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247 thoughts on “Chiropractic Neurology

  1. marcus welby says:

    JHawk: and I would argue that your “motion segment” concept is just another name for subluxation, or for manipulable lesion or whatever and that it translates to “some region of the spine where there seems to be pain, tenderness, or muscle spasm. Obviously, several vertebrae and several joints are involved and no chiropractor or MD or DO or PT can tell which one is the source of the pain without exhaustive testing and expensive imaging and facet blocks with local anesthetic. By the time such extensive evaluations have been completed, most patients are over their original symptoms, since we are talking about a mostly self-limited affliction with a good natural history overall. So you are left with saying there is a region of the spine involving several vertebrae and their articulations which you think is “dysfunctional” and in your mind, cries out for your manipulation treatment. Like almost any treatment in medicine, including most surgical operations, about 70% of patients will record some subjective short term improvement. The trick is to show that some physiological significant result of the manipulation has been effected and that it has some lasting health benefit. I am unaware that there is any significant evidence of this.

  2. jhawk says:

    @ marcus welby

    “JHawk: and I would argue that your “motion segment” concept is just another name for subluxation, or for manipulable lesion or whatever and that it translates to “some region of the spine where there seems to be pain, tenderness, or muscle spasm.”

    yes and usually a decrease in ROM as well. This is not my concept, this is how it is taught in manual medicine.

    “Obviously, several vertebrae and several joints are involved and no chiropractor or MD or DO or PT can tell which one is the source of the pain without exhaustive testing and expensive imaging and facet blocks with local anesthetic.”

    You may not be able to know 100% for sure what the pain generator/s is/are but you can come pretty close with a good history and physical exam. This is why it’s called a working diagnosis. Obviously, this is very case specific.

    “By the time such extensive evaluations have been completed, most patients are over their original symptoms, since we are talking about a mostly self-limited affliction with a good natural history overall. So you are left with saying there is a region of the spine involving several vertebrae and their articulations which you think is “dysfunctional” and in your mind, cries out for your manipulation treatment.”

    If other sources of LBP have been ruled out via history and exam a trial of spinal manipulation is warranted to decrease pain and duration of LBP as well as increase ROM.

    “Like almost any treatment in medicine, including most surgical operations, about 70% of patients will record some subjective short term improvement. The trick is to show that some physiological significant result of the manipulation has been effected and that it has some lasting health benefit. I am unaware that there is any significant evidence of this.”

    http://www.ncbi.nlm.nih.gov/pubmed/20053720 conclusion:Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.

  3. Harriet Hall says:

    @jhawk,
    In the reference you provided, patients knew they were getting manipulations; without a sham manipulation control group, isn’t it possible that the apparent superiority of manipulation was due to the therapeutic ritual and other non-specific effects of treatment?

  4. jhawk says:

    @ Harriet Hall

    It could be possible but I would think unlikely as the PT group received exercise, passive mobilization (could be considered a sham HVLA to some degree) and soft-tissue treatment and the back school group (exercise, education/ ergonomics), both of which would be amenable to these placebo responses and the SMT cohort showed superiority to both groups.

    Your thoughts?

  5. Harriet Hall says:

    @jhawk,

    I think most patients would be aware of the difference between mobilization and HVLA manipulation, especially if there is an audible “crack” which patients have come to expect at the chiropractor’s office. Wouldn’t it be a better control to do something like a manipulation at the “wrong” level?

  6. jhawk says:

    @ Harriet Hall

    “I think most patients would be aware of the difference between mobilization and HVLA manipulation, especially if there is an audible “crack” which patients have come to expect at the chiropractor’s office”

    I am not sure this is necessarily true as I see many patients that have never seen a chiropractor before and are unsure as to what a manipulation entails. (Obviously anecdotal and may not be generalizable to the public at large!)

    “Wouldn’t it be a better control to do something like a manipulation at the “wrong” level?”

    I think this would be tough as the research has shown we (manual medicine practicioners) are not as specific with our adjustment as we once thought. Therefore, we would probably end up mobilizing the “wrong” and the “right” level at the same time.

    Also, It appears the audible crack may not be necessary for full therapeutic value. http://www.ncbi.nlm.nih.gov/pubmed/20170777

  7. Harriet Hall says:

    @jhawk,

    Do you think there is some way to do a really effective placebo control for manipulation studies?

