Nov 16 2011
Chiropractic Neurology
Chiropractic is a diverse collection of beliefs and practices occurring under a broad regulatory label. The differences among various chiropractics are so stark that it is difficult to make general statements about chiropractic practice. At one end of the spectrum, however, are so-called “straight” chiropractors who adhere to the original philosophy of D.D. Palmer – that a vital force they call innate intelligence is response for health, and blockages in the flow of this magical force through the nerves are what cause illness. Such chiropractors believe they can influence non-neuromuscular conditions by restoring the flow of innate blocked by mysterious “subluxations” in the spine.
From chiropractors.org we have this definition of “straight” chiropractors:
Because straight chiropractors believe that nearly all diseases are caused by issues with the spine, they don’t believe they need any diagnostic tools. Traditional testing done by medical doctors and hospitals is not even considered by a straight chiropractor as being necessary. Diagnosis is done by finding the subluxations in the spine so that those can be corrected.
This particular version of chiropractic (by some estimates about a third of chiropractors follow this philosophy) is pure pseudoscience. It is, as indicated by the quote above, hostile to science-based medicine. After a century of such belief there isn’t a bit of evidence to support the notion of innate intelligence, chiropractic subluxations, or health benefits from this approach.
Some straight chiropractors even “specialize” – one specialty, chiropractic neurology, has been getting some press because hockey star Sidney Crosby has been going to a chiropractic neurologist, Ted Carrick, to treat his concussion. The main idea behind chiropractic neurology is the same as for straight chiropractic in general, just applied to neurological disorders.
Carrick claims that he can treat a variety of brain disorders with targeted manipulation and elaborate exercises and routines. In a PBS interview he said:
Well, we’re finding every day that more and more things that we didn’t think were associated with chiropractic treatment can be affected very nicely. There are testimonials from people who have had their eyesight and hearing back, and people waking up from comas.
Waking a patient from a coma is perhaps the ultimate rehabilitative claim in neurology. You will notice, of course, that Carrick refers to only “testimonials”. The reason for that is because there are no published articles establishing such bold claims. Chiropractic neurology does not appear to be based on any body of research, or any accumulated scientific knowledge. I am not aware of any research that establishes their core claims. A search on PubMed for “Carrick T” yielded nothing, and searching on “chiropractic neurology” yielded mostly studies about neurological complications from chiropractic treatment. There was one letter from the President of the International Academy of Chiropractic Neurology.
I followed that link to the IACN website, but found no references or links to any published studies establishing the scientific basis of chiropractic neurology. There was no science at all. I also noted that the IACN mission statement does not make any mention of promoting scientific research or science-based standards. Here it is:
The mission of the IACN is to provide an outlet for expression and communication of professional opinions for the benefit and enhancement of the neurological sciences as they relate to the chiropractic profession for the best service to humankind. Further, the IACN promotes the proper use of principles and techniques in the field of chiropractic neurology and support those principles, policies and practices that seek the attainment of the highest order of excellence in neurologic skills directed at patient care by doctors of chiropractic.
The IACN serves to promote the highest standards of moral and ethical conduct amongst chiropractic neurologists.
The wording is interesting – they talk about opinions, principles, and practices. They refer to the “enhancement of the neurological sciences” but it is not clear what that means.
Chiropractic neurology appears to me to be the very definition of pseudoscience – it has all the trappings of a legitimate profession, with a complex set of beliefs and practices, but there is no underlying scientific basis for any of it.
It should be noted that neurological symptoms are often especially vulnerable to placebo effects. Many symptoms, like vertigo, or “fogginess” are highly subjective. There is also a well-established “cheerleader” effect – if you take anyone with chronic neurological symptoms (such as chronic deficits from a stroke) and then give them any intervention, they will perform better. Just getting patients off the couch and moving will have some effect. Careful research is necessary to separate the specific effects of an intervention from the non-specific effects of motivation, mood, activity, and also just time. The brain can heal itself to some degree, and after an injury there can be an improvement for even years afterward.
Some symptoms are also susceptible to conditioning. Vertigo is perhaps the best example of this. At present the most effective treatment for chronic vertigo (a subjective sense of movement, such as spinning) is vestibular therapy – physical therapy designed to condition the patient to the symptoms, to diminish them over time. It is therefore possible that some chiropractic neurology interventions are simply providing this known mechanism. For example, here is a description of Carrick’s treatment of Hockey player, Crosby:
Carrick then signals to restart the gyroscope—with one difference. This time Crosby will be turned upside-down while he is also spun around. He hasn’t experienced this dual action yet. The door clangs shut. Above it, a stack of red, yellow and green lights shines while 10 high-pitched beeps signal the gyroscope is about to start. Ding! Ding! Ding! Ding! Ding! Ding! Ding! Ding! Ding! Ding!
