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Chiropractors as Family Doctors? No Way!

A recent three-part article published in ACA News advocates turning chiropractors into “conservative primary care providers” who would be the initial point of contact for patients, would serve as gatekeepers for referrals to medical doctors and specialists, and would co-manage patients with those specialists on a continuing basis: essentially, family doctors.  I think that’s a terrible idea. It might benefit chiropractors by increasing their market share, but it wouldn’t benefit patients. There is no evidence to indicate that chiropractors are capable of filling that role effectively or safely.

NUHS. The article was co-authored by several chiropractors on the faculty of the National University of Health Sciences, a school noted for integrating quackery with medicine. The “sciences” this school teaches are listed at the top of its website: chiropractic medicine, naturopathic medicine, oriental medicine, acupuncture, biomedical science, and massage therapy. The only one of those that even sounds like science, “biomedical science,” offers a bachelor of science degree with an integrative medicine focus and with no required core courses whatsoever!

Their doctor of chiropractic degree program says:

National University prepares students to become first-contact, primary care physicians fully qualified to diagnose, treat and manage a wide range of conditions.

Background. The authors say proposals to classify chiropractors as primary care physicians date back to at least 1967, with the Comprehensive Health Planning Councils. Arguably, the concept of chiropractors providing comprehensive health care dates back to the origin of chiropractic, since its founder asserted that all human disease was attributable to subluxations, 95% in the spine and 5% elsewhere. On the other hand, chiropractors used to claim they didn’t diagnose or treat illness, but only kept the spine in proper alignment so that the vitalistic force they called “Innate” could take care of anything and everything. In essence, doesn’t their aspiration to become “family doctors” amount to an admission that chiropractic is not the panacea they once held it to be? Doesn’t their wish to branch out demonstrate the failure of their discipline?

Their Arguments. They argue that more primary care providers are needed, and that chiropractors can fill the gap. They argue that using chiropractors as gatekeepers will reduce costs.

When chiropractic physicians functioned as primary care gatekeepers, pharmaceutical costs fell by 58.1 percent and hospital admissions by 43 percent. These are statistics that clearly support the value of the chiropractic physician in the primary care, gatekeeper position.

These statistics, even if correct, do not support the value of the chiropractor as gatekeeper. Cheaper is not better if it reduces quality of care. Of course pharmaceutical costs went down, because chiropractors can’t prescribe pharmaceuticals and they typically discourage patients from using them. They discourage surgery and conventional medical care, so it’s not surprising that hospital admissions fell; but maybe some of those patients would have been better off in the hospital. And I would guess that vaccination costs dropped too, since only around half of chiropractors support vaccination. We need to know the health outcomes for those patients, not just how much money was saved. Parents who belong to faith healing cults and never take their children to a doctor can cut medical costs to zero, but sometimes the children die.

Apart from the question of costs, the ability of chiropractors to function effectively as gatekeepers has not been tested in any formal study. It is questionable, to say the least. There is anecdotal evidence that occasionally a chiropractor makes a diagnosis that MDs have missed and that many chiropractors refer appropriately, but there is at least as much anecdotal evidence that chiropractors have missed diagnoses that would be obvious to any MD, and that they have failed to send patients to the emergency room for medical emergencies such as classic heart attack symptoms or fevers in very young infants.

They recognize that not all chiropractors are willing or able to carry out their vision:

Among the challenges is the diversity of our colleagues—those wanting to participate in primary care who order technical diagnostic procedures and clinical laboratory tests versus those who want to remain subluxation based. There are those who want to treat the whole person versus those who want to treat only musculoskeletal conditions. There are those of us who want to use treatment modalities beyond the adjustment, as well as those who feel we should adjust only the spine.

Managing Chronic Disease

“Conservative primary care physician” is language intended to clarify that as chiropractic physicians we do not address the complex primary care disease states that require pharmaceutical intervention and management.

Unfortunately, many do. I am increasingly hearing about chiropractors who profess to cure diabetes.  They call themselves “doctors” and many of their patients don’t realize they are seeing chiropractors.

Chiropractors aspire to being part of a health care team, managing musculoskeletal problems and “co-managing” chronic diseases by counseling on lifestyle, diet, and exercise. They want to manage psychosocial issues such as anxiety and depression, and they want to use preventive management strategies to reduce the incidence of cancer and dementia.  They want to.  But that doesn’t mean they can.

A Primer on the History and Physical. After saying in part 1 that chiropractors should provide primary care, they proceed in part 2 to a primer on how to take a history. The fact that they feel a need to explain this implies that chiropractors don’t already understand the basic principles. They proceed to explain how to ask about chief complaint, history of present illness, past medical history, family history, social history, and review of systems. They even feel a need to explicitly remind chiropractors to ask if the patient smokes!

Even their attempt to instruct chiropractors is flawed. For instance, they recommend simple lab tests, but their recommendations for sedimentation rates and CRP testing are not evidence-based and do not correspond to standard medical practice.

In part 3, they describe an office visit and comprehensive physical exam in great detail, with many recommendations that are non-standard and not evidence-based:

  • Routine pulse oximeter readings on every patient. (This may be routine in the ER, but it is not and should not be a routine part of every visit to a doctor’s office.)
  • If any vital signs are abnormal, instead of taking prompt and appropriate action, they recommend that “they should be tracked on a regular basis to determine if a specialist consultation and/or further medical intervention is needed.”
  • For trauma patients, they recommend assessing the patient’s short and long term memory and considering a mini-mental status test. (For most trauma patients this would be a waste of time.)
  • As part of the chest exam, they recommend testing tactile fremitus. Abnormal tactile fremitus is a sign of lung consolidation in patients with pneumonia. It is only appropriate as part of a directed physical to pin down a suspected diagnosis, and even then it is not a particularly useful test. It’s one of those things doctors learned in medical school but rarely if ever use in practice because there are far better ways to make the diagnosis.
  • “The role of testing for H. pylori infection in GERD (gastrointestinal reflux disease) remains controversial.” No, it doesn’t. There’s no controversy: there’s a clear consensus that such testing is not indicated. Some patients can be treated on the basis of symptoms alone; others will need endoscopy. H. pylori testing is done for suspected ulcers, not for GERD.

What really surprised me was their extensive coverage of the musculoskeletal exam. This is their particular area of expertise; surely chiropractors don’t need to be reminded about how to evaluate joint motion, muscle strength, and tender points. They ask “Is there any indication that the patient would be at increased risk for spinal manipulation of the neck?” It seems they recognize that neck manipulation can precipitate a stroke; unfortunately, there is no reliable way to rule out risk, and implying that chiropractors can do so is misleading and dangerous.

This whole exercise struck me as silly, condescending, and embarrassing. If chiropractors were already qualified to be primary care providers, they wouldn’t need to be given this information. If they are not qualified, a simplistic tutorial like this isn’t enough to educate them.

Legislation and Other Developments. Legislation has been proposed to expand the scope of chiropractic and even to authorize limited prescribing privileges. Government programs and insurance companies are considering expanding reimbursement policies. In some places chiropractors are authorized to do sports physicals as well as drug testing and DOT physicals for commercial drivers licenses. National University is even offering what they call a family practice residency.

Other Non-MDs Do It. It could be argued that other non-MD providers carry out primary care and gatekeeper functions. Physician assistants are one example whose training equips them to do the job well. My main concerns about chiropractors assuming these functions are:

  • Their thought processes and clinical judgment have developed in the context of a discipline that was originally based on erroneous ideas and that is still lacking in scientific rigor. (These authors still speak of the “subluxation.”)
  • Their training has not exposed them to seriously ill, hospitalized patients, which I think is essential to developing judgment about situations requiring emergency care or referral.
  • Many chiropractors espouse nonsensical tests and treatments. Just one example: according to an American Chiropractic Association survey, an appalling 38% of US chiropractors use applied kinesiology, one of the most ridiculous travesties in all of alternative medicine.
  • Patients under the care of chiropractors are less likely to get vaccinations; only around half of chiropractors recommend them.
  • Chiropractors should not be treating children, but many do so.

 

Bottom line: Some chiropractors are family doctor wannabes, but they are not equipped to fill that role.

 

 

 

 

Posted in: Chiropractic, Politics and Regulation

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349 thoughts on “Chiropractors as Family Doctors? No Way!

  1. DevoutCatalyst says:

    “…Finally, before starting your neck pain treatment, your chiropractor will do a general medical examination, checking your blood pressure, look for swollen lymph nodes, listen to your lungs, and perhaps even do a breast exam…”

    Perhaps?

  2. ConspicuousCarl says:

    Among the challenges is the
    diversity of our colleagues—those
    wanting to participate in primary
    care who order technical diagnostic
    procedures and clinical laboratory
    tests versus those who want to
    remain subluxation based.

    This is one of those paradoxes of moderation, normally seen only in religion. Insanity being optional among the membership somehow seems worse than when it was required. Under the old rules, they could at least pretend not to know that they were nuts. Now they know, but don’t care.

  3. tgobbi says:

    Thanks for this post, Harriet. It couldn’t have come at a better time because, coincidentally, I’m planning to attend a chiropractic lecture this evening and I have some unanswered questions that this “wellness-based” “doctor” evaded last time I went to one of his programs.

    A list of what he failed to answer and the egregious falsehoods he spouted is too long to include in my comments. A few examples about which I’ve already contacted you about directly will suffice.

    He regards himself as something of a cardiologist which was the thrust of his program (“Preventing Heart Disease”) but he strayed to other areas including the never ending “sugar is poison” scare; acidity causes cancer; Gerson therapy is an excellent healthcare choice. (MDs, he complained, are against Gerson because it’s so effective that it cuts into doctors’ incomes)!!! I brought up the general chiropractic anti-vaccination stance and asked him directly if he is pro or anti immunization. For some reason he refused to answer making me think that he’s probably in the vaccinations are bad camp but was too embarrassed to so state.

    I also asked him how much clinical experience he has as a practicing physician, how much hospital time, how much time with sick people. As his bona fides in this area he cited the experience he had at Palmer Chiropractic. As if that qualifies as clinical experience! I believe that most of the “patient” oriented experience chiro students experience is adjusting subluxations of friends, relatives and homeless people who wander into the schools’ clinics. What are the chances that he’s ever submitted a patient to an EKG, an echocardiogram, hooked someone up to a holter monitor or, for that matter, even listened to a heart through a stethoscope? Sometimes I get the idea that DCs are taught that the heart, like all other organs, are extensions of the spine.

    Tonight the “doctor” is speaking on “Spring Cleaning for Your Body and Mind. Learn how toxins from our food, air, water and households can contribute to chronic disease (heart, stroke, cancer and diabetes. Find out how to help your body fight these toxins naturally.” I’m going to try to get him to identify these toxins – you know, the ones that the quacks can see but that are invisible to science-based practitioners.

