelled collagen molecules that the mice made themselves using amino acids from the collagen meals they were given verses radiolabelled collegen that strangely passed intact from their gut and somehow got into their joints.

  78. GLaDOS says:

    nybgrus, I’m not saying that big things are never absorbed from the gut. That’s obviously false. For example, viruses.

    But you are mostly protein because you have that DNA transcription machine in all your cells. That machine uses amino acids, not peptides. You don’t need peptides as building blocks. And a gut that lets a lot of kilo Dalton sized things through is not a healthy gut.

  79. GLaDOS says:

    “Also, you derive schadenfreude when a CAM treatment fails.”

    That is incorrect. I would be very happy to learn that I might delay my own progression toward osteoarthritis by simply adding collagen supplements to my diet.

    A fine glass of shadenfreude cannot be enjoyed without first tasting a serving of moral outrage, which itself is rather bitter.

  80. JPZ says:

    @nybgrus

    The first part of your message seems to say that chiros are never practicing the scientific method, and that they only use pseudo-research wrapped in the trappings of science to back-fill beliefs that they don’t plan to change. You know more than I on this topic, and I trust your superior knowledge base. If a chiro tried to present actual science here, I am not sure it would have a snowball’s chance in hell of getting heard (of course their would need to get a LOT better at presenting the science).

    The second part of your post seems to say that pilot and animal data should not be discounted in establishing the Baysean prior, but they should not influence it much. In the absence of prior data on expected versus actual outcomes, the Baysean prior is established subjectively using all available evidence. If you and I discuss all available evidence and agree on a prior we feel best fits the data, then we have used the model appropriately. Others on SBM have resorted to dismissing data to include in the model based on false assumptions and therefore violate the model (SBM bias). Perhaps another reason I am not so quick to dismiss pre-clinical findings is that the change of a drug candidate getting through pre-clinical models is 1:250. For a nutritional product, it is 1:5. The chance of getting through clinical testing is 1:5 for a drug and 1:2 for a nutritional product. That might inflate my estimates of the Baysean prior as well.

    It isn’t DHEA, it’s DHA (docosahexaenoic acid), a structural lipid in the brain much like collagen is a structural protein in cartilage.

    Regarding collagen, those are all standard, highly validated techniques – and you do not seem to understand the models. If one organ takes up more of a orally-dosed compound (except the liver or adipose sometimes) than other organs, somehow that organ has an affinity for the orally administered compound. The everted gut sac model has long history of validation in multiple labs as well and is a much more complete test of the various factors that might break down a set of molecules before absorption (as opposed to CACO2 cell cultures or artificial gut models). The newer technology, dGEMRIC, showing increased cartilage deposition in human knees after collagen treatment is the empirical piece of the puzzle. Selective uptake, macromolecular absorption and empirical evidence of deposition indicating that the metabolism is not what it was assumed to be.

  81. JPZ says:

    @GLaDOS

    “A fine glass of shadenfreude cannot be enjoyed without first tasting a serving of moral outrage, which itself is rather bitter.”

    LOL! ;)

  82. nybgrus says:

    @GLaDOS:

    I’d have to re-read them in detail (which I am not keen to do), but my impression was that they had reasonable cause to assume that at least some of the radiolabel in the cartilage was from the original collagen hydrosylate. My point to JPZ was they had no way of telling how much was actually there – they could ONLY cite a relative change. How much of that was from the radiolabeled AA’s being incorporated and how much was direct from the macromolecule uptake of the gut is anyone’s guess (though ours would be “very little”). That is why I made the comment about 1:1 absorption – there is no way to verify that. But from a very strictly pedantic scientific standpoint JPZ is right – but what I feel gets lost upon him is how little that means to us clinically.

  83. nybgrus says:

    @JPZ:

    Never is always a strong word. I am sure I used it or at least implied it. But of course chiros do practice some real science – just not very often at all and damned near none of it has proven useful in any way. Everything is very preliminary.