  8. marcus welby says:

    As to the control group using manipulation at the wrong level, there is abundant evidence for this model in the frequent use of the “hole in one” concept by which many chiropractors do their dangerous neck cracking as a treatment for literally every complaint. They embrace an ideology that all vital forces pass through the foramen magnum and therefore treat low back pain, shoulder pain, bed wetting, autism, coccidynia, high blood pressure, constipation, you name it, by high velocity neck manipultation and evidently report or think they experience, similar outcomes with about 70% favorable short term benefit. In a UCLA study with several chiropractors listed as co-authors, about a third of patients reported significant short term neck discomfort following the neck cracking, with no strokes, but this was a small study with minimal numbers of patients. I would think such embrace of neck cracking for treatment of all patient complaints would validate the observation that it is the therapeutic clinical encounter and placebo effect which results in reported benefit.

  9. jhawk says:

    @ Harriet Hall

    “Do you think there is some way to do a really effective placebo control for manipulation studies?”

    I was re-reading over a study I had posted previously and it seems they incorporated aspects of both our comments for sham manipulation (decreased magnitude aimed to avoid treatable area’s of the spine ). It seems a reasonable sham manipulation to me. http://www.ncbi.nlm.nih.gov/pubmed/21245790

    SMT was shown to perform better than the sham in this trial.

    This trial is interesting to me as it sudies a group of patients with chronic non-specific LBP which is the 10% of LBP patients that have an extremely high cost on the healthcare system.

  10. jhawk says:

    @ Marcus Welby

    “As to the control group using manipulation at the wrong level, there is abundant evidence for this model in the frequent use of the “hole in one” concept by which many chiropractors do their dangerous neck cracking as a treatment for literally every complaint.’

    Saying many chiropractors is definitely an enormous stretch. This is a small minority.

    In regards to your dangerous neck cracking comment, I don’t think you understand how these manipulations (hole in one) are performed. The patient is usually side lying with no rotary or extension force being applied and therefore impossible to tear a vertebral artery.

  11. pmoran says:

    I was re-reading over a study I had posted previously and it seems they incorporated aspects of both our comments for sham manipulation (decreased magnitude aimed to avoid treatable area’s of the spine ). It seems a reasonable sham manipulation to me. http://www.ncbi.nlm.nih.gov/pubmed/21245790

    Was an exit poll performed to determine if patients could or could not tell the difference? How was conscious or unconscience practitioner “cueing” of the patient avoided? And, of course, there is no sham control group for the second phase of that study.

    I have been following this discussion with interest. I suggest that no matter how carefully such studies are performed there will never be absolute certainty either way regarding the questions that are usually being posed. After review of all the studies there will be a partly subjective judgment concerning the likelihood/unlikelihood that some patients are benefiting beyond all the non-specific psychological influences of the treatment environment (for the record, I think some probably are but it is genuinely difficult to be sure from the evidence base).

    I think we should go back to the beginning and consider the question from the practical medical viewpoint, that chronic low back pain is a difficult, costly condition. It causes much suffering, for which there are no entirely satisfactory conventional treatments.

    SBM/EBM is mainly interested in whether SMT “works” or not i.e. via some direct physiological effect on the pathology of LBP. It will ignore it as a treatment option if it is “only placebo” even though most of its own approaches to LBP are also not shown to have real efficacy beyond moral support and sound advice.

    Chiropractors desperately want vindication of SMT so they have been focusing on the same question. Yet that matters little for certain wider perspectives.

    From the patient’s point of view, and from the point of view of employers, worker’s compensation agencies and taxpayers it does not matter one jot whether any benefits are mainly due to placebo and other non-specific influences, so long as they are gained in a reasonably cost effective way and they are meaningful and objective e.g. — back to work earlier? — less analgesic requirement?

    So I suggest that it is pointless doing further “scientific vindication”/”better than palcebo” type studies if they will not change the possibilities/probabilities much. If chiropractors are game, they should look at studies that show more precisely what SMT can do in real-world practice and at what cost. It surely won’t matter if it is mainly placebo if can deliver the goods.

  12. nybgrus says:

    SBM/EBM is mainly interested in whether SMT “works” or not i.e. via some direct physiological effect on the pathology of LBP. It will ignore it as a treatment option if it is “only placebo” even though most of its own approaches to LBP are also not shown to have real efficacy beyond moral support and sound advice.

    A nice and oblique tu coque argument. SBM has never claimed issue with using placebo effects in the treatment of patients. It has issue with using a therapy which is entirely based in placebo and/or equally as useful as another non-placebo based intervention. In the case of acupuncture, that is pure placebo – there is no mechanism behind the needles actually penetrating the skin vis-a-vis relieving the back pain. Telling patients anything else is, to a greater or lesser degree, fraud and lying to the patient. Contrast this with an antibiotic, for example.

    In the case of SMT it is mostly placebo responses coupled with some “manual” therapy. There is absolutely zero indication that this is in any way different from a standard massage or PT exercises. So instead of having a chirorpractor claim some sort of otherwise unidentifiable hypomobile segments that they are “mobilizing” with SMT and utilizing “myofascial release” – which are both garbage that have no evidence and very little plausibility, SBM would demand that better motivating and massage techniques be used as adjuncts or in place of standard of care.