    These lectures are presented at our local park district’s senior center. I’ve cited the irresponsibility of exposing the public to such nonsense and urged them to preface the programs with some kind of disclaimer stating that chiropractic is out of touch with mainstream medical science. But I’m not holding my breath.

  4. windriven says:

    “Physician assistants are one example whose training equips them to do the job well. ”

    If we are ever to reach the goal of quality healthcare for everyone in this country we are going to have to manage scarce healthcare resources – like the time of fully qualified MDs – much better than we do now. Using PAs and other paraprofessionals within their areas of competency is an important step in that direction.

    However, using people outside their spheres of competency does no one any good. I am a physicist and that is only two letters away from physician but that does not qualify me to diagnose squat. If chiropractors wish to be primary care physicians there are any number of fine medical schools to which they can apply.

  5. Jan Willem Nienhuys says:

    About chiros treating babies: I recently counted al the complaints on 180 Dutch chiropractic websites (basically all sites that said anything at all about what they treat).

    The highest scores (100-120 sites) were of course lower back pain, headache, migraine, slipped discs, and arthrosis. But baby colic, excessively crying babies etc. scored quite high, in the same range (65-80 mentions) as whiplash, dizziness and pregnancy problems and even above explicit mention of lumbago.

    Altogether there are about 360 (= about 21 per million) practising chiropractors in the Netherlands, although there is no school for chiropractic, about 60 of them come from the USA. Their number is on the increase.

  6. @winddriven, I agree. If a physician employs a PA or a NP to do the simple things in their office, such as follow up visits or taking care of very simple problems, that’s absolutely fine. But it’s abusive and a danger to the patient when they are only allowed to see the PA or NP on their first visit, or when these para-medical professions round for doctors, or when doctors use them as replacements for themselves. The training a PA or NP does absolutely pales in comparison to the training we as MDs go through, especially our multiple year residency programs and fellowships, which is really where we learn to apply all the science we’ve been taught and how to actually manage patients.

    Note that I’m not disparaging PAs or NPs. They are very good at what they are supposed to do. The danger comes when they are asked to do things that they have no business doing.

    Regarding chiropractors as PCPs: that’s an absolute joke. It can never happen. They don’t know medicine. They don’t know physiology. They don’t know disease. A chiropractor is no better equipped to provide legitimate patient care than a drug-addicted gas station attendant, because they have had the exact same level of training: none. If a chiropractor isn’t an idiot because of what they believe in or what they taught, then they’re an idiot solely because they picked chiropractic as a “profession” when in fact it’s just organized thievery.

    An acquaintance (at best), who practices every sort of quackery you can imagine, recently asked me the importance of Brunner’s glands (in the intestines.) She told me that her chiropractor told her that “new research” has found that they are responsible for controlling nearly every aspect of the human body. He then proceeded to adjust her Brunner’s glands by rubbing under her armpit. Even this lady, who is a complete flake, found the chiropractor to be off his rocker.

    Sorry chiropractors, use of your services are decreasing. Just give up. Go back to school. Whatever it takes, but do the right thing, and quit inventing new diseases and charging people tons of money while doing nothing but exposing them to unnecessary risk of stroke, paralysis or death.

    There’s a great “skeptical chiropractor” message board here, where it’s full of disenchanted chiropractors who realize that their profession is a complete farce, but are so encumbered with student loans that they are forced to practice. I can’t imagine a sadder (professional) situation: http://chirotalk.proboards.com/index.cgi

    Lastly, chiropractors: when you write your name as “Dr. Backcracking Quack, D.C.”, you look like an idiot because you have the word “doctor” in their twice. I know you’re so proud of yourself for having completed 4 years of complete quack education, but nobody is impressed and nobody believes that you are actually a doctor. You simply do not have any knowledge of disease or disease management. You are a threat to anyone you treat and you are a horrible person who, if hell exists, will burn in the deepest pits of it because you are taking money from the sick while giving them false hope. That is pure scum.

  7. I just realized that in my typical anti-chiropractic rant, I failed to make any decent points. Based on the indisputable fact that a chiropractor has zero ability to diagnose or treat any disease (other than those they make up), the use of a chiropractor as a PCP would do nothing more but add extra cost to health care. If a patient comes in with ANY complaint, the chiropractor would not be able to treat them and would have to refer them to a family practice doc or specialist. But the chiropractor would still charge for the visit (the visit of which they provided zero care for, and if anything, likely delayed the patient’s treatment and tried to sell them on their quack practices.)

    The beauty of our healthcare system, as it stands (and it has many problems), is that a patient sees a PCP (usually a family practice or an internist) and the PCP can treat the vast majority of their complaints. It’s only when they have something that is outside the realm of a PCP that they are referred to a specialist.

    There’s no room for a quack chiropractor in this model. Because they are simply unable to treat or diagnose anything, they would have to refer everything out, and they would still charge for a visit. This drive to be a PCP, for a chiropractor, is only about increasing business in their declining and failing profession. It’s about increasing their income to payoff their student loans from their quack “higher education.”

    Not to mention that the possibility of a PCP flies in the face of the claims of nearly every quack chiropractor I’ve ran into on the internet. They tell me “We don’t cure disease.” I agree with them. They don’t cure anything. They simply prolong problems, deplete their clients of money, and delay their treatment.

    Ask a chiropractor what kind of bilateral optic atrophy occurs in patients between the age of 15-30. Ask them how they would manage an acute anaphylactic reaction. Ask them what they would do in the event a patient came to their office in acute decompensated heart failure. Or if the patient was having back pain, and the chiropractor sells them on their expensive multi-thousand dollar visit plan, puts them on their quack placebo back cracking machines, etc, but misses the diagnosis of any number of cancers that can present as vague back pain. Ask the chiropractor how they would manage a patient having seizures, or complaining of debilitating migraines, or a pregnant patient complaining of headache in their third trimester. Or how about a person with Raynaud’s, would the chiropractor suggest a workup for Lupus? Or if the patient has vague abdominal pain, would the chiropractor be able to treat their possible Hepatitis? Could a chiropractor diagnose Addison’s, or would they simply sell them supplements and whatever scam weight loss supplement they are pushing? A chiropractor fundamentally can’t treat lipid disorders, diabetes, hypertension, or any other common complaint. They’re worthless garbage.

    They’re quacks. They don’t know medicine. They have no business pretending to be a doctor. If we, as a country, had any dignity or balls we’d de-license the lot of them, and quit allowing all of these worthless, disgusting quacks to call themselves doctor and essentially practice fake medicine with a fake license.

  8. NateM says:

    “Parents who belong to faith healing cults and never take their children to a doctor can cut medical costs to zero, but sometimes the children die.”

    I think this line summarizes the entire fiasco of chiros as primary care physicians well.

    Let’s hope this never happens.

  9. “There are those who want to treat the whole person versus those who want to treat only musculoskeletal conditions. There are those of us who want to use treatment modalities beyond the adjustment, as well as those who feel we should adjust only the spine.”

    Well, those people should have gone to medical school and trained to be real doctors.

    There are lots of things I want to do that I am not qualified to do. Playing Madden on an Xbox 360 does not qualify me to coach an NFL team.

  10. Zetetic says:

    Jan Willem Nienhuys says:

    “But it’s abusive and a danger to the patient when they are only allowed to see the PA or NP on their first visit, or when these para-medical professions round for doctors, or when doctors use them as replacements for themselves.”

    In fact, PAs and ARNPs are widely used in primary care settings in the United States as the first provider a new patient may see. Of course, they cannot practice independently of MDs or DOs in a clinic. PAs have also evolved into “Hospitalists” and regularly round on post surgical patients operated upon by an MD or DO they are associated with.

  11. Harriet Hall says:

    About PAs and NPs: their training varies, and as long as they practice within the limits of that training and recognize when they need to ask for help, they can provide excellent care as first providers or even in specialty settings. I have been going to the Cardiology Clinic at Madigan Army Medical Center for some time now, but I’ve never actually seen a cardiologist. I started with a PA who saw me for several clinic visits, recommended and performed a treadmill test, and ordered echocardiograms; and when she left I was transferred to an NP. I think I know enough about medicine to judge whether they were competent, and they were. They could quote the latest literature and showed excellent clinical judgment. A couple of times the PA wasn’t certain about how to best adjust my medications and she consulted a cardiologist before deciding. I have no complaints.

    It boils down to one thing: people can do whatever they are adequately trained to do. Chiropractors are not trained to practice point-of-entry primary care. And I can’t even remotely imagine any chiropractor working at the Cardiology Clinic.

  12. Donna B says:

    Okay, the breast exam comment cracked me up.

  13. DevoutCatalyst says:

    @Donna B

    That quote was from an actual chiropractor’s website. You need not make this stuff up.

  14. “chiropractic physician” – BARF!

  15. tgobbi says:

    # SkepticalHealthon 24 Apr 2012 at 2:23 pm
    “chiropractic physician” – BARF!

    If I’m not mistaken there are some states that don’t allow chiropractors to call themselves physicians. California, at least the last time I checked, is one of them.

    I may have posted about this last week so if it’s a repeat I apologize. At a lecture (chiropractic for “sales pitch”) the speaker introduced himself as Dr. Lepzekuchen, stating that he had been a “physician” (and licensed acupuncturist) for X amount of years. At no time did he acknowledge the fact that he’s a chiropractor, not a doctor. This, in my opinion, is unethical at the very least. It’s a case of intentionally obfuscating who and what he really is – and I’ll bet that many in attendance walked away thinking that they had been listening to a legitimate healthcare professional.

  16. rwk says:

    @ Dr Hall
    Sorry you have to take cardiac medications as you look fairly healthy. If I had to, I’d get them after a consult with a
    cardiologist.

    You say
    “people can do whatever they are adequately trained to do. Chiropractors are not trained to practice point-of-entry primary care”

    Have you looked at the course catalog for NUHS?

    “And I can’t even remotely imagine any chiropractor working at the Cardiology Clinic”.

    I did for eight years in a proper hospital cardiology dept as a non-invasive technician. I continued to work one year after DC graduation. The DO cardiologists were very supportive and helped me get accepted to CCOM/Midwestern University.

    And, the second to the last time I took my father to our family MD, a nurse practitioner saw him. If she didn’t have
    her computer with to constantly look up medications,indications,etc., she would not have been able to handle the visit.

    The last visit, my father actually saw the MD who disagreed with the NP’s intervention.
    So if you can train NP’s and PA’s to look up drugs online ,do physicals and make diagnosis’……………….
    The next visit,

  17. rwk says:

    Bad grammar apologies : NPs and PAs ( no apostrophe)

  18. nybgrus says:

    I was wondering if our resident chiros would come out of the woodwork with some very poor arguments.