    I think Dr. Hall’s statement still fits well – we do not “dimiss” we simply think that the evidence presented simply doesn’t add up to much. But I suppose we could get into semantics and rounding error here. Is me saying that “piece of evidence [X]” only increases the Bayesian by 0.1% “dismissing” it? I suppose it could be – I would be saying, essentially, that it is positive, it does improve the Bayesian prior, but it may as well not have existed since it does so to no appreciable degree. So yes, we “dismiss” the evidence in that sense, but we aren’t really being dismissive.

    It isn’t DHEA, it’s DHA (docosahexaenoic acid), a structural lipid in the brain much like collagen is a structural protein in cartilage.

    Mea culpa. I was going off memory and did not look up the quotes. That does change things a bit…. but as I said in my original comment “And even then, comparing uptake and bioavailibility of similar compounds is only moderately interesting at best.

    and you do not seem to understand the models

    I am sure I don’t fully. However:

    If one organ takes up more of a orally-dosed compound (except the liver or adipose sometimes) than other organs, somehow that organ has an affinity for the orally administered compound.

    I do get that. However – why the affinity? What does that affinity mean? And is that affinity clinically relevant? None of those questions are answered by the studies.

    The affinity could be simply because a collagen like macromolecule will stick in a collagen matrix better. It could simply mean that it is hanging around that area longer, producing a stronger signal without interacting at all with the chondrocytes. And it could mean that 26 such macromolecules vs 10 proline residues are absorbed, which means pretty much nada clinically speaking (it could also, as GLaDOS pointed out, mean that the radiolabeled residues are being incorporated preferentially into cartilage since the proportion of amino acid residues used in collagen production is higher in… collagen!)

    In other words, as I have said repeatedly – very interesting from a bench science perspective and certainly I wouldn’t begrudge some further study. But nothing that makes me feel the Bayesian has changed significantly.

  84. JPZ says:

    @nybgrus

    “In other words, as I have said repeatedly – very interesting from a bench science perspective and certainly I wouldn’t begrudge some further study. But nothing that makes me feel the Bayesian has changed significantly.”

    Missed the point again. Scott Gavura and GLaDOS both said eating collagen can’t put collagen in the knee. This is SBM dismissal. The data say feeding collagen increases cartilage in the human knee as measured by dGEMRIC, and there is a supporting animal study showing labeled oral collagen preferentially accumules in the cartilage. If this is evidence that eating collagen can put collagen in the knee, how can someone continue say that it can’t happen without presenting counter evidence? The counter evidence you have presented amounts to hypothetical speculation about how proteins might be metabolized or just saying “I don’t believe it.”

    Again, this is not to prove any clinical benefit, it is to prove that the SBM bias is insoluble when exposed to evidence to the contrary. The Baysean prior is a larger and slightly corollary point about accepting limited data in determining the probabiliy of better describing the underlying relationship before the next experiment. SBM bias is the willingness to ignore counter evidence in order to maintain one’s opinion about a subject that is unpopular on SBM.

    Let me see if I can simplify this discussion. If you tell me than A cannot exist, and I show you B and C as evidence A exists. Do you,
    - Yell louder that A cannot exist
    - Turn you back, fold your arms and pout
    - Find every fault you can with B and C with addressing A (even though none are fatal flaws)
    - Admit B and C provide some evidence of A, but D and E would be better evidence
    - Say that B and C do indeed provide partial support for the existance of A, but A alone is not enough for clinical practice

  85. nybgrus says:

    I take B and C and say that it still doesn’t materially change A. I think that has basically been what the SBM line has been here and that everything else has been a very nit-picky sort of discussion. I certainly don’t think I have said anything different.

    I think we have also called into question just what exactly and how much B and C prove anything about A. And I think that is a valid criticism. In other words, it isn’t that the evidence is contrary and we aren’t changing a stance on it. It is that we already knew that evidence (in general, as GLaDOS pointed out) and find it unimpressive. In other words, we knew the general concepts of B and C and you giving us specific examples just fit in with what we’d already been saying. I don’t see a bias there – it has nothing to do with popularity.