    In other words, as I have said repeatedly, incorporating placebo effects and responses into actual medical care is perfectly reasonable. Using a therapy that only “works” by effecting placebo responses (even the “real” ones of Beneddetti’s neurophysiology) is unethical, counterproductive, and of very low utility. Hence, acupuncture and chiropractic have no place in medical treatment of any pathology.

  13. pmoran says:

    SBM would demand that better motivating and massage techniques be used as adjuncts or in place of standard of care.

    Thanks, Nybgrus, for yet again missing my point, with those muddled, dogmatic assertions. I was talking to how we should deal with the uncertainties that some treatment modalities pose and will almost certainly continue to pose for the future.

    Your argument appears to be leaning towards denying patients possible benefits rather than risking that a treatment might be wholly placebo. I was suggesting that while there is any uncertainty the patient’s perspective should prevail.

    Finally, how do you know massage is not a placebo? What placebo-controlled studies demonstrate that with any adequacy?

  14. jhawk says:

    @pmoran

    “Was an exit poll performed to determine if patients could or could not tell the difference?” Not to my knowledge but I think it would have been an interesting poll if it were done.

    “How was conscious or unconscience practitioner “cueing” of the patient avoided?” It think they did the best they could by having a very standardized adjusment performed the same way on all patients but cueing could have happened.

    “And, of course, there is no sham control group for the second phase of that study.” This would have been nice as well but I am not sure it was needed as the SMT group showed superiority over sham at all previous intervals.

    “I have been following this discussion with interest. I suggest that no matter how carefully such studies are performed there will never be absolute certainty either way regarding the questions that are usually being posed. After review of all the studies there will be a partly subjective judgment concerning the likelihood/unlikelihood that some patients are benefiting beyond all the non-specific psychological influences of the treatment environment (for the record, I think some probably are but it is genuinely difficult to be sure from the evidence base). I think we should go back to the beginning and consider the question from the practical medical viewpoint, that chronic low back pain is a difficult, costly condition. It causes much suffering, for which there are no entirely satisfactory conventional treatments.”

    I think I mostly agree with you here. Much of chronic LBP is probably multi-causal and trying to find one certain procedure to cure it is not going to happen. Just think of all the possible NMS contributors to LBP that are not even in the LB region. An example may be decreased ankle dorsiflexion leading to compensatory gait patterns which can increase load on the LB structures leading to pain . This is only one possible problem out of the whole lower extremity kinetic chain that could contibute to LBP. Furthermore, no LBP RCT will able to account for all these possible contributors. I think pragmatic trials for MSK medicine are a good way to go as they can at least demonstrate effectiveness of a treatment approach for such a multfaceted condition as chronic LBP.

    “If chiropractors are game, they should look at studies that show more precisely what SMT can do in real-world practice and at what cost. It surely won’t matter if it is mainly placebo if can deliver the goods.”

    If you have not already, take a look at some of those trials I posted earlier in response to chris repetsky about halfway up this thread. The second and fourth posted trial are both in line with your comment. The third study is interesting as well.

  15. jhawk says:

    @nybgrus

    “In the case of SMT it is mostly placebo responses coupled with some “manual” therapy. There is absolutely zero indication that this is in any way different from a standard massage or PT exercises.”

    Interesting you say zero indication, as about 10 posts back there is a trial that directly contradicts your opinion. http://www.ncbi.nlm.nih.gov/pubmed/20053720 conclusion:Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.

    “So instead of having a chirorpractor claim some sort of otherwise unidentifiable hypomobile segments that they are “mobilizing” with SMT and utilizing “myofascial release” – which are both garbage that have no evidence and very little plausibility, SBM would demand that better motivating and massage techniques be used as adjuncts or in place of standard of care.”

    Myofascial release, hypomobile joints and mobilization are not spefic to chiropractic as you imply. They are used by all practicioners of manual medicine (PT, DC, MD physiatrist and sports med docs).

  16. nybgrus says:

    I was talking to how we should deal with the uncertainties that some treatment modalities pose and will almost certainly continue to pose for the future

    You were? Because it sounded a lot like your usual rhetoric in which using a treatment modality that depends entirely (or at least predominantly) on placebo responses for any effect is OK for medical doctors to turn a blind eye to in certain cases. None of the discussion in context related to anything where there was truly uncertainty – i.e. chiropractic or acupuncture. So forgive me, if I somehow misread your intended message.

    Your argument appears to be leaning towards denying patients possible benefits rather than risking that a treatment might be wholly placebo.