    Thanks for not disappointing and packing your post with the usual high density of logical fallacy and low level of substance.

  19. @rwk, are you drunk? I mean seriously.

  20. rwk says:

    @nybgrus
    I’m not trying to convince you or SkepticalHealth

  21. Gordon20 says:

    @HH

    “There is no evidence to indicate that chiropractors are capable of filling that role effectively or safely”.

    I believe there has been some evidence that a role similar to a NP or PA (including MD oversight) has been filled effectively and safely, as seen in the HMO BCBS Illinois 3 year study with a substantial population. The full text articles are more informative than the abstracts. There are potential faults in the conclussions as well. I believe this was the study alluded to in your commentary.

    http://www.jmptonline.org/article/S0161-4754(07)00076-0/abstract

    http://www.jmptonline.org/article/S0161-4754(04)00050-8/abstract

    Conclussions and Results from the abstracts:

    “Results

    Clinical and cost utilization based on 70274 member-months over a 7-year period demonstrated decreases of 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 85% pharmaceutical costs when compared with conventional medicine IPA performance for the same health maintenance organization product in the same geography and time frame.

    Conslussions:
    During the past 7 years, and with a larger population than originally reported, the CAM-oriented PCPs using a nonsurgical/nonpharmaceutical approach demonstrated reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone. Decreased utilization was uniformly achieved by all CAM-oriented PCPs, regardless of their licensure. The validity and generalizability of this observation are guarded given the lack of randomization, lack of statistical analysis possible, and potentially biased data in this population.

    Results

    Analysis of clinical and cost outcomes on 21,743 member months over a 4-year period demonstrated decreases of 43.0% in hospital admissions per 1000, 58.4% hospital days per 1000, 43.2% outpatient surgeries and procedures per 1000, and 51.8% pharmaceutical cost reductions when compared with normative conventional medicine IPA performance for the same HMO product in the same geography over the same time frame.

    Conclusion

    In the limited population studied, PCPs utilizing an integrative medical approach emphasizing a variety of CAM therapies had substantially improved clinical outcomes and cost offsets compared with PCPs utilizing conventional medicine alone. While certainly promising, these initial results may not be consistent on a larger and more diverse population.”

  22. @rwk, I think it’s despicable that you ridicule a NP who references scientifically-derived information on medications to ensure she doesn’t make a mistake, while you practice a wholly unscientific and largely made up religion, errrr, “profession.” Your anecdote is poignant though, as you were obviously unable to do anything to help your father. Pretty pathetic that you, being a “doctor”, has nothing to offer the sick, eh? Didn’t he have any “spinal cord interference” that you could “unblock?”

  23. rwk says:

    @SkepticalHealth
    As I’m sure you really know,my point was anyone can be trained to look up conditions and make prescriptions
    based on that. That’s what Nybgrus is learning to do. You don’t happen to get Monthly Prescribing Reference
    yourself do you?

    Nope,I couldn’t unblock my father’s spinal cord interference.

  24. Harriet Hall says:

    @Gordon20,

    Those studies measured costs, utilization, and patient satisfaction, not objective clinical outcomes. They only showed that chiropractors can save money and please patients, but so can quacks. They doesn’t constitute evidence that chiropractors can fill a family doctor role safely and effectively. And the studies were published in the JMPT, which is strongly pro-chiropractic and publishes a lot of questionable studies that would not be acceptable to a mainstream medical journal.

  25. Harriet Hall says:

    @rwk,
    “anyone can be trained to look up conditions and make prescriptions
    based on that. ”

    That is not a fair or accurate description of what PAs and NPs are trained to do.

  26. PJLandis says:

    @ Gordon20

    These numbers are unbelievable,if replicated these results would revolutionize healthcare around the world! “…demonstrated decreases of 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 85% pharmaceutical costs…”

    But the real lead is that the authors themselves question the “validity” of these results because of the lack of randomization, lack of statistical analysis, and biased data.

    You have to wonder if they understand things like randomization and bias, why they didn’t control for them? Perhaps the results of a fair test wouldn’t be so world changing after all.

    @rwk

    Chiropractors could be trained to look up conditions and make prescriptions, but that would be reckless and dangerous to their patients. Nurses and Doctors have a general training, academic and hands-on, in medicine that is reinforced, updated, and verified by reference materials. They do more than follow instructions from a book which is exactly what a Chiropractor would be doing in the position of a Primary Care Physician.

  27. nwtk2007 says:

    The whole idea is silly. Chiro’s in general lack the training and especially the experience to be PCP’s. They should stick with their treatment of musculoskeletal conditions and, of course, those who practice the “religion” of chiropractic, removing subluxations to free the bodies innate intelligence to heal itself, should find a hole to hide in or just go away.

    However, in my experience in both the chiro world and the medical world, I find that there are just about as many MDs who shouldn’t be PCP’s as chiro’s. The sheer number of “medical professionals” who are clueless to the harm they do and the mistakes they make, the lives they endanger through misguided action or the lack of action, is staggering.

    I thank god every time I go to the MD or take my kids to their MD that the MD has the good sense to do as I tell them to.

  28. Harriet Hall says:

    @nwtk2007,

    Are chiropractors constitutionally incapable of discussing any issue about chiropractic without using it as an opportunity for a gratuitous defensive tu quoque attack on MDs? I won’t even bother to ask if you can provide any evidence putting the “lives they endanger” into perspective with the “lives they save.” See http://www.sciencebasedmedicine.org/index.php/death-by-medicine/

    Your comments are self-contradictory: if no chiros are equipped to be PCPs and there are “just about as many MDs who shouldn’t be PCPs,” wouldn’t that imply that no one should be a PCP? And what qualifies you to think MDs should do what you tell them to? What colossal hubris!

  29. I agree with Dr. Hall. @nwtk2007, unless your a pediatrician too, and aren’t treating your own kids because of your high ethical standards, then I’d have to believe that your pediatrician is infinitely more well prepared to treat your kids than you are. In fact, if you are somehow bullying your pediatrician to bend to your will, then you are receiving substandard medical care. Any doc who has put in hours at any type of walk in facility knows the stress of dealing with a concerned parent (“NO! MY KID NEEDS ANTIBIOTICS FOR HIS VIRAL PHARYNGITIS!!!!”) I’d love to know what your source of knowledge is for your opinion that “The sheer number of ‘medical professionals’ who are clueless to the harm they do and the mistakes they make, the lives they endanger through misguided action or the lack of action, is staggering.”

  30. nwtk2007 says:

    @ Harriet, with regards to your statement, “And what qualifies you to think MDs should do what you tell them to? What colossal hubris!” -

    I’m sure you do. I guess some of us are just a bit smarter or a bit more, “in the know” on certain issues which PCP’s regularly encounter. Oh, I wouldn’t pretend to tall a doc how to perform procedures which I am not able to do by lack of training. The same would apply to a mechanic or a chef.

    I know some very talented and gifted MD’s and DO’s. I also encounter some incredible BoZo’s too. I especially liked the one who recommended medication and “yogurt”. Oh how we wished it had just been a type-o.

    Goofuses all over Harriet, just say’in. On a similar note, I am wondering why you continually attempt to bait chiro’s into debate with articles like the one above. I suspect its because you enjoy it.

  31. lilady says:

    Ahem, NPs and PAs are quite qualified in the terciary care hospital emergency rooms that I have ever been a patient in, or brought family and friends to, for treatment.

    NPs and PAs do “triage” to evaluate a patient with a simple cut that will require suturing, so that this patient does not occupy a cubicle where patients who have serious injuries require treatment. Qualified (in emergency care) NPs and PAs provide a level of care to their patients that is equal to care provided by E.R. physicians, for these “select” group of patients.

    NPs have set up autonomous OB/Gyn practices. These practices have been evaluated and found to be a viable alternative for women whose pregnancies are not deemed high-risk. And, OB NPs, do not hesitate to refer a pregnant woman to a high-risk physicians practice, when her condition warrants that referral.

    Why shouldn’t a doctor or a NP refer to a medicine reference book, with a patient who has a documented history of allergy to penicillin? I requested clindamycin when I had a suspect salivary gland stone…it is easier on my digestive tract than tetracycline.

    BTW, when I brought my children to their pediatrician for a “sick” visit, I understood why he questioned me about the history of fever and activity level…a consistently high temperature along with listlessness…is much more significant than a child who (seemingly) is not bothered by spiking a high fever.

    My personal belief is that pediatricians are overworked and under-appreciated in our society. When you consider that they monitor a child’s development, and are “generalists” who deal with patients who cannot describe their symptoms…they do a spectacular job of caring for our children.

  32. Harriet Hall says:

    @nwtk2007,

    “I am wondering why you continually attempt to bait chiro’s into debate with articles like the one above.”

    I wasn’t trying to bait them into debate. I didn’t think my arguments were debatable. :-)

  33. nwtk2007 says:

    @lilady, I have a very close friend who is a NNP working for a very large group of OB’s. From what I have seen it’s actually the NNP’s who direct the patient care, especially in the smaller affiliate hospitals. In fact, the most common MD comment to the NNP’s is, “what do we do next?” These NNP’s are some of the most impressive health professionals I have seen. Incidentally, my own daughter is in an NP’s office at this very moment getting seen for a typical PCP case. The NP runs the clinic as the “doctor” of the clinic.

    @Harriet, So if not for debate, then just to, once again, start an anti-chiro thread going…yes, and to bate chiro’s into posting. No need to bad mouth chiro’s if they are just going to ignore you.

  34. Harriet Hall says:

    @nwtk2007,
    to “start an anti-chiro thread going…yes, and to bate chiro’s into posting. No need to bad mouth chiro’s if they are just going to ignore you.”

    You may not believe me, but I have no desire to bait chiropractors and I have long since had my fill of debating with them. I would be happier if chiropractors ignored what I posted or presented a rational counterargument backed by evidence. What I write is not for the benefit of chiropractors but for the enlightenment of others. I can’t help it if what I say strikes a nerve and provokes a defensive response. The chip on your shoulder is very evident in the way you responded to a post that you apparently actually agree with.

    And if you would read more carefully, you would realize that I am careful not to bad-mouth chiropractors. I try not to insult individuals but only to critique false claims and fallacious arguments.

  35. pmoran says:

    Harriet: Those studies measured costs, utilization, and patient satisfaction, not objective clinical outcomes. They only showed that chiropractors can save money and please patients, but so can quacks. They doesn’t constitute evidence that chiropractors can fill a family doctor role safely and effectively. And the studies were published in the JMPT, which is strongly pro-chiropractic and publishes a lot of questionable studies that would not be acceptable to a mainstream medical journal.