This is a very dramatic treatment, sure to impress the naive. It follows a common philosophy in dubious neurological treatments – the notion that you can “rebuild the brain” by stimulating it. While it is true that activity and simulation are better than no activity and stimulation, it does not follow that simply increasing stimulation will increase the brain’s plasticity or recovery (a simplistic more-is-better philosophy). That basic notion was researched and discarded decades ago, for example with specific reference to psychomotor patterning treatments.
Chiropractic neurology is an excellent example of exactly why we need science-based practices. Without a grounding in objective evidence there does not appear to be any limit to the degree that beliefs systems can be led astray. Any treatment can deceptively seem to work, and humans are very good at backfilling in justifications and explanations for phenomena that do not even exist. Left to our own devices we will tend to develop elaborate, but entirely fictitious, belief systems.
We figured our centuries ago, however, that systematic methods of controlling variables, controlling for bias, and rigorous statistical analysis can compensate for such human foibles. Until chiropractic neurology (and similar practices) avail themselves of such methods there is no reason to take their claims seriously.
247 Responses to “Chiropractic Neurology”
Great article as usual, Dr. Novella.
One thing I’m curious about. How do these “doctors” actually “specialize” in these sorts of fields? I always see them claiming to be “Chiropractic Pediatricians” or “Chiropractic Neurologists”. Is there any sort of regulatory body for these groups (laughable as though that may seem) or do a bunch of them just get together and decide to hang up a shingle and make a specialty? I’ve even seen “Chiropractic Veterinarians” claiming to adjust horses, dogs, and other animals! As far as I’m aware, doing so is illegal in my home state of Ohio, and several other states as well.
Yesterday, I passed an office that had a shingle out for a “chiropractic neurologist”. Very timely. I wondered what the angle was, other than “advanced woo.”
(I was actually unaware of what happened to Sidney Crosby, despite living in Pennsylvania. Clearly, I am under a rock.)
I’ve often wondered about the angle as well. If the mystical “subluxation” is the cause of all disease, why do you need numerous specialties?
Thank you for this, Steve. I had a chance to read the Macleans issue with the Crosby story in it. My heart just dropped. Sid is arguably the most likable player in the game, a real national treasure, and I was devastated to learn that he’d pinned his hopes for recovery to such rank nonsense — and horrified to see Canada’s most popular news magazine giving the situation a stamp of approval. (Not that I’ve taken Maclean’s seriously in recent years — as news magazines go, the respect it gets is far out of proportion to the quality of its content.)
This is the same “science” under which Robert Melillo has launched his Brain Balance chain of “fraudchises”. He is a student of Carrick’s and claims all sorts of credential which don’t exist. I am all for the pursuit of alternate views and ideas, however, at some point we need to call it a day and recognize what can be supported by science and what can not.
A treatment which seems to have positive effects with no mechanism of action should be rigorously deconstructed to better understand it and to permit the prolieferation of its positive effects to other possible patients. To claim efficacy based upon false premises, irreproducible results is simply criminal.
Specialties, you ask why, Chris Repetsky? Amongst other things, maybe so as to snooker NASA out of some advanced subluxation technology and snag an endorsement (sort of) while they’re at it is why,
http://www.spaceref.com/news/viewpr.html?pid=18731
A thirst for legitimacy runs deep in every chiropractor’s heart is my guess. Chiropractic Neurology, Chiropractic Astronautics, why the hell not? Eye hath not seen, nor ear heard, neither have entered into the heart of man, the things that Chiropractic will soon do — for duty and humanity.
How horrid. I wonder how much lobbying money was tossed at the Space Foundation to achieve that. Why else would someone like NASA agree to certify something with absolutely zilch in the way of proven clinical value? Maybe my youth has made me too optimistic…
I often find myself in debates with my peers here at med school. Sadly, I’m the odd man out in terms of woo and pseudoscience. I always advocate for 100% informed consent and the removal of non-scientific healthcare modalities from treatment regimens, yet I meet with opposition when voicing these opinions. It may be a lonely post to occupy, but I’m sticking to my guns, popular opinion or not!
The mission statement is, indeed, quite interesting. Rather wordy, though. Let me offer some editorial help:
“The mission of the IACN is to be a propaganda mill for the infiltration of a legitimate medical specialty by quacks. IACN will promote its ideology at the expense of new patients drawn in by pseudoscientific claims. IACN will also make sure everyone in this new fake specialty toes the line and doesn’t give the game up.”