    My argument is not hinged on risk, as you frame it. If there is a risk that a treatment might be placebo that means we don’t reasonably know if it is or not. That is not the case with acupuncture, chiro, or pretty much all of CAM. However, toss in my general aversion to employing treatments for which there is no evidence (one way or the other) and yes, that does indeed limit what treatments may be offered to patients, regardless of what ephemeral benefit you or said patient may somehow perceive. That’s the whole point of basing medicine in evidence and science though – so we don’t just make things up that “sound good.”

    And yes, as we’ve discussed before, the effect size and nature of placebo effects make them not useful as stand alone treatments.

    In other words, I am not concerned with risk – we know acupuncture is placebo – and I am not concerned with denying patients possible benefits, because placebo only is, IMO, not a benefit to the patient. It would be a delusion to think otherwise.

    I was suggesting that while there is any uncertainty the patient’s perspective should prevail.

    This is often what you argue, but you offer no threshold. The nature of science is such that there will always be at least some uncertainty. There is no such thing as 100.00% certain. So at what point do you determine something is certain enough? From our discussions it seems you are quick to change that threshold depending on your own notions of the topic at hand.

    Case in point is chiro vs acupuncture. You seem to be totally fine with acupuncturists and have consistently argued that it should be used for certain indications. Yet you don’t afford chiropractic the same degree of acquiescence.

    Regardless, your threshold seems to be much high than mine (i.e. I am willing to be “certain” sooner than you are).

    Finally, how do you know massage is not a placebo? What placebo-controlled studies demonstrate that with any adequacy?

    I don’t think I actually said it wasn’t placebo. However, besides the fact that Bradford-Hill criteria seem to support it as an active intervention, there is no mysticism or false claims associated with massage. And if there is, I would certainly be against that. Intent, presentation, and claims are also very important in determining the ethical standing of a treatment, especially when it may well include placebo elements. A chiro claiming that there are “hypomobile segments” that only they can detect and “mobilize” while doing nothing more intricate or directed than a good massage changes the game.

    But the real point with the chiros is that the rest of their professional “package” beyond LBP treatment is hokum doing backwards science to justify its existence. So instead of recommending a chiro for LBP, the better answer is to incorporate the massage and manual aspects of the treatment into standard of care – I did after all say there was some actual effect there.

    As an example, if the Memorial Sloan-Kettering Cancer Center (MSKCC) offered foot massages to its patients saying it would help them relax and de-stress, I would be all for it. Instead, they offer reflexology and call it “light touch massage.” Same exact actual treatment, framed differently. One I am certainly against and the other very much for.

  17. nybgrus says:

    @jhawk:

    The article really doesn’t demonstrate anything I haven’t already known or written about at some point.

    First off, the mean values have massive variance across each and every group and data point. Each and every group has a CI that is almost as big (and sometimes bigger) than the mean itself. Heterogeneous data like that puts a lot of noise in with any signal that may be there.

    Secondly, the baseline (discharge) disability score mean for the SMT group was massively lower than the two other groups. It then proceeded to increase, whereas the other groups stayed the same. There was statistical difference but no real clinical difference in pain scores between any of the groups.

    But more to the point, it can be explained by SMT being quite superior. Or it can also be explained by exactly what I have seen to be the case in many other studies – the novelty of being in the chiro group effects more placebo response. We also can’t discount that the randomization may have skewed the results because they baselines and then trend were so different.

    But I will concede that my statement can’t really stand as is. PT may not be as effective. I will re-phrase myself to say that there is nothing in the chiro arsenal that can’t be employed by PTs equally as effectively with minimal additional training (basically, learning a couple new tricks but mostly sticking to evidence based guidelines). This is essentially what Marcus Welby has been arguing as well.

    Interestingly enough, SMT patients were more prone to relapse and requiring further treatment. This further supports my assertion that SMT is mostly placebo since placebo responses are quite ephemeral in nature. The paper itself further supports this notion when it says: “spinal manipulation was given by a physician
    while the other interventions by a physiotherapist, a patient’s different attitude to the two clinical categories may have influenced the results.” First off they are calling a chiro a physician. Secondly, nobody was blinded to any of this. In other words, many confounders in this study.

    And as a further bit I found interesting because the chiro contingent here has been having a go at claiming cost-efficiency of their brand of treatment:

    , but long-term results were obtained at the price of returning more often for further treatment in the follow-up. Thus spinal manipulation seemed to be less effective than physiotherapy in promoting self-treatment

    The entire discussion section is an interesting read with all the drawbacks to the study.

    In sum though, as I said, SMT is mostly placebo and studies such as this one with piles of noise don’t really offer persuasive evidence otherwise. I will be more careful in how I phrase things though, since I will concede that standard PT may itself be sub-optimal therapy for LBP.