    Actually a lot of everyday primary medical practice IS easy. The majority of patient complaints derive from minor, self-limiting and even non-diagnosable conditions and a great many medical consultations involve routine medical housekeeping such as checkups and referrals to specialists. Also nowadays the majority of serious life-threatening medicine is carried on at the specialist level.

    So I am not at all surprised when such studies reveal somewhat discomforting results for us “proper doctors”, including bothersome figures regarding adverse drug reactions. However, as you say, Harriet, without longer term outcomes and proper controls we cannot say with certainty who is being better treated overall.

    NPs are relatively safe because of their subordinate role within the conventional medical system (notwithstanding the likelihood that experienced midwives will be rather more cluey about some things than the average young doctor). I cannot see chiropractors easily slipping into that role. They will be overqualified in some respects but seriously underqualified and undertrained in others.

  36. nwtk2007 says:

    I think if you, yourself, would read more carefully, you’ll see that I agreed with you that chiro’s are not qualified to be PCP’s. Defensive?

    Nor do I try to insult individuals but rather, I critique false claims and fallacious arguments; to the enlightenment of others.

  37. Harriet Hall says:

    @nwtk2007
    “you’ll see that I agreed with you that chiro’s are not qualified to be PCP’s. Defensive?”

    Read my last comment again: I saw that you agreed with me and I said so. But then you tried to defend chiropractic indirectly by going on the attack against medical doctors.

    I agree with you that there are doctors who shouldn’t be PCPs and who don’t practice good medicine, but that’s a different subject. The topic was the suitability of chiropractors. Your tu quoque comments about doctors contribute nothing to that topic.

  38. Cowy1 says:

    “I critique false claims and fallacious arguments; to the enlightenment of others”.

    This occurred where?

    Re chiropractors, I have yet to meet one that wasn’t overtly or covertly antivaccine despite being within a 20min drive (in Chicago traffic no less) of the supposedly evidence-based NUHS.

    Also, via FB, I have friends in their final year of chiropracty school putting posts up asking people to come into their clinic so they can get enough patient contacts to graduate. Not exactly ringing endorsements of your typical chiropractor’s training.

    At one of the schools they only have to do 25 H&Ps to fulfill their graduation requirements! For comparison’s sake, I’ve done that many in a single week during my 3rd year of medical school and am probably going to finish around 500 (rough guess) for the year.

  39. rwk says:

    @ Cowy1
    Are those students really your friends ? Especially now. If they only knew.
    How long do your H&Ps take to complete? The NUHS protocol used to take 2-3 hours. Ridiculously long
    but comprehensive.
    Dr. Hall should sit in on a few lectures,tour the school and then comment.
    There’s no doubt that one gets more real world experience in medical school after the second year.

    @pmoran
    Thanks for being honest.

  40. Cowy1 says:

    @rwk

    FB “friends” now, mostly folks from undergrad and HS that I rarely get to talk to but their posts pop up with alarming frequency. Every single one of them spews a nice anti-medicine, anti-vaccine post about every week and a few are involved with “Maximized Living” which apparently has a strong presence on chiropracty campuses.

    Time available to do H&Ps varies by rotation. Outpatient at County I would often see 10 patients by myself during the day (with physician oversight, obviously) and half of those would be full H&Ps. Inpatient medicine (for example) allowed more time for “formal” H&Ps but even at the beginning of the year these rarely took more than 2 hours to complete even when I included the patient’s travel history back to the Eisenhower administration.

    Didn’t have to beg in any of these people either as they had actual, honest-to-god medical problems. As for chiropracty students spending 3 hours on an H&P routinely they still only have 25 to do to graduate, a task I’d still be able to polish off in a couple of weeks even if I worked that slow. Not exactly a ringing endorsement of the educational quality of their programs especially given that some of the were likely done on some of their family members and friends.

  41. weing says:

    @pmoran

    “Actually a lot of everyday primary medical practice IS easy.”
    It sure is. It also reminds me of what my calculus professor would say when asked if the test he was about to give us was hard. “It’s easy, if you know the math. It’s impossible to figure out, if you don’t know it.”

  42. Harriet Hall says:

    @rwk,
    “Dr. Hall should sit in on a few lectures,tour the school and then comment.”

    1. If you are arguing that chiropractic students are taught to do a thorough history and physical, that would mean that the “primer” offered in this 3 part article is unnecessary and demeaning. Obviously the authors don’t think chiropractors are skilled at H and P.
    2. Did you miss my point about the need to develop clinical judgment and experience by caring for seriously ill hospitalized patients? Touring the school and sitting in on lectures couldn’t answer my objections.
    3. Do you think chiropractors are qualified to act as family doctors?
    4. By the way, homeopaths do really intensive, long histories on their patients, but with no benefit to patients. An over-long history-taking session in medical practice could mean the doctor is incompetent and unable to hone in on the essentials.

  43. nybgrus says:

    This is entertaining. RWK seems to be having an argument in his own head and then writing it down. He blatantly disregards other posts and just writes against the objections and thoughts coming from the internal dialogue he is having.

    It smacks of trying to convince himself that chiropractic is a valid field, while deep down realizing it isn’t. My genuine sympathies to you – it would be terrible to be in your position.

  44. @rwk, I truly feel bad for you. It’s blantantly obvious in your posts how frustrated you are having picked such a worthless, useless career. The mere fact that you constantly visit this site shows that you do have an interest in science and evidence-based medicine, and yet you are fundamentally unable to practice these because you chose an inherently unscientific profession. I feel for you. I do. The simple truth is that a chiropractor can not treat or cure any disease. They may or may not be able to help with some pain relief in certain specific types of back pain. But no one should employ chiropractic because of the high probability of being recruited into a world of quackery.

    Sucks to be you. By the way, a 2 hour H&P is extraordinarily inefficient. I bet in your scummy real life practice, where you’re likely paying some scam marketing service to recruit patients by telling them lies (“Did you know that driving your car can cause your spine to come out of alignment?!?! You better see your chiropractor NOW! to get these subluxations fixed and restore natural energy and balance!”), that you do not spend 2 hours doing a H&P.

    If you have to talk to a patient for 2 hours to figure out what their problem is, you suck. (Further proof that chiropractors have no idea what they are doing, and are complete quacks.)

  45. nybgrus says:

    Ouch. Not that you are incorrect, but still… Ouch.

    For the most part I try to view things like this the same way I view religion. Yes, it is all BS. Yes, it does lead to harm. Yes, it does need to be completely done away with. But for the most part it is tough to blame the individual chiropractor since more than likely (s)he was duped. The colleges need to be done away with.

  46. Scott says:

    Actually a lot of everyday primary medical practice IS easy. The majority of patient complaints derive from minor, self-limiting and even non-diagnosable conditions and a great many medical consultations involve routine medical housekeeping such as checkups and referrals to specialists. Also nowadays the majority of serious life-threatening medicine is carried on at the specialist level.

    The real trick, of course, ends up being distinguishing the interesting minority from that uninteresting majority.

  47. Sam Homola says:

    Warning: This presentation by the president of a chiropractic college, on “The Doctors” TV show, April 23, might raise your blood pressure:

    http://www.youtube.com/watch?v=CM3E6NTGpOg

  48. Josh Berndt says:

    Chiros claim to be the experts in diagnosing and treating LBP, yet this mostly benign self-limiting condition has become a billion dollar a year epidemic in this country. I can’t wait to see how they would go about “treating” sore throats and ear aches…..Oh I bet I know, manipulate the spine and send them home with natural supplements. What about cancers and diabetes, manipulations and supplements!

    The use of the term physician should be reserved for medical doctors only, period.

    The video is entertaining. You can see why patients with no medical knowledge fall for this. Look at this new technology, the LX900B can find the mysterious, imaginary subluxations I have been telling you about. Your back pain is from your neck that doesn’t hurt??? I’m supposed to go to this guy instead of a family practice physician??? C’mon people.

  49. rwk says:

    @ Skeptical
    The 2 hour H+Ps were only what we had to do in school. It doesn’t happen in real life.
    I do locum tenens work only, when I want to so I don’t have the marketing service you’ve decided
    I have. I don’t have to take work if I don’t want to. Get it?
    I’m here so you might know there are exceptions out there. You’ve met all the bad DCs but your
    comments and insults reach the good ones as well
    From my perch of this fence,I read tons of opinions and crazy thoughts by professionals and lay people
    who obviously have little inside knowledge of the chiropractic profession but instantly get behind whoever
    authors an article on this site.

    @ Nybgrus
    I really am puzzled that you or anyone seriously think the profession is going to go away. Not in your
    lifetime and you’re along way off from hanging out your practice sign.
    I wouldn’t be here though if I wasn’t interested in learning and observing honest critical thinking in action.
    Lighten up

    @ Dr.Hall
    you say
    ” Did you miss my point about the need to develop clinical judgment and experience by caring for seriously ill hospitalized patients?”
    No. And I don’t deny that that experience is lacking. But NUHS have long tried to improve that situation:
    http://www.nuhs.edu/academics/college-of-professional-studies/chiropractic-medicine/program-overview/clinic-internship-program/
    Notice the hospital rotations.
    Were you not aware of this in your investigation?
    NUHS have long tried to foster interprofessional relations with the medical community. So, who do you think is stopping more of that from happening?

  50. Harriet Hall says:

    @rwk,

    I’m aware that there are limited opportunities for chiropractic students to participate in hospital rotations and in what they call “internships” but I have not seen any evidence that these amount to anything comparable to the hospital-based training of MDs where they assume primary responsibility for patients. In fact, I don’t think hospital accreditation standards would allow that. If you can provide details of what these chiropractic opportunities actually entail, please do.

  51. If I ever had to mentor a group of “chiropractic students” at the hospital I’d freak out. There is indisputably nothing that a chiropractor could contribute to any inpatient situation.

    @nybgrus, I agree that it sucks a lot of people get duped into going to quack chiropractor school, but… When do we blame them for continuing to practice quackery? In my heart I believe that it is worse to knowingly practice quackery than to unknowingly practice it. I guess they are just financially strapped and they risk not being able to feed their families.

    It is just *so* scummy.

    I just can’t think of another word for chiropractors than scum. What sort of scum makes up (ridiculous) diseases and tells people they have them, and that they can cure them? It’s just so slimy. Stealing from the dying should be punishable with jail time and forfeiture of all assets. ;)

  52. rwk says:

    @SkepticalHealth
    Besides not mentioning my last post to you, what do you think of Sam Homola DC ?
    Would you mentor him,discuss health or accept a referral for co-management?