    As GLaDOS said – yes, we all have known that macromolecules do permeate the gut in toto from time to time. But that a gut which accepts a large amount of such macromolecules is undoubtedly diseased. So citing a specific example of bench science that shows collagen specifically can do that doesn’t change our understanding.

    Demonstrating it selectively accumulates in cartilage also doesn’t really demonstrate anything either since it is a relative change and there are many mechanisms by which that may reasonably happen (once again, as GLaDOS pointed out as well).

    So there isn’t a bias you are finding, nor a shifting of goal posts. Merely a lack of absolutely explicit and incredibly detailed discussion on the very fine specifics of each case. Which once again reflects the nature of this site as being clinically oriented rather then bench science oriented.

  86. a few random thought.

    One question I would be curious about is the concept of oral tolerization with collagen in patients with RA. Considering the speculation that some subsets of OA may have an autoimmune component, perhaps there’s a long shot for research in that direction. Although seeing if the RA research pans (panned) out would seem advisable. I can’t find a whole lot googling the topic. Maybe because it just didn’t work or maybe I’m not using the correct key words.

    Guys, (and you too GLaDOS) It seems you are going round and round on this topic. GLADOS makes an excellent point that recommending unproven therapies is…bad. But having been on the otherside of that argument (doctors reluctant to prescribe medication for my autoimmune thyroid disease until TSH exceeded 10, because my subclinical hypothyroidism “couldn’t be causing symptom”.) I would suggest that it’s a pain to wait for science to catch up. When there is undocumented or questionable safety, certainly caution is best, but when the risks are well documented and the patient is advised of them, it seems reasonable to include the patient in the decision making process.

    As Harriet Hall observed in the HPV thread, even from a clinical viewpoint it is useful to understand the research aspect of the subject. This way, as research develops, the patient/consumer may have some expectation of the form therapies will take. I’m perfectly happy to hear, “we’re working on it.” or “with the information we have now, this therapy looks like a very bad bet.” But if you tell me something is “implausible, nearly impossible” then I’ll certainly have a slap my forehead moment if it becomes a treatment standard five years later (maybe a little shad..she..gloating will result).

    Oh shoot, not finished with my ramble, but must come up with some sort of lactose free, soft food dinner. Yum.

  87. GLaDOS says:

    “Regarding collagen, those are all standard, highly validated techniques – and you do not seem to understand the models.”

    Correct, I don’t understand the model. So help me out by explaining how the researchers can differentiate:

    1. Collage in stomach with C14 labelled amino acids –> broken down into individual amino acids in the gut by protease –> collagen synthesized by chondrocytes using C14 amino acids absorbed from gut.

    2. Collagen in stomach with C14 labelled amino acids –> exact same molecule incorporated into cartilage.

  88. GLaDOS says:

    Michelle you are an adult and can take some risks with your own health if you want. The problem is, once parents think that hormones are useful outside the recommended therapeutic levels, then kids are given the hormones.

    So there need to be a line between sufficient evidence verses not enough evidence yet.

  89. JPZ says:

    @HH

    Thank you for your examples, they once again demonstrate that you personally don’t overstate the science with any regularity that I have seen. I found your level of criticism inconsistent between the three examples, but I was open to calling that “editorialization.” If we were to disagree over those inconsistencies, I do not think it would illuminate the reader all that much.

    @nybgrus

    If anything less than 2 RCTs doesn’t significantly alter the Baysean prior in your eyes, then you effectively deny any data that is not a RCT can be of significant use in evaluating the Baysean prior. That is consistent with my contention of a SBM bias. More worrisome, it seems OK with you that your colleagues base their assumptions on false pretenses as long as those false pretenses are meaningless compared to clinical trials. Since two of your colleagues lied about laws surrounding dietary supplements (which I have shown 3-4 times now with references) to influence the audience here, I question the wisdom of your point of view.