  18. nybgrus says:

    sorry for the double post:

    myofascial release may not be absolutely unique to chiros, but it most certainly started in the osteo/chiro camp and is BS no matter who uses it, so I fail to see your point about it being used by others.

  19. jhawk says:

    @nybgrus

    “Or it can also be explained by exactly what I have seen to be the case in many other studies – the novelty of being in the chiro group effects more placebo response.”

    Both the back school and PT groups had 15 hours of contact time and the SMT group had 2 hours of contact time yet the chiro group had more of a placebo response?

    “But I will concede that my statement can’t really stand as is. PT may not be as effective. I will re-phrase myself to say that there is nothing in the chiro arsenal that can’t be employed by PTs equally as effectively with minimal additional training (basically, learning a couple new tricks but mostly sticking to evidence based guidelines). This is essentially what Marcus Welby has been arguing as well.”

    I will side with the WHO organization recommendations (2200 hours of extra training for healthcare professionals with a 1000 hours of supervised clinical experience) over yours and Marcus.

    “Interestingly enough, SMT patients were more prone to relapse and requiring further treatment. This further supports my assertion that SMT is mostly placebo since placebo responses are quite ephemeral in nature.”

    Or this could be due to the fact that SMT group was not allowed to give the exercises given in the other two groups to prevent recurrence.

  20. jhawk says:

    @ nybgrus

    As to cost effectiveness, http://www.ncbi.nlm.nih.gov/pubmed/21229367

    “the better answer is to incorporate the massage and manual aspects of the treatment into standard of care – I did after all say there was some actual effect there.”

    This systematic review blatantly states that massage is unlikely to be cost effective and that SMT is cost effective yet you espouse the opposite.

    Sorry for the double post.

  21. pmoran says:

    NybgrusFinally, how do you know massage is not a placebo? What placebo-controlled studies demonstrate that with any adequacy?

    I don’t think I actually said it wasn’t placebo. However, besides the fact that Bradford-Hill criteria seem to support it as an active intervention, there is no mysticism or false claims associated with massage.

    This is what I mean by muddled. Massage might also be placebo, yet you advised it as an alternative to SMT, which you oppose because it might be a placebo. — mysticism and false claims from some chiropractors? Been to a health spa lately?

    If we are going to oppose mainly placebo treatments to the extent that you seem to wish (except, a little hypocritically, when your patients force you to confront them in the privacy of your consulting room) then let’s do so with some clarity of mind.

  22. Harriet Hall says:

    To my mind, massage by a practitioner who offers to produce relaxation and comfort is more acceptable than manipulation by a practitioner who claims to be correcting a poorly defined defect based on questionable evidence. IMHO placebo treatments are acceptable as long as they are provided without lying to the patient. I think certain SMTs are more effective than placebo for certain musculoskeletal conditions, and I am frustrated that chiropractors have not been able to figure out what they are doing or who is likely to benefit. SMTs are effective treatment in some cases and placebos in other cases.

  23. marcus welby says:

    JHawk: I think you are giving out misinformation. Re: neck cracking, the most recent surveys of chiropractors, as I recall, show some 2/3 or 3/4 of them using high velocity neck cracking, which is considered dangerous among ER physicians, neurologists, and neurosurgeons. Anyone with more than a passive knowledge of the anatomy understands the vulnerability of the vertebral arteries where they exit the safety of the bone in C-2 and twist around to enter the foramen magnum. That is exactly where one would expect the a artery to be torn by a sudden twist of the neck and that is exactly where the arteriograms demonstrate the artery dissection to occur. As to your claims that this is done with patients on their side, all the videos I see when I Google chiropractic neck manipulation are by chiropractors with the patient either supine or seated and the practitioner above the patient. The attempt to elicit an audible “pop” when nitrogen gas exits soluble form and becomes a bubble, so the patient is impressed that something important (a bone out of place, perhaps going back into place?) has taken place, has real dangers. As one who has spoken to the mother of a dead young girl whose neck was cracked by a chiropractor over 150 times as treatment for a tailbone pain, and who started having seizures immediately after the final manipulation while on the examining table…I understand the dangers and advise all patients to “never let them touch your neck.” I have also spoken to surviving patients in wheelchairs who were never to walk again after chiropractic neck manipultation for low back pain, and patients who needed craniotomy to treat the stroke which occurred immediately following neck cracking for shoulder pain treatment. I know the official chiropractic position is that the neck cracking is safe, but that is not the position of the medical practitioners who deal with strokes and their sequelae.