  53. Harriet Hall says:

    @rwk,
    “what do you think of Sam Homola DC ?
    Would you mentor him,discuss health or accept a referral for co-management?”

    This question was not directed at me, but let me answer it:

    Sam Homola limited his practice to short term treatment of musculoskeletal problems and used spinal manipulation rationally. I have great respect for him. I know he wouldn’t in his wildest dreams imagine he was qualified to act as a family physician. He wouldn’t try to co-manage patients or ask for mentoring in the medical arena. Why did you even bring him up? As far as “discussing health,” I would “discuss health” with anyone. What does that have to do with the subject under discussion?

    I wish just once a chiropractor would comment on one of our articles without changing the subject, introducing irrelevancies, or attacking mainstream medicine. I guess that’s too much to ask.

  54. rwk says:

    @Dr Hall
    You don’t get it. My comment as directed to SkepticalHealth not you. You are reasonable sometimes.
    He is not ever. If you read his garbage then you know how vile he is . I wanted to see if he thinks all
    chiropractors are shite then what does he think of Homola? If he thinks Homola is a reasonable DC then
    he should change his comments to reflect.
    Please comment on that.
    By the way, SkepticalHealth’s site is down and his comments have disappeared. What’s up with that?
    Maybe there is a god.

  55. rwk says:

    As I await moderation on my last comment I found this:

    http://places.blumenthals.com/thread6da0.html?tid=32f18842809d30df&hl=en

    It looks as if like Skepticalhealth and skepticalhealth.com are done.

    It’s a good day.

  56. nybgrus says:

    there’s more of that internal dialogue, rwk.

    I never said it would go away any time soon. I said it should go away… and the sooner the better.

    As for Sam Homola, I’ll comment exactly what I’ve said before – there are always exceptions. However, we have no way whatsoever to determine who those exceptions are a priori. The default training and education of chiropractors is quackery and nonsense. Those few (and yes, they are few) that manage to realize this and limit themselves to the very narrowly defined area with some evidence are indeed the exception.

    SkepticalHealth indeed does have a very abrasive nature in these posts. However, the only difference between him and Dr. Hall (and myself for that matter) is the way in which he says things. We otherwise don’t fundamentally disagree.

    So there is nothing to “lighten up” about. I spend countless hours researching in depth chiropractic curriculums, schools, licensing exams, and evidence for efficacy and found nothing redeeming. Not all individual chiropractors are evil people. Most are indeed “scum” as SH would say – they practice rank quackery and cheerfully dupe people out of their money (like the one of that inane show that Sam linked to). Some are just painfully oblivious. Some are trapped, unable to stop practicing quackery since it is their only means of livelihood. And a very few genuinely practice that incredibly narrow scope of limited MSK treatment.

    BTW – note that in the video clip, besides being a load of sciencey sounding yet utter BS, no one once mentioned sinister causes to be ruled out for chronic low back pain with no identifiable etiology or trigger or relief.

    Sorry, rwk, but really chiros are not qualified to do much of anything at all and the fact that they think they are makes them even more dangerous.

  57. @rwk, I deleted my website about a week ago. I’m back to being busy again and hadn’t made a new post in almost 6 weeks I had been compiling my longer posts into a book, but have realized that I could never publish it. CAM practitioners are a childish and vindictive bunch. After seeing chiropractors be crybabies when I point out that they are, in fact, advertising treatment for completely fake and made-up diseases, and then get “revenge” by slandering real doctors, I realized that it would be suicide for my career to publish my scathing (but honest) reviews of CAM practices. If you just google and read the lies these morons write about people like Dr. Hall, Dr. Gorski, Dr. Barrett, etc, you’ll see why someone who still has many years left as a practicing doctor doesn’t want their name out there being harassed by a bunch of pseudoscientific mentally handicapped wannabes.

    As an example, one article I wrote described “ileocecal valve syndrome”, which is a completely fake disease that a typical quack chiropractor was advertising on their webpage. Of course, the symptoms of the disease were completely vague and could be applicable to half the population (“Are you tired? Do you feel overworked? You may have ileocecal valve syndrome! You need a chiropractor to adjust you!”.) And the only cure of course is to visit your chiropractor and let them adjust you. Just pure scam. In fact, I don’t think I saw a single chiropractic practice’s website that didn’t promote quackery. One of these incompetent goobers left a comment threatening me with everything under the sun, including a hilarious promise to put my website on “ripoffreport.com.”

    While I did not care one bit about having my website linked on a “ripoffreport” website, I did care about eventually having my name linked to that website. Why? Because I saw people writing things on there like “Dr. XXxxxxx RAPED ME!!! HE IS A JERK AND RAPED ME!” No, Dr. Xxxx wasn’t me, but I wouldn’t doubt, for a single second, that if these a-holes will lie to the sick and dying and steal money from them, that they would just as easily write crap like that about me. Especially after seeing the lies they’ve written about the Doctors that write on this website.

    So, congratulations. My fear of having patients Google my name and seeing a bunch of quacks lie about me caused me to take down my website. I enjoyed the link you posted where someone was asking about my website. Unfortunately you cannot accuse someone of libel if they are writing nothing but facts, so I never had a legal threat. (If they did, some poor bastard in Ghana at the gas station is probably scratching his head.)

    Re: Sam, I have no opinion of him. I do not know him or anything about him. Dr. Hall has written multiple times that he is not a quack at all, and I trust Dr. Hall’s opinion and I trust her to give out good information. If he knowingly deceived patients, then he’s scum, but from what I’ve read about him he doesn’t practice quackery. So I’ll accept that. Otherwise I’ve only read two of his articles here, I believe the first was somewhat critical of chiropractors, and the second was a generic back pain article which I didn’t particularly enjoy because I didn’t see the point of it. My comments were posted in that thread.

    Now, @rwk, what is your opinion of chiropractors who treat anything besides LBP? What do you think of them treating “nervous system interference”, “spinal network analysis”, “ileocecal valve syndrome”, “restoring body balance”, “NUCCA therapy”, etc? It’s interesting that it seems all chiropractors end up practicing the same quackery. They sure must be learning this in school. It blows my mind that states allow people to call themselves “doctor” when they’ve learned nothing but fantasy. By the same write, authors of books like Lord of the Rings and Harry Potter are equally as qualified to practice “medicine” as chiropractors are. There’s no difference. (Well, to be honest, I’d rather have a fantasy author work on me, because they’d be less likely to cause paralysis, stroke or death.)

  58. Scott says:

    @ rwk:

    Until the supposed “good” chiropractors take action against the legions of dangerous quacks who claim to cure asthma, colic, etc., discourage the use of real medicine, and merrily cause strokes while denying the risk exists, the entire profession is hopelessly tainted. No consumer can know what they’re getting, so the only safe course of action is to avoid chiropractors entirely.

    If you want chiropractic to become a credible health profession, and make it vaguely credible to even THINK about maybe giving them a VERY LIMITED primary role, clean up your peers first.

  59. DavidRLogan says:

    I’m stuck several steps before the issues raised by the OP (sorry…completely ignorant of chiro). What is the proposed (physiological) mechanism for chiro, anyway? When I pop my knuckles, for instance, a small amount of gas may be released when the joint capsule stretches. Isn’t an “adjustment” the same thing? I’m not condescending…but can someone persuade me that an “adjustment” is any different than popping my knuckles, which is prima facie non-therapeutic?

    The best I could find is the notion of (paraphrasing) “spinal joint restriction”. Now it is true that, when the relation between bones is disturbed, the brain will tighten muscles to compensate (for instance tighten psoas and rectus femoris when we’re sitting). But how would “adjustment” change this? The loss of mobility is neuromuscular, not because of lack of mobility at the joint capsule! And in fact the lumbar spine in particular is designed for stability, not mobility. It’d be a total disaster to increase mobility at the lumbar spine by any means, particularly for a non-athletic, injured population.

    Lastly, the notion of a nervous system treatment is hard to understand. Diabetes, for instance, is related to the activity of TVRP sensory afferents…but if chiropracty targeted those neurons we already would have cured diabetes. Even in a “nervous system” treatment (whatever that means), the only treatment of which we’re capable is pharmacological (at least at present level of technology).

    What I’m getting at here is that, unless some reasonable mechanism for chirocpracty can be elucidated, why argue the number of patients one sees? If the treatment does nothing it won’t help to see 1000′s of patients or take 100′s of OG chem classes. Even if Chiro schools were much *better* we would see the same results(potentially dangerous if lumbar/cervical mobility is in fact emphasized). HOWEVER, I’ll be open to suggestion if anyone can explain to me how this works…again I profess complete ignorance of chiro.

    Have a nice morning everyone.

    -David

  60. Harriet Hall says:

    @DavidRLogan,

    I’ll stand up in favor of one thing about what chiropractors do. Spinal manipulation therapy is an effective treatment for common low back pain, although it is not more effective than other treatments. It is also offered by non-chiropractors like DOs, PTs, and Physical Medicine and Rehabilitation specialists, but arguably chiropractors are the most skilled at those manipulations. No one knows why it works, but there are several hypotheses. One of the things that annoys me most about chiropractic is that their associated nonsense has given manipulation a bad name, and has interfered with an objective assessment of its value.

  61. DavidRLogan says:

    Thanks, Dr. Hall.

  62. nwtk2007 says:

    I agree with you Scott, chiropractic is already hopelessly tainted.

    @David Logan, I can’t understand why you would think that increasing mobility of the lumbar spine would be a thing to avoid. I would think that if one were so stiff in the back that they couldn’t even put on their socks, it might be a good thing.

    All the various hypotheses as to how it works are, for the most part, related to use and the normal changes associated with regular use versus non-use. I went to the van Cliburn piano competition a few years ago and every single pianist went through a complete knuckle popping prior to their piece. So there must be something to the notion of increased mobility, at least short term. Also, I have treated thousands of patients, necks and backs, and just based upon experience and seeing the improvement in their conditions and their pain relief, I can tell you, at least based upon my experience, it is the most therapeutic thing I do in the treatment of injures. Those at this site would argue that the evidence is not there to support it but I think that it just hasn’t been adequately researched and I, for one, will not dismiss what I see on a daily basis and claim its all in their head or that its just placebo effect. For those of us who do the treatments, it just means that the evidence out there is not up to the skeptics “standards”.

    As to some of what you mentioned regarding lower back stiffness, I have done literally hundreds of ROM checks before and after lumbar manipulation and in literally every single case in which I am able to do a quality manipulation, the ROM instantly improves. Before you cry that its anecdotal, keep in mind that this is something I see all the time. In fact, I’ll check it again on my next low back patient. I occasionally have patients who are afraid to have the manipulation performed. Invariably, when I finally get them to allow it, the improvement is almost instantaneous. Maybe not 100%, but in the majority of cases. I regret that I haven’t kept a running record of this outside of their charts.