    @GLaDOS

    If the gelatin substrate from the gut reaches the cartilage at 260% of the rate of any other tissues, why do you still think that feeding collagen can have no effect on the cartilage for the sole (false) reason that it is all amino acids? We can talk a lot about macromolecular absorption and radioisotope dilution and substrate affinity, but that original fact is the bottom line, right?

  90. GLaDOS says:

    JPZ, you were saying collagen, not amino acids, were getting absorbed from the gut, into the bloodstream, then into the joints.

    Are you now saying amino acids are getting absorbed rather than collagen?

  91. GLaDOS
    “Michelle you are an adult and can take some risks with your own health if you want. The problem is, once parents think that hormones are useful outside the recommended therapeutic levels, then kids are given the hormones.
    So there need to be a line between sufficient evidence verses not enough evidence yet.”

    Yes, I agree, although I would speculate that the decision process falls along a black, gray white spectrum, with adults having more (but not complete*) control over the risks they take for themselves over the risk they accept for their children.

    I would guess that black areas would generally be therapies where the risk is high or unknown, the risk of not treating is low, or the therapy is implausible and unproven and inaccurately presented. Gray areas might include off label medications or modified surgeries for adults or children for whom the risk of not treating is high, low risk therapies or interventions that are plausible but lack evidence (the lack of which the patient or parent is informed). White would be therapies sported by good evidence.

    I only dwell on this because I’ve had to deal with finding therapies for my son with a low researched condition as well as comparing newer less proven surgeries to older more invasive surgeries. So it helps me to come up with concrete decision making criteria that include other variables besides RCT.

    I know zilch about endocrine issues or inappropriate hormone use for children. Does that spectrum I outlined provide the potential for adequate protection for kids, while providing the ability to treat rare or under researched conditions?

    *not a lot of use having a prescription system if doctors just prescribe whatever the genera adultl population wants.

  92. GLaDOS says:

    On an individual, case-by-case basis, potentially any action is justified. Shooting someone may even be justified –e.g., Hitler throwing babies off a cliff. Best to shoot him, IMHO.

    So yes, there’s always a gray zone. If the day comes when practice guidelines have erased the gray zone, the humans are dead and have been replaced by robots. Or maybe some very powerful managed care company.

    In someone with a known history of hypothyroidism, I would have a lower threshold for treating than in someone first presenting with a TSH of 8-9 without any symptoms where I might simply repeat the test in 3 months.

  93. ConspicuousCarl says:

    JPZ on 21 Nov 2011 at 2:29 pm

    @ConspicuousCarl

    And did you read my replies? You pointed out very pertinent aspects of the law that require cross-referencing with other laws to properly understand. I believe I provided those cross-references.

    Yeah, that part was pretty funny. Your own source actually provided instructions on how to do what you said could not be done, and then you switch from it being a clear source to something which can’t be understood.

  94. @GLaDOS – I apologize if it sounded like I was saying that you practiced dogmatically evidence based medicine. That was not my intention at all. I don’t think you are a robot (although if you were, you would have some incredible software, sense of humor is almost impossible to program, I understand) and I certainly don’t think you are anywhere as evil as the typical managed care company (I only suggest you are a little evil, cause I’ve never meet anyone who wasn’t a little evil, except for my grandma…)

    I was genuinely just thinking aloud to figure out what sort of evidence/therapy reasoning process I look for in a healthcare practioner. So my comment was more tertiary to your previous comment, not a direct response.

  95. lizditz says:

    Going back to the original topic of this post, chiropractic neurology:

    From the website of the American Chiropractic Association, which bills itself as:

    The American Chiropractic Association (ACA), based in Arlington, Va., is the largest professional association in the United States representing doctors of chiropractic. ACA promotes the highest standards of ethics and patient care, contributing to the health and well-being of millions of chiropractic patients.