  24. jhawk says:

    @ Harriet Hall

    “I am frustrated that chiropractors have not been able to figure out what they are doing”

    One of the major reasons SMT is thought to work is by disrupting articular and periarticular adhesions of the ZP joints by gapping and placing a quick stetch on the surrounding capsule. Here is a study that looks at this gapping via pre and post MRI on healhty subjects, http://www.ncbi.nlm.nih.gov/pubmed/12435975.
    This same researcher is now doing a follow up study on acute LBP patients, http://nuhs.edu/media/185553/h0107.pdf

    Hopefully this somewhat of an answer to your frustration.

    Also, I am curious what you thought about the sham manipulation in the study I posted a few comments back in response to your question.

  25. jhawk says:

    @ marcus welby

    You said: “As to the control group using manipulation at the wrong level, there is abundant evidence for this model in the frequent use of the “hole in one” concept by which many chiropractors do their dangerous neck cracking as a treatment for literally every complaint.”

    In response I said : “In regards to your dangerous neck cracking comment, I don’t think you understand how these manipulations (hole in one) are performed. The patient is usually side lying with no rotary or extension force being applied and therefore impossible to tear a vertebral artery”

    Both of these comments are obviously talking about the hole in one/upper cervical technique which is almost wholly done in the side posture postion with no rotary component. So no I am not giving out misinformation.

  26. pmoran says:

    Harriet: To my mind, massage by a practitioner who offers to produce relaxation and comfort is more acceptable than manipulation by a practitioner who claims to be correcting a poorly defined defect based on questionable evidence.

    Agreed, more or less, but that is not an accurate refection of the stand-off that we seem to have reached.

    I submit that there is insufficient difference in either the quality of the evidence for, or the plausibility, of massage, (or even of physiotherapy for that matter) and SMT as treatments for low back pain for there to be strong opposition or endorsement of either.

    On both scientific and compassionate grounds we have no basis that would support such discrimination.

    I, too, certainly like to point out the problems with the evidence when chiropractors get too pretentious about chiropractic’s scientific status, but in all scientific honesty the status of SMT is not clear. We do know its effects are not dramatic overall, but even those studies may obscure dramatic responses in a few that may not be obtainable any other way.

    SMT is also not synonymous with chiropractic. It is used by many doctors without the least taint from traditional chiropractic mythology. Do we oppose that too, Nybgrus, or were the remarks that suggest that intended to refer to myofascial release and other dubious elements of chiropractic?

  27. Harriet Hall says:

    SMT to treat certain kinds of limited musculoskeletal low back pain is supported by evidence. SMT to correct subluxations is not.

    “studies may obscure dramatic responses in a few that may not be obtainable any other way.” That’s the excuse CAM practitioners offer to discredit controlled studies. In a study of any treatment there might be a few patients who respond differently, but if they were more than a small minority it would show in the statistics.

  28. nybgrus says:

    I really didn’t think my comment was that cryptic. Very, very plainly it all boils down to what you tell the patient. Give them a massage and say that it will help them relax and relieve some tension which may well help their MSK complaint, no worries. Give them a massage and tell them you are mobilizing frozen segments which are causing some kind of nebulous impingement, and we have an issue.

    And of course, not everyone will respond the same. Personally, I love massage. I actually have chronic joint paint since all my joints are slightly hypermobile since I have a mild form of Ehlers-Danlos (as diagnosed by my rheumatologist). So besides a massage being very helpful, the notion that a chiropractor would want to make my joints even more mobile seems, well, like a bad idea. But my girlfriend can’t stand massage – to her it is pure torture.

    So now frame it in the sense of the utility and MOA of the intervention (a hypothetical). If my girlfriend has LBP and a chiropractor whom she believes to be a physician and have an actual evidence base for his treatments recommends some sort of SMT manipulation she would tolerate the discomfort thinking there was some sort of independent mechanism for relieving her pain. I would bet that she would be one of those that derive no improvement, subjective or otherwise, from chiropracty. Tell her its just massage and that the relaxation would probably help her, and she would turn it down stating that she knows it would not relax her.

    And of course, Dr. Hall is spot on – there most certainly is some utility to SMT in certain pathology. We don’t have a good handle of what, exactly, is involved in the SMT (i.e. what are the necessary vs extraneous bits) and which pathologies it actually would be helpful for. But the parts that are somewhat useful lose utility when framed from the perspective of a chiropractor – because then you are lying about the MOA to heighten the putative effect.

    So while SMT is not synonymous with chiro, the chiros are certainly saying that chiropractic is synonymous with SMT. So when used dubuiously, I am against it. When used within an evidence base, why would I be against it? The only difference between an MD and a DC using the evidence based parts of SMT is that the chiro will undoubtedly go much further than that, since otherwise their entire job would be reduced to something that a casual worker with a week’s training could do.