  63. DavidRLogan says:

    Thanks for the reply, nwtk. In response to your question, my thought was this: shear forces on each joint are relative to the anatomy of surrounding joints. For instance, as you probably know, all-things-equal females have greater incidence of ACL problems…a wide pelvis means a greater q-angle, and a greater q-angle increases forces on the knee (that is by no means an explanation for all ACL problems…just trying to illustrate the point).

    So the same is true, I think, of joint relations generally. My understanding of your “stiff back case” is this: loss of mobility at the hips means the CNS will “transfer” that mobility-and force-to the lumbar spine and its movers (for instance, erector spinae). When someone bends to pick up their socks, if the hips and ankles aren’t adequately (emphasis on adequately!) mobile, mobility will come from the lumbar spine, which is “asked” to handle more force than usual. Therefore stiffness occurs…an analogy: if you fuse two links on a chain, the next link will take on more force when the chain moves.

    So that’s why I said what I did. And in someone already suffering more *serious* problems than stiffness (pain, disc problems, etc), the ability to handle that mobility is even less, or rather, I think increasing mobility is a bad idea.

    I won’t call “anecdotal” on you, though some probably will. Thanks for your perspective…but how do you respond?

  64. @nwtk2007, I’m always troubled by your posts because you make such spectacular claims, which I simply do not believe. We, as in “all of medicine”, are simply not good at treating back pain and we simply don’t have much to offer. Either you’re the single best practitioner (I believe you’re a PT?) on earth, or you exaggerate or misinterpret the amount of pain relief you achieve. Remember that most patients will get better with or without therapy, and also that when you do “something”, and then say “do you feel better now?” the answer will almost always be “yes.”

    Also, I’m interested in hearing your definition of “manipulation therapy” compared to @nwks.

  65. nwtk2007 says:

    Actually Skepticalhealth, I generally don’t ask if a patient feels better after a manipulation. In most cases they simply express how they feel differently spontaneously. Sometimes its the old stiff drink response; some sort of yelp or gasp and then ahhhh. But not always. Some folks just can’t be manipulated and with some I have to refrain from it due to various contraindications. Some never give in to allow it. Anyway, I mostly don’t ask. Oh, and I’m not a PT. I’m a quackypractor who treats mostly MVA’s and work injuries. As to my spectacular claims, they just don’t seem that spectacular to me or the guys I work with, especially the sheer numbers of folks we have seen. Not so busy now. Too many scamsters chasing prospective patients and channeling them to other clinics (preying on their ignorance) and too many drug addicts. Most people definitely prefer a pain pill, hydrocodone, to physical medicine. Seeing LOTS of that. And in these great days of economic crash, a person would rather have cash than have his broken neck fixed. Literally, many would just continue to squirt blood if there’s no cash payout to it.

    I understand what you’re saying Logan. In that light I think manipulation can get all the connected, movables to do their fair share of the motion and restore good ROM. And yes, if this is what you mean, a hyper-mobile or unstable joint need not be manipulated. But usually, the ones adjacent to it are hypo-mobile. In those terms, I can relieve a great deal of lower back problems by manipulating the lower thoracic spine. If I missed your point, sorry.

  66. nwtk2007 says:

    Actually Skepticalhealth, I generally don’t ask if a patient feels better after a manipulation. In most cases they simply express how they feel differently spontaneously. Sometimes its the old stiff drink response; some sort of yelp or gasp and then ahhhh. But not always. Some folks just can’t be manipulated and with some I have to refrain from it due to various contraindications. Some never give in to allow it. Anyway, I mostly don’t ask. Oh, and I’m not a PT. I’m a quackypractor who treats mostly MVA’s and work injuries. As to my spectacular claims, they just don’t seem that spectacular to me or the guys I work with, especially the sheer numbers of folks we have seen. Not so busy now. Too many scamsters chasing prospective patients and channeling them to other clinics (preying on their ignorance) and too many drug addicts. Most people definitely prefer a pain pill, hydrocodone, to physical medicine. Seeing LOTS of that. And in these great days of economic crash, a person would rather have cash than have his broken neck fixed. Literally, many would just continue to squirt blood if there’s no cash payout to it.

    I understand what you’re saying Logan. In that light I think manipulation can get all the connected, movables to do their fair share of the motion and restore good ROM. And yes, if this is what you mean, a hyper-mobile or unstable joint need not be manipulated. But usually, the ones adjacent to it are hypo-mobile. In those terms, I can relieve a great deal of lower back problems by manipulating the lower thoracic spine. If I missed your point, sorry.

  67. Harriet Hall says:

    @nwtk2007,
    “I have treated thousands of patients, necks and backs, and just based upon experience and seeing the improvement in their conditions and their pain relief, I can tell you, at least based upon my experience, it is the most therapeutic thing I do”

    You will see what is wrong with your statement if you replace it with a hypothetical statement from around 1800:
    “I have treated thousands [maybe just hundreds back then] of patients with bloodletting to balance the humors, and seeing that they recovered from their illnesses and didn’t die, I can tell you, at least based upon my experience, that it is the most therapeutic thing I do.”

    That’s why we need science, and chiropractors have had over a century to validate what they do with science, but they haven’t succeeded.

  68. nwtk2007 says:

    I won’t argue that Harriet. But I’m betting that was never said about blood letting either.

    I had a reply for Logan and Skepticalhealth if you’d be so kind as to moderate it.

  69. rwk says:

    @dr hall
    I do believe nwtk2007 said ROM assessment was performed after treatment. What’s unscientific about
    that?

  70. Josh Berndt says:

    The effects of manipulation are neurophysiological. The manip doesn’t increase joint play, stretch capsules to new resting lengths, increase length of tight muscles around the joint. The “tightness” treated is typically present as a form of defense not defect. For example…Brain receives input from a disc, decides this is threatening, creates pain and “tightness” to protect what the brain percieves as a threat. The manip stimulates afferents that mediate this cycle at the spinal cord level by inhibiting C-fiber input.

    Throw in the patient’e expectation that they will get better following a manip and you have a good option for the treatment of acute mechanical back pain.

  71. Josh Berndt says:

    Another to remember when thinking about manipulations and LBP. This isn’t a stand alone make or break part of their care. Proper education, not harmful education about degenerative diseases, subluxed vertebrae, etc….and graded exercise should follow all manips and be the main component of care for LBP.

  72. nybgrus says:

    I went to the van Cliburn piano competition a few years ago and every single pianist went through a complete knuckle popping prior to their piece.

    And many professional baseball players wear mis-matched socks or always use the exact same helmet every time they bat. Clearly, mis-matched socks must improve baseball playing.

    Also, I have treated thousands of patients, necks and backs, and just based upon experience and seeing the improvement in their conditions and their pain relief, I can tell you, at least based upon my experience, it is the most therapeutic thing I do in the treatment of injures.

    And Dr. Jay Gordon has seen literally thousands of patients and, based upon his experience, concludes that vaccines are harmful and cause autism.

    Those at this site would argue that the evidence is not there to support it but I think that it just hasn’t been adequately researched

    Some would argue that using the power of my ancient ancestors to cure vague headaches has no evidence to support it, but I think that it just hasn’t been adequately researched.

    But I’m betting that was never said about blood letting either

    Hmm. Funny you should say that:

    “The ancients, in Galen’s opinion, thought it [bloodletting] nothing less than the most effective of all remedies”

    Galen on Bloodlettings

    I do believe nwtk2007 said ROM assessment was performed after treatment. What’s unscientific about
    that?

    Where to start? Measurements can easily be biased – after all, he is not blinded as to whom he is manipulating. Patient suggestibility is a huge confounder – they could very easily be (consciously or not) limiting ROM and then removing that block after the suggestion of improvement post manipulation (we call that “placebo” around these parts). Oh, and there is no independent verification nor an actual analysis of the data involved, making it very prone to confirmation bias and recall bias.

    Science is more than just claiming you have a bunch of numbers. Not that y’all would know that, of course.

    Like hitting dingers off a T-ball

  73. nybgrus says:

    Throw in the patient’e expectation that they will get better following a manip and you have a good option for the treatment of acute mechanical back pain.

    Except that the evidence demonstrates it is effective in chronic, not acute, settings

  74. Josh Berndt says:

    The CPR regarding LBP supports manipulation if symptoms have been present less than 16 days.
    Spine. 27(24):2835-2843, December 15, 2002.

  75. nwtk2007 says:

    nybgrus, you really think the knuckle popping doesn’t effect the pianists playing other than as a “charm”? Sorry, but you are way wrong. You ever heard of Andre Watts? All of your other remarks rate no response.

    Thanks for the input Josh Berndt.

  76. Harriet Hall says:

    “ROM was performed after treatment”

    In his demonstrations of how the PowerBalance wristbands don’t really work, Richard Saunders shows that if you ask a person to extend his arms and turn his upper torso as far as possible and then shortly afterwards ask him to do it again, he will always be able to turn a little farther on the second trial.

  77. Harriet Hall says:

    “All of your other remarks rate no response.”
    Pay no attention, nybgrus. This translates as “I don’t have a rebuttal.”

  78. @nwtk2007, the comments made by nybgrus do warrant response. Your entire defense of your supposed magical healing abilities are based off of anecdotes, and nybgrus simply showed that other people have come to the same conclusions as you using complete quackery (as in bloodletting.) If science has shown us anything, its that our own observations can’t be trusted. You have broken the very first rule.

    —-

    Regarding chiropractors and their quackery, I just got Twitter-spammed by one of those automatically generated “newspapers” composed of links scraped from tweets. Here’s the link:

    http://paper.li/DrYolandaLoafer/1329515458

    Here is every article summarized:

    - “Is Your Desk Job Damaging Your Back?”, advocates the use of acupuncture and chiropractic to treat “desk back”:

    Chiropractors use hands-on manipulation of the spine to correct the misalignments responsible for the pain. At 212 Chiropractic, Dr. Goldberg often incorporates new, advanced therapies with these traditional spinal adjustments to bring patients optimal pain relief and well-being. Among these technologies are cold laser therapy, decompression therapy, and the Graston instrument. (Learn more about these services on the practice’s website at (removed so I dont get spam-moderated) and click here to read about Ion Detoxification Foot Baths)

    “We’re all about wellness,” adds Dr. Goldberg. “We have many patients who come to us regularly for preventive care. So often, people wait until their backs hurt before they take care of it. Just like you get your teeth cleaned regularly to avoid cavities and other problems, it’s important to take care of your back.”