There. That expresses the meaning and intent without all the high falutin’ words.
It’s kind of hard to follow how a subluxation in the spine can be the cause of a concussion when we already know it was caused by a blow to the head, no? I mean, this is beyond implausible, it’s tautologically false.
The mechanism by which the blow to the head causes the concussion is by the force of the blow transferring down to the neck and producing a subluxation there. Any swelling is then a consequence of the subluxation.
Isn’t it obvious?
*remove tongue from cheek*
@ Scott: Indeed it is obvious!
I recall being given a good lesson in chiropractic cause and effect when I was in grade school, via a song: “The head bone connected to the neck bone….” So of course the force applied to the head transfers down via bone connection to the neck and then to the back producing a subluxation. And equally of course, when the back is adjusted, a healing force is transferred “back” up the same pathway and takes care of the concussion. What could be simpler? And you can verify it all by reading testimonials.
I don’t know why chiros feel a need for this whole neurology angle. Their methods obviate the need for any other kind of medicine, especially as they fix everything from asthma to zygomycosis.
We figured out centuries ago, however, that systematic methods of controlling variables, controlling for bias, and rigorous statistical analysis can compensate for such human foibles.
Agreed that the scientific claims are bunkum, even if patients can be helped a little by the non-specific influences you describe.
However, I disagree with the “centuries ago” in the above. It is somewhat humbling to note how very recently mainstream medical teaching was dominated by the opinions of ancient philosophers and, more latterly, the opinions of the esteemed professors of one’s particular country or city.
Possibly the first ever mathematical comparison of outcomes (not a RCT) was performed by Pierre Charles Alexandre Louis on the effects of blood-letting on fevers. That was not published until 1835, but bloodletting continued, I believe, until the beginning of the last century.
The first ever randomized controlled trial was of a serum treatment for diphtheria performed in 1898 (Fibiger J. Om Serumbehandling af Difteri. Hospitalstidende 1898; 6: 309-325, 337-50.)
“The British Medical Research Council’s trial of streptomycin for pulmonary tuberculosis, published in 1948, has been proposed as the first randomised trial in which random numbers were used and allocation of patients was effectively concealed.” (from “The controlled clinical trial turns 100 years: Fibiger’s trial of serum treatment of diphtheria”. Asbjørn Hróbjartsson, PhD student, Peter C Gøtzsche, director, Christian Gluud, chief physician.© British Medical Journal 1998).
I suggest that despite occasional more sophisticated studies the medical literature was dominated by personal case series and individual case presentations until shortly after the second world war. I don’t know for sure, but I suspect that penicillin, radiotherapy for cancer and the early chemotherapies and many other commonly drugs entered wide use without the kind of testing we would consider necessary today. (Of course, they did have clear and consistent objective effects in patients able to serve as their own control).
What’s more, the technology of the clinical trial and how we interpret them is still evolving.
But Dr. Novella, you forgot to mention how much post-graduate (that is to say, post DC) training the “chiropractic neurologists” have.
This (or a variation) appears on the blogs and or webpages
300 hours! Imagine that! Isn’t that a big number! Well, except that I invested twice that many hours commuting to work in a single year.
Emily Willingham recently calculated the number of hours of study to complete a PhD in the sciences. Her estimate? 15,000.
Going back to the “chiropractic neurolologists” — how do they get those “300 hours”? Well, you can do almost all of it online.
Sunday classes? If you elect to do your training live, classes are held Friday, Saturday and Sunday at various hotels convenient to airports and other impressive academic venues.
And yet the “chiropractic neurologists” claim their training and experience are equal to MDs and DOs:
I found that wording on 27 chiropractic websites. It also goes along with
Boy, gaining an “intimate knowledge of clinical and physiological neurology” all in 300 hours!
To me, the worst part of “chiropractic neurology” is (as Citizen Deux mentioned) is that they prey on desperate parents of children with autism, ADHD, and other issues. It’s worse than despicable.
I first ran across Dr. Carrick (his PhD is in Education) after I saw a chiropractor’s ad for “brain mapping” in my local newspaper and I investigated and wrote about the appallingly poor research behind it. http://www.chirobase.org/06DD/blindspot.html. Carrick retaliated with a virulent ad hominem attack on me http://www.blindspotmapping.com/hariett_hall_syndrome.html that misrepresented what I had written and failed to respond to my specific criticisms of his work. He accused me of deception and fraud and included an indirect threat of legal action. He claimed I had attempted to “tarnish the credibility of an entire profession by inference.” He called me “confused and perhaps psychotic.” He says I did not discuss validity vs. reproducibility with him. (I did, and I have the e-mails to prove it.) His misunderstanding of validity was also pointed out by other chiropractors in letters to the editor following publication of his study. He demonstrates that he still does not understand what validity means. IMHO he is not a good scientist and is not a nice human being.