    On behalf of its members, ACA lobbies for pro-chiropractic legislation and policies, promotes a positive public image of chiropractic, supports research, provides professional and educational opportunities for doctors of chiropractic, and offers leadership for the advancement of the profession.

    Here is the ACA public statement (in part) on attention deficit hyperactivity disorder (ADHD):

    Helping Children with Attention Deficit Disorder

    ….doctors of chiropractic are offering promising results with non-drug treatments that focus on postural muscles, nutrition and lifestyle changes that affect brain activity.

    What evidence do chiropractors have that this approach is as effective as researched treatments?

    Oh, woops (emphasis added):

    Although currently no studies comparing chiropractic neurological and medical treatment for ADHD are available</b., chiropractic neurologists are compiling the data.

    So they don’t have any evidence that “the chiropractic approach”, as they mis-label it, is more effective than tested treatments, but the chiropractic profession is fine with selling it anyway.

    I have more questions:

    What is the evidence that postural muscles have anything to do with ADHD?

    What training do chiropractors have in postural changes not connected with spinal manipulation?

    Why should a parent pay for advice on “nutrition and lifestyle changes” from a chiropractor?

    What specific training do chiropractors have in nutrition?

  96. WilliamLawrenceUtridge says:

    One of the distinctions between doctors (and science-based medicine in general) is the insistence on testing before implementing. Nowadays, you want to approve a new drug, you test it beforehand to demonstrate effectiveness – to the point that it’s illegal to charge money for it while clinical trials are still underway. Only once effectiveness is demonstrated can it be sold.

    The contrast with chiropractic care is pretty obvious – a single manipulative intervention and they’re still evaluating the data over a century later? And that data mostly comes from non-chiropractors?

    And chiropractors accuse doctors of massive collusion to support the profitability of the pharmaceutical-industrial complex. Pot, kettle, except the kettle isn’t actually black.

  97. Blue Wode says:

    WilliamLawrenceUtridge wrote on 24 November 2011 at 13:58 “One of the distinctions between doctors (and science-based medicine in general) is the insistence on testing before implementing. Nowadays, you want to approve a new drug, you test it beforehand to demonstrate effectiveness – to the point that it’s illegal to charge money for it while clinical trials are still underway. Only once effectiveness is demonstrated can it be sold.

    And in the case of chiropractic…

    “…if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.”

    Beware the spinal trap
    http://www.guardian.co.uk/commentisfree/2008/apr/19/controversiesinscience-health

  98. jhawk says:

    @ WilliamLawrenceUtridge

    “One of the distinctions between doctors (and science-based medicine in general) is the insistence on testing before implementing. Nowadays, you want to approve a new drug, you test it beforehand to demonstrate effectiveness – to the point that it’s illegal to charge money for it while clinical trials are still underway. Only once effectiveness is demonstrated can it be sold. ”

    If comparing a drug (acetaminophen) to SMT is unfair per Harriet Hall then comparing drug trials to SMT tials is unfair. Medicine does test before implementation on drugs but what about the rest of medicine?

    Example of testing after implementation in medicine. Pot, Kettle!

    http://www.nejm.org/doi/full/10.1056/NEJMoa013259

  99. WilliamLawrenceUtridge says:

    What about the rest of medicine? Yep, knee debridement should have been tested before widespread implementation. Based on the reference provided in your post, the self-correcting nature of science has worked for the treatment of osteoarthritis of the knee. For nearly 20 years, debridement of the knee was practiced and found to improve functioning and pain. It was tested and failed, and now I doubt you’ll find any surgeons still performing it. The lesson to draw from this, naturally, is that surgical treatments should be tested the same way pharmaceuticals are (keeping in mind the enhanced difficulties like controlling for surgical skill and the far more complicated nature of cutting someone open versus giving them a pill).