    - “Benefits Of Chiropractic Services For Athletes”, claiming that they can improve the performance of athletes through routine adjustments of subluxations:

    For the last few decades, the value of chiropractic services has become increasingly clear as more patients suffer the results of spinal misalignments (subluxations). Adjusting the vertebral column has relieved tension and pain for millions of people. For some, their new-found comfort has allowed them to return to their jobs without the pain they once endured. For others, relief has meant they can enjoy the active lifestyles that were becoming more difficult due to back and neck problems. Still others are athletes. For them, chiropractic care has not only provided comfort, but also improved their athletic performance.

    Improving Athletic Performance Through Routine Adjustments

    Other sports are high-impact, and place a significant level of stress on the spine. For example, hockey, wrestling, and football can place as much stress on the body as an auto collision. This creates trauma on the spine, and can move vertebrae out of alignment. The misaligned vertebrae can interrupt nerve transmissions that branch out from between the vertebrae. The results of these subluxations also include a loss in range of motion, headaches, inflammation and soreness, and slower recovery following minor injuries. These and other side effects impair an athlete’s performance these conditions needs chiropractic services.

    A chiropractor can adjust vertebral misalignment’s, and restore the spinal column’s natural position. In doing so, he or she can minimize – and in many cases, eliminate – physical ailments due to the subluxations. Because high-contact sports produce frequent misalignment’s receiving regular chiropractic care can be a valuable tool for athletes.

    Even those who participate in low-contact sports, such as golf, tennis, and bowling, place great strain upon their bodies. For this reason, they, too, can benefit from regular spinal adjustments.

    - “Chiropractic boosts immunity”

    - “Chiropractic can help regain energy, find weight loss success, and feel better than ever”:

    Here are some basic solutions to overcoming minor discomfort that you tend to ignore or take meds for. Get some basic exercise in each day. Studies have shown that a 20 minute a day walk that causes you to perspire can have tremendous benefits. Look into getting some free or paid nutrition counseling. Everyone’s body is different and can require different things as well as lack certain vitamin absorption so it is very important to get to know your body this way.

    A simple alternative health care treatment can all help you regain energy, find weight loss success, and feel better than ever. When you move away from dependence on artificial drugs and expensive physical therapy and embrace a natural wellness path through good nutrition, regular exercise, and even chiropractic care, acupuncture, and massage, you may find that you feel better than you thought possible. It’s a good plan and one that’s much easier to accomplish than you might suspect.

    - Apparently chiropractors recognize that people are scared to visit them, due to fears of stupidity being contagious:

    You may feel timid about going to a different professional health services that you might not be fully aware of, such as chiropractic. Well, as much as I hate to admit, you aren’t the only one. This is why we believe in open communication with complete feedback starting from your first visit. As with every positive relationships, we emphasize on the importance of open dialogue. Our goal is not only to help you maximize your health but for you to explicitly understand the changes happening in your body.

    (You have to appreciate the irony of a chiropractor saying that he wants to not only maximize health, but understand the changes happening in the body… Because the CHIROPRACTOR obviously has no idea how the body works when they make all of their ridiculously false claims.)

    - Several videos advertising diet quackery and back pain quackery related to chiropractors

    - “Chiropractic manipulation of the spine may cause strokes and even death”, oops, this is how I got spammed. Dr. Ernst posted this story and I retweeted it. Gotta love these automatically generated quackery newspapers:

    Well over 500 cases have been documented where a patient has suffered a stroke after getting his or her neck manipulated and many have died subsequently. What seems to happen is that certain manipulations carried out by chiropractors – particularly those that involve forceful rotation of the neck to one side – may over-stretch an artery that runs along the spine. If that happens this vessel can dissect or disintegrate, resulting in a blockage of blood flow to the brain, ie. a stroke.

    Most chiropractors adamantly deny that their treatment is to blame. Strokes happen all the time, they rightly say. Lots of patients who suffer strokes haven’t been anywhere near a chiropractor. This is undeniably true, so the decisive question is this: do patients who consult chiropractors have more strokes than patients who do not?

    Sorry, I’m tiring out here.

    Other stories include “chiropractic care for degenerative disc disease” – LIE. “Chiropractic and your baby” – LIE.

    Etc.. RWK, this is why your profession is a joke. It does nothing but advertise lies to deceive patients. It’s scummy and pathetic.

  79. nybgrus says:

    In his demonstrations of how the PowerBalance wristbands don’t really work, Richard Saunders shows that if you ask a person to extend his arms and turn his upper torso as far as possible and then shortly afterwards ask him to do it again, he will always be able to turn a little farther on the second trial.

    Ah yes, forgot that one as well!

    Pay no attention, nybgrus. This translates as “I don’t have a rebuttal.”

    Thank you Dr. Hall. I was about to say the same thing myself.

    you really think the knuckle popping doesn’t effect the pianists playing other than as a “charm”? You ever heard of Andre Watts?

    No, I haven’t heard of him. What does that matter? And besides, my point actually wasn’t that knuckle cracking is a charm (though I certainly think it is), but moreso that the evidence for it and the way you presented your argument are exactly alike. I was pointing out the fallacy in your way of thinking about the topic and the absolute worthlessness of the “evidence” you presented to support it. I mean really, you cite a bunch of piano players doing something ergo it is evidence that your spinal manipulations do the same thing and by extension “work?” Pitiful.

  80. nybgrus says:

    @Berndt:

    Your article is a cohort of 79, with a multivariate analysis demonstrating the possibility of patient stratification.

    Cochrane, on the other hand, says differently:

    The review shows that while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low-back pain, there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain. Any demonstrated differences were small and were only seen in studies with a high risk of bias.

    Compared with:

    The results of this review demonstrate that SMT appears to be as effective as other common therapies prescribed for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy.

    So indeed, when you look at the totality of the evidence, it is much more strongly in favor of treatment of chronic, not acute, LBP.

  81. nwtk2007 says:

    Well I’m so sorry Harriet and skepticalhealth, but nybgrus’ quirky attempts to insult do not need a response. Nor does the lengthy discourse of a subluxation based chiro’s ad.

    And skepticalhealth, you say my, “defense of your supposed magical healing abilities” .. What magical healing abilities? Its just basic manipulation and ROM evaluations. I never said it was scientific in the sense that you describe, just experience which, even my daughter would tell you, does not a scientific study make. Therefore I simply state it as an observation, made by myself and others with whom I have worked. But I’m not saying its quantified or on the level of “your standard” of evidence.

    The evidence, scientific as in “up to your standards”, for manipulations effectiveness, is simply not out there. But the argument for it is there, none the less, in terms other than “your standard”. But that’s the nature of it all isn’t it? I’ve seen some of the greatest of the early molecular biologists argue to very nearly the point of blows to the chin over what one thought was scientific evidence and the other didn’t. These same individuals still differ in their opinions. Yet they continue with their work as they see fit as will I. Thus your attempts to insult do no harm.

    I guess, to summarize, I would just say that despite the lack of “your standard” of evidence, manipulation certainly appears to be effective and that perhaps someday it will be adequately shown. But I’ve stated on this blog before, the very nature of manipulation and all of the other confounding factors many here have cited, make it very difficult indeed.

  82. Harriet Hall says:

    @nwtk2007,

    So if I understand you correctly, you admit that what you are doing is not supported by scientific evidence but you prefer to be guided by your personal experience. Other than the fact that it is “your” experience, why would you think your beliefs are any closer to reality than the beliefs of medieval bloodletters?

    Instead of arguing and trying to defend your position, why not admit that it is indefensible on the grounds of logic, evidence, and critical thinking and that you simply choose to operate outside the realm of science and do it anyway? That yours is a belief-based opinion.

  83. jhawk says:

    @HH
    chiro as PCP? yes way!……. if said chiro attends med school and residency!! IMO, we are not trained for this role.

    “In essence, doesn’t their aspiration to become “family doctors” amount to an admission that chiropractic is not the panacea they once held it to be?” I would imagine the writers don’t hold this opinion as many other chiro’s don’t at the present time. I was never trained in this belief of panacea and can admit chiro is not a panacea or even remotely close quite easily.

    “Doesn’t their wish to branch out demonstrate the failure of their discipline?” I would say no, more of a hope of progression away from the panacea you mention.

    “This whole exercise struck me as silly, condescending, and embarrassing. If chiropractors were already qualified to be primary care providers, they wouldn’t need to be given this information. If they are not qualified, a simplistic tutorial like this isn’t enough to educate them.” I thought the same thing. I am not sure who the expected audience was. Maybe those who graduated many years ago as the full Hx and exam is definitely taught in at least the past ten years.

    “I wish just once a chiropractor would comment on one of our articles without changing the subject, introducing irrelevancies, or attacking mainstream medicine. I guess that’s too much to ask.” Did I win a prize?!

  84. Damn, Dr. Hall’s second paragraph (comment above mine^^^) is the absolute brutal truth about chiropractic. I like!

    /thread

  85. nybgrus says:

    The evidence, scientific as in “up to your standards”, for manipulations effectiveness, is simply not out there. But the argument for it is there, none the less, in terms other than “your standard”.

    So lets build an entire health practice, complete with colleges, licensure, and concrete claims of treatment for various indications, call ourselves “doctors,” advocate that we act as primary care physicians, have a whole pile of journals and articles… all based on absolutely nothing but “the argument” for the existence and validity of what we do.

    You know… that sounds a lot like acupuncture, homeopathy, reiki, and naturopathy. And those are all a total load of hooey. Good thing that nwtk2007 has “treated thousands of patients… and just based on experience… can tell [us], at least based on [his] experience, it is the most therapeutic thing [he does] in the treatment of injuries.” Otherwise I would be worried that chiropractic is a total load of hooey as well.

    I mean, clearly the evidence is there… just not to “our standards” but some “other standards.” And as we all know, standards are things that inherently vary depending on the circumstance and can obviously change depending on what we need to prove. As long as nwtk2007 has patients of a “different standard” that matches his standards, then everything will work out the same right? As long as everyone believes it works and is true, we don’t need no stinkin’ “standard” of evidence!

    Instead of arguing and trying to defend your position, why not admit that it is indefensible on the grounds of logic, evidence, and critical thinking and that you simply choose to operate outside the realm of science and do it anyway? That yours is a belief-based opinion.

    Because then how could he (they) justify working side-by-side with actual evidence based health practitioners, act as PCPs, and get more money? Somehow “my belief based magic with no evidence should totally work with your actual evidence based medicine” just doesn’t seem to jibe.