So if a regular chiropractor strokes out a patient does he refer to a chiropractic neurologist?
There are also Chiropracty Internists (http://www.councildid.com/index2.html) and radiologists (www.dabcr.com). Kind of hilarious.
Edzard Ernst has taken up referring to chiropractic as “Marketing Based Medicine”.
This is particularly appropriate to the chiropractors claiming neurologic expertise.
pmoran – I agree that significant adoption of scientific methods into the practice of medicine is as recent as you suggest. I was referring more broadly to scientific methodology.
Dr Novella,
What is your opinion of Dr.Carrick’s rebuke of Harriet Hall and the neurophysiology contained therein ?
http://www.blindspotmapping.com/hariett_hall_syndrome.html
rwk, probably the same way Dr. Hall thinks about it, as she mentioned above: “He called me “confused and perhaps psychotic.” He says I did not discuss validity vs. reproducibility with him. (I did, and I have the e-mails to prove it.)”
Chris,
why not read it yourself?
Yes, I read Dr. Hall’s comment, didn’t you?
And I don’t have access to her emails.
Dr Hall should now prove she was unfairly beaten up in that arcticle.
@ Dr. Novella
There are several factual errors in your post that I would like to address. These factual errors keep coming up at SBM, especially when chiropractic medicine is the topic.
First, the SBM site and authors claim to providing evidence to support science, yet your research was poorly done, not factual, incomplete, misleading with a false, invalid conclusion.
Error 1
“This particular version of chiropractic [straight] (by some estimates about a third of chiropractors follow this philosophy)
You cite chiropractic.org, a website. Why isn’t didn’t you cite some peer-reviewed literature? A google search is lazy, Dr. Novella and this figure is inaccurate (and overestimated). Please see Chiropractic Technique Principles and Procedures (3rd ed) or Principles and Practice of Chiropractic (Haldeman et al).
You also state incorrectly “Because straight chiropractors believe that nearly all diseases are caused by issues with the spine”.
Truth:
“Although the profession today emphasizes the important relationship between health and the structure and function of the neuromusculoskeletal system, it does not promote a monocausal concept of subluxation induced disease” (Chiropractic Technique: Principles and Procedures, 3rd ed, 2011).
This nonsense that contemporary DCs “believe” that subluxation causes organic disease is demonstrably false. Repeating this falsehood again and again does not make it true.
Error 2:
Dr. Carrick, DC, PhD is not a straight chiropractor, he is a CMCC grad class of 1979. He happens to work at Life University. The article you might be referring to, in last week Macleans, demonstrates that Sidney’s Crosby’s treatment plan was multi-modal (thus not only manipulative therapy which is what “straight” chiropractic is founded on (i.e. only manipulation not “mixed” with other forms of therapy). The treatment plan included using the gyrostim, opticokinetic tracking exercises, music therapy, proprioceptive exercises and strength and conditioning exercises. This is not straight chiropractic Dr. Novella. I have to ask, to you even read the article in Macleans?
Error 3
” A search on PubMed for “Carrick T” yielded nothing.”
Another classic example of poor research and laziness on behalf of a so called “expert” in science-based medicine. Dr. Novella, Dr. Carrick’s name is not Ted. It’s Frederick. Frederick Carrick. A bit of research into the matter before your critique would have produced a different result when correctly inserting Dr. Carrick’s name in a PubMed search.
“Carrick FR”[Author]
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Carrick%20FR%22%5BAuthor%5D
This has got to be the most incredibly ignorant thing I have seen yet in the latest chiropractic bashes that occur at SBM. You did not conduct a proper research. The methodology of you post is flawed and invalid. Also, Dr. Carrick is a clinician and not a researcher exclusively. His latest research involves the use of the Gyrostim and its effects on balance. Do you think that the Mayo Clinic and US Air Force, the only other 2 locations in the world that have this technology are interested in placebo effects, Dr. Novella? Please.