  29. nybgrus says:

    @jhawk:

    I will side with the WHO organization recommendations (2200 hours of extra training for healthcare professionals with a 1000 hours of supervised clinical experience) over yours and Marcus.

    As I have pointed out to NMS-DC, the WHO stance re: chiropractic is not something to hang your hat on or be proud of. It is purely a document derived from being forced to acknowledge you exist and trying to make sure you kill and harm as few people as possible. It in no way, shape, or form endorses chiropractic treatment as efficacious or evidence based. Since the WHO doesn’t have the power to simply expunge chiropractic from existence and since it cannot ignore the health seeking attitudes of people, no matter how uninformed they are, they created the document to try and assure some kind of minumum standard to try and protect people seeking out your services. It does a poor job at that, IMO.

  30. pasisuni says:

    Telepathy , schizophrenia, paranormal scams, Homeopathic Medicine, million-man James Randi

    Who is protecting those criminals and not publishing truth and what is truth?
    There are houndred’s offices that sell paranormal scams(astrology, medicine…), can Uri Geller read peoples
    mind? Why is James Randi offering one million when Internet is full with documents on Vinko Rajic and his telepathy.
    What about this?
    “Vinko Rajic can use telepathy , he is maybe the only person that can use telepathy all the time , send
    and receive voice and video on distance of few kilometer. It works all the time and 100% correct.

    I think it is important for science and human kind to make research on Vinko’s brain and find out how this works.
    Vinko’s telepathy manifest itself exact like “Schneider’s first-rank symptoms”.
    I think it would be extremely important to find out what kind of waves transmit my thoughts. Using
    Vinkos brain I think it would be possible to find out how telepathy works and I think it would be possible to find out
    if some Schizophrenics are telepathic to. ”
    Who has interest to have telepathy “not existing”, and who has interest in sealing all those scams and show’s on
    scam’s? Many people are loosing money because of all those scams, WHY?

  31. gbove says:

    I think that some perspective can be found in the knowledge that there remains no evidence in support of the majority of medical practice. Medical doctors throwing stones at chiropractic or any other practice should watch out for their glass house.

  32. gbove says:

    I think that some perspective can be found in the knowledge that there remains no evidence in support of the majority of medical practice. Medical doctors throwing stones at chiropractic or any other practice should watch out for their own glass house.

  33. Harriet Hall says:

    @gbove,

    “there remains no evidence in support of the majority of medical practice”
    This oft-repeated criticism of medicine is demonstrably false.
    There is good evidence to support the majority of medical interventions. 78% of them are supported by some form of compelling evidence. 38% of them are supported by RCTs. Keep in mind that because of ethical and practical considerations, RCTs can’t be done for many interventions known to be effective, like setting broken bones and removing inflamed appendixes.
    http://sram.org/media/documents/uploads/article_pdfs/5-2-06.Imrie-Ramey.pdf

    Also keep in mind that medicine is constantly striving to become more and more evidence-based and has a solid track record of questioning itself, studying common practices and discarding those that are proven effective. Contrast that to the track record of CAM. What has chiropractic ever tested, found ineffective, and discarded?

  34. WilliamLawrenceUtridge says:

    Citation needed gbove.

    Also, if there was no evidence supporting medicine, does that mean chiropractic “works”?

    A lack of evidence for an intervention seems like nothing more than a lack of evidence for that intervention. I can’t see how a lack of evidence for medical interventions (if that statement is even true) can somehow validate chiropractic theory and practice. Seems like the answer is to test, abandon what doesn’t work and keep what does. Chiropractors can justifyably criticize medical practices, which means those practices should be tested or improved. But they’re hypocrites if they don’t also test their own.

  35. pasisuni says:

    Telepathy , schizophrenia, paranormal scams, Homeopathic Medicine, million-$-man James Randi

    Who is protecting those criminals and not publishing truth and what is truth?
    There are houndred’s offices that sell paranormal scams(astrology, medicine…), can Uri Geller read peoples
    mind? Why is James Randi offering one million when Internet is full with documents on Vinko Rajic and his telepathy.
    What about this?
    “Vinko Rajic can use telepathy , he is maybe the only person that can use telepathy all the time , send
    and receive voice and video on distance of few kilometer. It works all the time and 100% correct.

    I think it is important for science and human kind to make research on Vinko’s brain and find out how this works.
    Vinko’s telepathy manifest itself exact like “Schneider’s first-rank symptoms”.
    I think it would be extremely important to find out what kind of waves transmit my thoughts. Using
    Vinkos brain I think it would be possible to find out how telepathy works and I think it would be possible to find out
    if some Schizophrenics are telepathic to. ”
    Who has interest to have telepathy “not existing”, and who has interest in sealing all those scams and show’s on
    scam’s? Many people are loosing money because of all those scams, WHY?