  86. jhawk says:

    @DavidRLogan

    “So the same is true, I think, of joint relations generally. My understanding of your “stiff back case” is this: loss of mobility at the hips means the CNS will “transfer” that mobility-and force-to the lumbar spine and its movers (for instance, erector spinae). When someone bends to pick up their socks, if the hips and ankles aren’t adequately (emphasis on adequately!) mobile, mobility will come from the lumbar spine, which is “asked” to handle more force than usual. Therefore stiffness occurs…an analogy: if you fuse two links on a chain, the next link will take on more force when the chain moves”

    I agree. protective tension. But I think we must ask first why is there loss of mobility at the hips? For example, hamstring hypertonicity due to protection of an irritated sciatic nerve. Can the hip range be increased to ease the excessive load on the Lx spine.

    “The best I could find is the notion of (paraphrasing) “spinal joint restriction”. Now it is true that, when the relation between bones is disturbed, the brain will tighten muscles to compensate (for instance tighten psoas and rectus femoris when we’re sitting).” to my knowledge yes.

    “But how would “adjustment” change this? The loss of mobility is neuromuscular, not because of lack of mobility at the joint capsule!” Not all loss of mobility is neromuscular IMO. You can have facet capsule (or almost any other soft tissue structure) adhesion/scar tissue limiting this range in the absence of protective tenison.

    “And in fact the lumbar spine in particular is designed for stability, not mobility.” I agree to a point but I think you need the perfect combo of both mobility and stability in the Lx spine. So to sum up, you could have a mobiltiy or a stability problem it depends on the patient.

  87. Harriet Hall says:

    @jhawk,
    “Did I win a prize?!” Yes, congratulations! Too bad you are the exception rather than the rule.
    Your prize comes with a homeopathic monetary award. I dipped the cash in water and poured the water into my toilet. It is now part of the global water cycle and you can access it by drinking water anywhere. :-)

  88. nybgrus says:

    Not all loss of mobility is neromuscular IMO.You can have facet capsule (or almost any other soft tissue structure) adhesion/scar tissue limiting this range in the absence of protective tenison.

    I absolutely agree.

    The problem is that there is no evidence and very little a priori likelihood that physical mobilization would offer anything more that short-term resolution of the problem. If the capsule is fibrosed to begin with, and you mobilize it, you will inevitably trigger a new or increased inflammatory response (i.e. the same mechanism by which the fibrosis originated). This will lead to either diminished return of mobility, return to baseline, or actually worsening of the mobility problem in the first place by more extensive fibrosis.

    Any tissue that is agrravated and fibrosed will re-fibrose (often to a greater extent) on re-aggravation. Take abdominal adhesions for example.

  89. nwtk2007 says:

    OK gees, then why is mobility prescribed after knee injury/surgury now versus immobility?

    Just say’in. You can throw a lot of hyperbolie at it but in the end, its mobilization that is the key. Its just too simple. Try to look ahead.

    Take a prize Harriet. For what ever it might be worth.

  90. @nwtk2007, one of the reasons early ambulation is recommended after major surgery such as a knee arthroplasty is to prevent the occurrence of a deep venous thrombosis. This actually involves science, medicine, and a solid understanding of physiology, so I won’t bother going into further detail with you. You can’t “manipulate” yourself out of a pulmonary embolism.

  91. jt says:

    God forbid someone would recommend that people be educated about alternatives to a system of thought which has produced the world’s sickest populations at the highest costs.

    The rates of obesity, diabetes, heart disease, and cancer continue to rise along with the many thousands of dollars spent on medications and their direct-to-consumer advertisements.

    The paradigm of health care is shifting away from easy acceptance of “side” effects and untested combinations of synthetic drugs towards a better understanding of the Hippocratic oath: “First, do no harm”.

    I implore you to ignore these words and continue on with your life, satisfied in your superiority. Continue to help people realize that the use of alternative medicine “should be discouraged”. You are doing God’s work.

    I wish you the very best. Here’s to hoping you don’t help to push the next Vioxx on a few thousand unsuspecting consumers. And if you do, here’s to hoping you can cover it up better than Merck did and make a couple of million in the process.

  92. nwtk2007 says:

    Nicely said.

  93. @jt, spoken like a true idiot.

  94. Chris says:

    And repeatedly. jt, get a new gig.

  95. This thread truly highlights what a scam chiropractic is. Not once could any of our resident chiropractors begin to justify their existence at all. At best, they could give a couple of “well, it’s possible that…. ” or “in the chance that this may be happening, then this may slightly help…. but I don’t have any evidence whatsoever…” They can’t even really show any evidence that they are somewhat effective at the one thing they may or may not be useful for (which is the one condition that we really don’t have *any* good treatment for.) …And yet they are the largest organized group of practicing quacks, insurance companies have been duped or sued into paying for this elaborate placebo, and they have 4 year education institutions that grant a completely useless doctorate in a field that has no proven efficacy.

    I’d happily give up everything for a job in the FTC/FDA that would allow me to prevent all of these different quacks from making all these false advertisements. I’d be on tour, from Keywest to Portland, knocking on the door of every one of these pricks.

  96. nybgrus says:

    OK gees, then why is mobility prescribed after knee injury/surgury now versus immobility?

    Well, besides the DVT issue, we are talking about the intentional and deliberately graded prevention of significant fibrosis and stricture. If you immobilize a joint, regardless of its condition, you will get contracture of the ligaments and tendons. If the joint has been replaced, you will also get some fibrosis.

    In all cases of orthopedics vis-a-vis mobility, there is a trade-off between the pros and cons of mobility. Your inane comment makes it sound like mobility is a slam dunk, 100% good and beneficial action to take. It is not and in actual discussions of actual medicine with actual doctors, we always acknowledge this. In fact I have lecture slides of the “pros and cons” of early mobility. It just so happens that in general, the pros of mobility outweigh the cons and that is why we prescribe it. In certain, more complicated cases, we amend the recommendation and delay mobility, have a slow progression of mobility, on have mobility of certain kinds, start with passive mobility, etc.

    Furthermore, the example in chiropractic is a capsular space already fibrosed and the remedy is to force it to mobility. That is fundamentally different from mobility shortly after knee injury/surgery. The fact that you can’t seem to grasp that further belies the poor training and understanding chiros have. You look at something actual medical doctors do, and ape it without understanding or even knowing the underlying principles involved. And then translate that to whatever other aspect you want to justify your own practice.

    Why not use the example of acetabular injury? Or complicated recons of hip joints? Those don’t warrant early mobility and in fact I just had a patient we did a total hip on that was prescribed bed rest!

    The problem with chiropractic is that there is no such consideration for nuance and difference in patient, presentation, and location. It is like all you can do is grunt, “Joint not moving, must make move. Joint move is better.”

    Oh wait. You did exactly that:

    Just say’in. You can throw a lot of hyperbolie at it but in the end, its mobilization that is the key. Its just too simple. Try to look ahead.

    Because yes, clearly, in all cases at all times, the more a joint can move, the better.

  97. nybgrus says:

    and yes, jt is a blithering idiot.

    Thanks, but I will continue to learn and practice the medicine that has doubled life spans in just two generations and procuded the healthiest (yes, you read that right) populations in the history of the world.

    You can feel free to go back in time and fear death from a minor cut, have grotesque deformity from fractures, die rapidly from diabetes, or even just go back 30 years and watch as children have a 90% mortality from leukemia which now has a 90% survival.

    I’d suggest you read a book and get an idea of just how incredibly better off we are than we have ever been.

    You sound like a spoiled teenager who complains because the new BMW you just got for your 16th birthday is the wrong color.

    Yeah, we’ve got more obesity and cancer than ever before. The former because of lifestyle that has nothing to do with medicine, but is certainly supported by the fact that we can keep you alive longer with our medical knowledge as an obese person! And the latter because cancer is a disease of old age and guess what? Thanks to actual medical science (i.e. not chiropractics, CAM, or other quackery) people are living longer than ever!. Forgive me, but I’ll trade some cancer risk for living twice as long as my great grandmother.

    The paradigm of health care is shifting away from easy acceptance of “side” effects and untested combinations of synthetic drugs towards a better understanding of the Hippocratic oath: “First, do no harm”.

    I’ll do you one better – how about “first actually do something?” You can’t have “effects” without “side effects.” The sad part is that chiropracty has very little “effects” but very distinct side effects. Like stroke. Like worsening of pain. Though I suppose you are helping with the obesity problem by lightening consumers of the contents of their wallet.

    Here’s to hoping you don’t help to push the next Vioxx on a few thousand unsuspecting consumers.

    Here’s to hoping you can develop a brain cell or two of critical thinking and understand the concept of small effect sizes and the laws of large numbers. I won’t hold my breath though.

    Nicely said.

    Only an idiot would think so.

    I can understand why SkepticalHealth has such venom… when such blitheringly stupid comments are made ad nauseum it is difficult not to. Especially when, as SH pointed out quite nicely, not a single one of you can even begin to offer justification for the existence of your “profession” beyond “I believe it to be true, and one day, some day, there will be evidence to prove I am right. It is just sooooo complicated to test, and nobody really understands it, but I believe it, I see it, and therefore we should have an entire college system devoted to it.” Tooth fairy science. Bah.

    Replace the words “chiropractic college” with “megachurch,” “chiropractics” with “doctrine”, “subluxations” with “God,” and “fee for adjustment” with “tithe” and there’d be no fundamental difference. The evidence is the same, the rhetoric is the same, and the utility is the same.

  98. DavidRLogan says:

    Thanks for the comments, everyone. Very interesting. And despite all the flaming I always learn from the MD’s on here…you too Skeptical Health thanks for all the good info.

  99. jhawk says:

    @nybgrus

    “The problem is that there is no evidence and very little a priori likelihood that physical mobilization would offer anything more that short-term resolution of the problem. If the capsule is fibrosed to begin with, and you mobilize it, you will inevitably trigger a new or increased inflammatory response (i.e. the same mechanism by which the fibrosis originated). This will lead to either diminished return of mobility, return to baseline, or actually worsening of the mobility problem in the first place by more extensive fibrosis.
    Any tissue that is agrravated and fibrosed will re-fibrose (often to a greater extent) on re-aggravation. Take abdominal adhesions for example.”

    Potentially, if the scar tissue is laid down due to an acute inflammatory process such as your abdominal adhesion example. I don’t think this is the case in many instances though. Scar tissue can be laid down due to a chronic degenerative process without inflammation. For example, the push to move to the terminology of tendonosis instead of tendinitis. When laid down in this degenerative manner it makes sense, IMO, to apply physical mobilization to increase range and reduce scar tissue.

  100. jhawk says:

    @HH

    Will this monetary award pass through my portable mercola-toxin elimanation-life extension water filter?! I am afraid not to use it and it was extremely pricey but I may be able to pay it off with this award if it will pass through!!!

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