Futhermore, Dr Carrick has a 3 year waiting list, all patients who have “failed” at the hands of “medical specialists”. Do you really think that any doctor, regardless of field of study, would have a 3 year waiting list if his outcomes weren’t largely successful? Can’t you see how you are grasping at straws to make your argument? More errors:
Error 4
“Chiropractic neurology does not appear to be based on any body of research, or any accumulated scientific knowledge. ”
Please see aforementioned PubMed results for a brief introduction to some of the concepts behind chiropractic neurology. For a more in depth look into precisely what is chiropractic also known as “functional” neurology, please refer and buy the textbook “Functional Neurology for Practitioners of Manual Therapy” by Dr. Randy W. Beck, DC, PhD.
http://www.amazon.ca/Functional-Neurology-Practitioners-Manual-Therapy/dp/0443102201
I have this text. Feel free to buy it and truly investigate chiropractic neurology. I have the text myself and we could debate “contentious” points. But it’s fully referenced and cites peer-reviewed literature.
Error 5
“It should be noted that neurological symptoms are often especially vulnerable to placebo effects. Many symptoms, like vertigo, or “fogginess” are highly subjective.”
Sidney Crosby, the best hockey player in the world since Wayne Gretzky had 8 months of the “gold standard” of treatment with Dr. Michael Collins. 8 months of treatment with the best neurologists, physicians, neurocognitive specialists etc.. all using their best clinical experience and brain-based research into vestibular rehabilitation. None of them could get Sidney Crosby symptom free. Your argument doesn’t hold water. He would be highly susceptible to their “cheerleader effect”. Especially because they were considered “the best”.
So, your argument rests on the premise that one of the best athletes in generation, aged 24, who underwent the “gold standard” in vestibular rehabilitation, was somehow placeboed by a chiropractor? It’s the world’s best case study in my opinion and as a DC, this is going to be investigated and researched to the hilt because Dr. Carrick may have found an innovative way of diagnosing and treating concussions. There is nothing to hide in this case. This is being investigated already. I’ll be the first guy to post results of the study here, regardless of the results. From what I have heard from academics (it’s not only DC/PhDs who are researching this area) who are working alongside Dr. Carrick is that the initial data is favourable and it’s been replicated.
Then you continue:
“Chiropractic neurology appears to me to be the very definition of pseudoscience – it has all the trappings of a legitimate profession, with a complex set of beliefs and practices, but there is no underlying scientific basis for any of it.”
You say this despite not a) knowing anything regarding the subject except what you’ve “heard” from the outside without any real or legitimate investigation into the matter. Proof of this is your PubMed search which you didn’t even know Dr. Carrick’s name is Frederick and not his colloquial name “Ted”.
Then the grand (incorect, infactual) conclusion
” Without a grounding in objective evidence there does not appear to be any limit to the degree that beliefs systems can be led astray. Any treatment can deceptively seem to work, and humans are very good at backfilling in justifications and explanations for phenomena that do not even exist. Left to our own devices we will tend to develop elaborate, but entirely fictitious, belief systems.”
Beliefs systems Steven. This post is about your belief system that chiropractic is illegitimate. You don’t even both to research ahead of time the content of your post. You simply could have written an inquisitive commentary, but instead you but your own bias’ and “belief system” into it. Read the research, and if you really want to learn about chiropractic neurology, then read the textbook. It’s there for everyone to see. Then, maybe go observe a treatment and get educated rather than making wild guesses and labelling some pseudoscience rather truly investigating and researching the matter.
Albert Einsten wrote “Condemnation without investigation is the highest form of ignorance”. You sir, have just proven this to the highest order. I await your reply.
NMS-DC
NMS-DC, that was tl;dr.
Chiros inventing their own neurology without studying neurology as practiced by actual neurologists –total scam.
Everyone in this scam suffers, including the poor young people deluded into thinking they’re becoming “functional neurologists.”
@GlaDOS
Sorry that my post does not meet your attention span requiring less than 2 minutes of reading.
It’s not chiropractors “inventing” neurology, it’s chiropractors interpreting neurosciences in a functional way. We (DC and MD) are both using the same pool of information, we’re just applying it differently. But, what do you really care, you aren’t interested in truly learning about chiropractic neurolog; you’re content being a lemming and not critically thinking for yourself.
Regards,
NMS-DC
NMS-DC, your references are freakin’ hilarious:
http://www.ncbi.nlm.nih.gov/pubmed/17604555
J Altern Complement Med. 2007 Jun;13(5):519-26.
Posturographic changes associated with music listening.
Carrick FR, Oggero E, Pagnacco G.