  36. lizditz says:

    Carrick’s back in the news, because Crosby is still not fully recovered:

    NHL Today, 1/16/2012

    Pittsburgh Penguins captain Sidney Crosby, still bothered by motion and balance issues as he recovers from a recurrence of his concussion symptoms, plans to visit this week with the chiropractor who helped him return to the ice last fall.

    The Penguins announced Monday that Crosby will meet with Ted Carrick, a chiropractic neurologist who has offices in Marietta, Ga., and Cape Canaveral, Fla. Carrick helped Crosby recover from some of his concussion-related problems, including dizziness and a lack of balance, before training camp began in mid-September.

    “Sidney has made a lot of progress but he is still having some symptoms, so this is the next step in his recovery,” Penguins general manager Ray Shero said in a statement released Monday. “Obviously he won’t be back in the lineup until he is symptom-free.”

    Both hockey fans and chiropractors are spreading the news…The science-based medicine evaluation of “chiropractic neurology” or its other moniker, “functional neurology” not much in evidence.

  37. Enkidu says:

    Sadly, Sidney Crosby went back on the IR due to concussion symptoms only a few games after he returned to hockey. He’s still out and hoping to play again soon, but one has to wonder if his career is done.

    Anyways, excellent article, I don’t know how I missed it. I think around this time I was distracted by Jaromir Jagr’s use of acupunture to treat his groin injury (ouch) and the local press that was receiving.

  38. lizditz says:

    The original Sports Illustrated article gave too much credence to Carrick, but at least had this:

    After seeing Carrick at Crosby’s press conference, Henry Feuer, the consulting neurosurgeon for the Colts and a veteran of 40 years on NCAA and NFL sidelines, read some of his studies. “I just can’t get a grasp of what he’s doing,” Feuer says. “If I had another guy like Crosby, would I send him to Carrick? The answer is no. I just see anecdotes, and that’s not what we’re looking for. The real evidence-based stuff is where medicine is today.”

    But the SI article today had exactly 0 criticism of Carrick or his pseudoscience:

    Pittsburgh Penguins star Sidney Crosby will meet with a specialist this week because of lingering concussion-like symptoms.

    Crosby hasn’t played since Dec. 5 following a recurrence of the symptoms that sidelined him for more than 10 months last year. The team says Crosby will work with chiropractic neurologist Dr. Ted Carrick, who treated Crosby for similar symptoms last summer.
    [snip]
    Carrick worked closely with Crosby last summer after Crosby’s progress slowed. Carrick said in September that Crosby would have a “very good outcome” following his rehab.

    Yahoo sports called Carrick “a concussion specialist” (!)

  39. DrRobert says:

    I’m at the point where I can’t be “politically correct” with chiropractors anymore. They are cranks. They are pure quacks. Tonight I’ve read how chiropractors “treat” concussions, how they can diagnose and treat “ileo-cecal valve syndrome” and how they can diagnose food allergies with applied kinesiology. There may be a couple of them out there that specifically treat only certain types of lower back pain and don’t give their patient radiation therapy (X-ray) in the process, but I believe they are few and far in-between. If such a person exists, I apologize, but your profession is just filled with disgusting quacks.

  40. Enkidu says:

    I was just mildly reprimanded by Dan Rosen (NHL writer) on Twitter. Rosen tweeted an article about Crosby… linked within there was another article that had a paragraph questioning Carrick (http://www.nhl.com/ice/news.htm?id=612050):

    “Carrick specializes in a field called chiropractic neurology [..] The field is considered non-traditional, and some medical doctors have said that unorthodox treatments, such as putting a concussion victim into a tumbling chair, could be counterproductive and might actually worsen a patient’s condition.”

    This is the response I got from Rosen when I tweeted an exerpt from this passage: “Pretty sure they wouldn’t put him at risk. I’m not a doctor. I have no idea if you are. But I know I’m not one to judge.”

    Yup, let’s not judge, let’s just let people do whatever and not ask critical-thinking questions. Head in the sand. Lalalala.

    We can “judge” if a coach should have pulled a goalie in a game, but asking questions about potentially dangerous health practices? WHY YOU BE ALL JUDGMENTAL.

  41. DrRobert says:

    @Enkidu, it’s a shame that main stream medicine isn’t more vocal in speaking out against these quacks.

    Fact: chiropractic neurology is complete quackery.

  42. mdcatdad says:

    According to a report in today’s Washington Post Pittsburgh Penguins hockey star is being treated by a chiropractic neurologist for his lingering symptoms from too many concussions

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