    I fail to see how this justifies chiropractic treatment of autism, allergies or acute infection. I fail to see how this justifies chiropractics practicing for over 100 years on the basis of a concept that was never tested (subluxations). In addition, surgical procedures have a grounding in a recognized body of knowledge that grants it a significan degree of prior probability (vis. anatomy, physiology, the germ theory of disease, biomechanics, and probably a lot more). It’s at least a reasonable conjecture that smoothing out the cartilage of the knee would allow it to function better. The idea that an invisible displacement of the vertebrae that can’t be demonstrated with any sort of medical imaging can affect the immune or central nervous systems – much less solid ground there.

    Certainly, I would heartily support the implementation of an FDA-style clinical trial system that requires an evidence-base before the large-scale implementation of surgical interventions. The same way I would support chiropractors who support merging their discipline with physiotherapists to provide relief of musculoskeletal complaints. I would continue to oppose nutters who think manual manipulations can have some sort of impact on any bodily system beyond joints, bones, muscles and the occasional pinched nerve. The overall point is that flaws in one system do not justify flaws in another – it merely justifies eliminating or improving the flaw based on the best evidence available. There is some justification in saying surgeons have less right to criticize chiropractors than say, medical doctors. Of course, there’s the little asterisk next to this statement in that, as I said, surgeons are working within an empirical system that changes over time and is based on evidence. Most chiropractors do not appear to have said asterisk.

  100. jhawk says:

    @WilliamlawrenceUtridge

    “What about the rest of medicine? Yep, knee debridement should have been tested before widespread implementation. Based on the reference provided in your post, the self-correcting nature of science has worked for the treatment of osteoarthritis of the knee. For nearly 20 years, debridement of the knee was practiced and found to improve functioning and pain. It was tested and failed, and now I doubt you’ll find any surgeons still performing it. The lesson to draw from this, naturally, is that surgical treatments should be tested the same way pharmaceuticals are (keeping in mind the enhanced difficulties like controlling for surgical skill and the far more complicated nature of cutting someone open versus giving them a pill).’

    I agree and would argue that SMT is tougher to study than a pill as well.

    “I fail to see how this justifies chiropractic treatment of autism, allergies or acute infection.”

    It does not and I did not imply such. Only a small minority of chiro’s would make this justification as there is evidence against. It is sad that there is this minority though.

    ” I fail to see how this justifies chiropractics practicing for over 100 years on the basis of a concept that was never tested (subluxations). ”

    ACA’s definiton of subluxation:
    A motion segment, in which alignment, movement integrity, and/or physiological function are altered although contact between joint surfaces remains intact.

    “In addition, surgical procedures have a grounding in a recognized body of knowledge that grants it a significan degree of prior probability (vis. anatomy, physiology, the germ theory of disease, biomechanics, and probably a lot more). ”

    SMT also has a major grounding in anatomy, physiology and biomechanics.

    “It’s at least a reasonable conjecture that smoothing out the cartilage of the knee would allow it to function better. The idea that an invisible displacement of the vertebrae that can’t be demonstrated with any sort of medical imaging can affect the immune or central nervous systems – much less solid ground there. ”

    I would argue that is also reasonable to take a patient with decrease ROM, pain/tenderness and tissue texture change and mobilize/adjust this area to allow it to function better.

    “Certainly, I would heartily support the implementation of an FDA-style clinical trial system that requires an evidence-base before the large-scale implementation of surgical interventions.”

    I would support as well but I think it will be tough to get implemented due to factors you mentioned previously.

    ” The same way I would support chiropractors who support merging their discipline with physiotherapists to provide relief of musculoskeletal complaints.”

    I would argue this is the great majority of what chiro’s already do (treat MSK issues)

    ” I would continue to oppose nutters who think manual manipulations can have some sort of impact on any bodily system beyond joints, bones, muscles and the occasional pinched nerve. ”

    Agreed.

    “The overall point is that flaws in one system do not justify flaws in another – it merely justifies eliminating or improving the flaw based on the best evidence available. ”

    I agree.

    “Most chiropractors do not appear to have said asterisk.”

    I think the prefession has been building this asterisk steadily over the past 30 to 40 years and will continue.

Comments are closed.