Source
Carrick Institute for Clinical Ergonomics Rehabilitation and Applied Neuroscience, Cape Canaveral, FL, USA. drfrcarrick@gmail.com
Abstract
…
DESIGN:
Computer dynamic posturography (CDP) provided stability scores in 266 subjects without a history of falls or vertigo. Subjects were randomized into several different music listening groups and one control group. The music listening groups were given a daily specific music listening task and CDP was obtained 10 minutes, 1 week, and 1 month after the subject’s treatment in a blinded fashion.
RESULTS:
Tests of postural stability have shown that 73% of 266 subjects without neurologic signs or symptoms were found to have balance abnormalities [lolwut?] associated with an increased probability of falling. We have demonstrated positive changes in stability scores in these subjects who underwent a variety of music listening tasks, with the music of Nolwenn Leroy found to be significantly superior to other music tested. [L O L W H A T ?]
Also, Int J Adolesc Med Health has an eigenFactor rating equivalent to “nobody cares.”
NMS-DC
DC’s may be using the same pool of information, but don’t you actually have to get in the pool, not just dip your toes in to be experienced enough to swim? With only 300 hours … let me repeat that … 300 hours of training, it is obvious that chiropractic neurologist are trying to swim without actually getting in the pool.
Harriet Hall wrote: “I first ran across Dr. Carrick (his PhD is in Education)….”
Ahhh. If there is one doctoral degree that is used outside its scope to generate really crazy things, it’s this one. It seems to be the default degree for someone wanting a PhD after their name yet having just enough integrity to avoid diploma mills. However in Carrick’s case, his degree is apparently a distance-learning-online thing from a “respected virtual institution” called Walden University, a place with a non-competitive admissions setup. (You pay, you can go.)
Add all that to a DC degree and I don’t think one can claim to be a neurologist of any kind.
Oh the ol’ “interpreting” gambit –i.e., “You and I are seeing the same dots. We just connect them differently.”
Guess you didn’t follow the whole biology verses intelligent design debates.
What you are calling an interpretation might be considered a proto-hypothesis. It’s not worth much until you formulate your explanatory model in a manner that
a) differentiates it from the current scientific consensus
b) can be subjected to some test that might prove it false.
So good luck with that.
@lizditz: Thank you for that wonderful link to the “chiropractice neurology diplomate courses” online. Great stuff. I especially liked their summary on all the wonderful things that happen when you take their courses and get your largely distance-based degree:
The first is vague but with the all-caps seems an invitation to feeling good. The second is about making more money. Third, social status. Fourth, fifth, and sixth, status and money. Seventh, something right out of “The Power of Positive Thinking” with hints of multi-level marketing. And the eighth, a feverish, status-protecting sort of thing with early Protestant-like use of overcapitalization of nouns (in deference to anything that might be connected to god.)
That is truly quite a list of reasons to add another layer of sCAM to your portfolio.
One of Carrick’s 6 studies listed by NMS-DC is http://www.ncbi.nlm.nih.gov/pubmed/9345682 I analyzed that study at length in the Scientific Review of Alternative Medicine. There is so much wrong with it that it serves as a good example of bad science and poor reasoning.
“Physiological cortical maps were used as an integer of brain activity before and after manipulation of the cervical spine” What does this mean? Translation: a paper-and-pencil map of the blind spots where the optic nerve enters the retina was proclaimed to be a physiological map of cortical function! The size of the blind spot was interpreted as an “integer”of brain activity! This is not even understandable scientific terminology, and it puts the lie to NMS-DC’s claim that “We (DC and MD) are both using the same pool of information.” The pool of information in medical science is that the size of the blind spot is an anatomical feature and that it does not vary significantly between the two eyes. Carrick found that everyone had a blind spot on one side that averaged half again as large as that on the other side and he didn’t even appear to notice that his observation contradicted all previous observations and even the conclusions of one of the references he cited in support of his hypothesis!
I may decide to post the entire text of my analysis of that article: it’s illuminating and amusing. It demonstrates that Dr. Novella’s poor opinion of the concept of chiropractic neurology is spot on.
I’m just about to finish my Neurology clerkship; shelf tomorrow. When all is said and done I’ll have ~300hrs of in hospital time this month actually taking care of sick patients. This is opposed to watching some video for a few weekends in a Motel 8 banquet hall.
While rigorous, I’m really only scratching the surface of neurology here, really only learning enough to realize I don’t know jack about it and if someone comes to my practice someday with MS, instead of trying to mess with it myself, I’ll be involving a real (MD/DO) neurologist who probably has 20k hours of formal training in it so they can be taken care of appropriately.
It is actually incredibly ridiculous that chiropractors, who have probably never actually taken care of a person with MS or parkinson’s or insert-stroke-type-here are trying to pass themselves off as neurologists. I mean, if all it really takes to learn this stuff is some shoddy coursework learned part-time over a few weekends, then I ought to be able to call myself a Neurologist, a Family Practice doc and an honest-to-god internist (but I get bonus points here because that rotation was 3 months long). Of course I wouldn’t do this as I’ve got the humility to know that I shouldn’t be pretending to be something I’m not.
“There are several factual errors in your post that I would like to address. These factual errors keep coming up at SBM, especially when chiropractic medicine is the topic.”
First things first, Chiropractic is not medicine. Medicine is treatment modalities proven to work by science, not testimonials.
“This nonsense that contemporary DCs “believe” that subluxation causes organic disease is demonstrably false.”
Then why does it abound in their literature?
“Although the profession today emphasizes the important relationship between health and the structure and function of the neuromusculoskeletal system, it does not promote a monocausal concept of subluxation induced disease” (Chiropractic Technique: Principles and Procedures, 3rd ed, 2011).”
Then what, may I ask, makes Chiropractors unique at all? If they don’t believe their adjustments are fixing nerve interference, then they are just performing generic manipulations already practiced by physical therapists, a profession that is already established in science and not anecdotes.
“His latest research involves the use of the Gyrostim and its effects on balance. Do you think that the Mayo Clinic and US Air Force, the only other 2 locations in the world that have this technology are interested in placebo effects, Dr. Novella? Please.”
Hasn’t really stopped them before? The Mayo Clinic has an entire department dedicated to “alternative medicine”, utilizing numerous treatments with absolutely zilch in the way of demonstrated scientific benefit. They have patient testimonials, and nothing more.
“Futhermore, Dr Carrick has a 3 year waiting list, all patients who have “failed” at the hands of “medical specialists”. Do you really think that any doctor, regardless of field of study, would have a 3 year waiting list if his outcomes weren’t largely successful? Can’t you see how you are grasping at straws to make your argument?”
Hulda Clark also had a ton of patients clamoring to get to her. Doesn’t mean a thing.
“http://www.amazon.ca/Functional-Neurology-Practitioners-Manual-Therapy/dp/0443102201
I have this text. Feel free to buy it and truly investigate chiropractic neurology. I have the text myself and we could debate “contentious” points. But it’s fully referenced and cites peer-reviewed literature.”
Who exactly does this peer review? Real scientists, or more DCs trying to justify a 300 course hour specialty?
“Sidney Crosby, the best hockey player in the world since Wayne Gretzky had 8 months of the “gold standard” of treatment with Dr. Michael Collins. 8 months of treatment with the best neurologists, physicians, neurocognitive specialists etc.. all using their best clinical experience and brain-based research into vestibular rehabilitation. None of them could get Sidney Crosby symptom free. Your argument doesn’t hold water. He would be highly susceptible to their “cheerleader effect”. Especially because they were considered “the best”.
So, your argument rests on the premise that one of the best athletes in generation, aged 24, who underwent the “gold standard” in vestibular rehabilitation, was somehow placeboed by a chiropractor? It’s the world’s best case study in my opinion and as a DC, this is going to be investigated and researched to the hilt because Dr. Carrick may have found an innovative way of diagnosing and treating concussions. There is nothing to hide in this case. This is being investigated already. I’ll be the first guy to post results of the study here, regardless of the results. From what I have heard from academics (it’s not only DC/PhDs who are researching this area) who are working alongside Dr. Carrick is that the initial data is favourable and it’s been replicated.”
Please provide sources to the statements of these academics concerning Carrick’s research and outcomes.
“Albert Einsten wrote “Condemnation without investigation is the highest form of ignorance”. You sir, have just proven this to the highest order. I await your reply.”
Einstein also said “Most people say that is it is the intellect which makes a great scientist. They are wrong: it is character. “
NMS-DC
“Although the profession today emphasizes the important relationship between health and the structure and function of the neuromusculoskeletal system, it does not promote a monocausal concept of subluxation induced disease” (Chiropractic Technique: Principles and Procedures, 3rd ed, 2011).
This nonsense that contemporary DCs “believe” that subluxation causes organic disease is demonstrably false. Repeating this falsehood again and again does not make it true.
Error 2:
Dr. Carrick, DC, PhD is not a straight chiropractor, he is a CMCC grad class of 1979. He happens to work at Life University. The article you might be referring to, in last week Macleans, demonstrates that Sidney’s Crosby’s treatment plan was multi-modal (thus not only manipulative therapy which is what “straight” chiropractic is founded on (i.e. only manipulation not “mixed” with other forms of therapy). The treatment plan included using the gyrostim, opticokinetic tracking exercises, music therapy, proprioceptive exercises and strength and conditioning exercises. This is not straight chiropractic Dr. Novella.”
NMS-DC didn’t add the “nutritional service” that most all our local chiropractors seem to be advertising. I suspect that today’s chiropractors have found increased competition from the acupuncturists, naturopaths and nutritionists and have needed to diversify the “treatments” that they offer.
The title of chiropractic neurologist seems to me custom made to attract parents of children with real and imagined learning disabilities, developmental delays, behavior problems…a growing market in the times of increased parental focus on such things.
Our son has an annual consult with a pediatric neurologist who is on his crania-facial team. Thus far, she has always been happy with his progress and seen no reason to believe that any delays that he has are due to neurological differences rather than his cleft/hearing differences. She has seen no need for additional tests or treatments. Which is great, because he already have his plate full with needed tests, treatments, therapies.
From the little I have heard about the local chiropractic neurologist, I have very little faith that I would get the same opinion from him.
@micheleinmichigan
You bring to mind another good point I’ve often wonder. Does your average joe ever walk into a Chiro office and get told “Nope, you’re perfectly healthy! No adjustment or other therapies needed!”
Though it’s only my opinion, somehow, I doubt it.
# Harriet Hallon 17 Nov 2011 at 2:54 am
Posts:
“One of Carrick’s 6 studies listed by NMS-DC is http://www.ncbi.nlm.nih.gov/pubmed/9345682 I analyzed that study at length in the Scientific Review of Alternative Medicine. There is so much wrong with it that it serves as a good example of bad science and poor reasoning.
“Physiological cortical maps were used as an integer of brain activity……….snip….”"
1.- “Scientific Review of Alternative Medicine”? – I cannot find this among the indexed journals at pubmed. Please provide a pubmed link.
2.- You failed to provide a link to your chosen snipped quote. A partial quote without a link to the entire body of text referenced is…well …. just not very ‘sciencey’.
I see the objectives of “Functional Chiropractic Neurology” and in particular, the application to neurological rehabilitation, as an obvious parallel to the usual Alt-Med strategies. The DC will do nothing meaningful in terms of treatment for the patient and, as is usually the case, slight improvements will be perceived in the patient’s condition due to the normal wax and wane of these kinds of maladies – AND THEN – They will take all the credit!
@nobs,
1. SRAM is not in PubMed. When it was reviewed for inclusion, CAM advocates on the committee shot it down. It is now defunct, but it was a far more scientific, reliable source than some of the PubMed listed CAM journals. I am planning to post my article on SBM so you can judge for yourself.
2. I DID provide a link to my snipped quote: it is taken from the abstract of Carrick’s study: http://www.ncbi.nlm.nih.gov/pubmed/9345682 The complete text is “DESIGN:Physiological cortical maps were used as an integer of brain activity before and after manipulation of the cervical spine in a large (500 subjects), double-blind controlled study.”
3. Can you envision any context where “Physiological cortical maps were used as an integer of brain activity” could make sense? Do you know what the definition of “integer” is? Do you think it is possible to get a “cortical” map by mapping the blind spots on the retina? Have you read Carrick’s study? What do you think of his data and reasoning?
Regarding Ted vs Frederick Carrick – I read numerous articles on Ted Carrick (which is who I was asked about), including his own website, without there being the slightest hint that “Ted” is a nickname for “Frederick”, which is the name under which he has published. I find that very odd, even unprofessional. Most people who have published in the literature are clear about their professional name.
I also searched for articles on chiropractic neurology, and could find none. I am familiar with the studies that Harriet examined before, but did not make the connection to this Carrick.
The rest of the so-called “errors” are not. I quoted a chiropractic source which states that straight chiropractors believe all illness comes from the spine. So at least some believe this. I had already stated that there is a variety of views and practices under the umbrella of “chiropractic.”
I maintain there is no scientific basis for chiropractic neurology. Incorporating mainstream functional practices does not count – because they are not “chiropractic” nor developed by or unique to chiropractic neurologists. Their practice seems to be based on pseudoscientific principles with some functional interventions thrown in. That doesn’t make them science-based. This is similar to naturopaths throwing in some basic nutritional advice and calling it “naturopathic.”
The defense of Crosby’s anecdote is absurd. It’s still just anecdotal. I would note that in the interview Carrick said Crosby’s function was “supernormal”, but when he was formally examined he was just mildly improved. Never underestimate the power of delusional marketing.
Without a carefully documented cased description, we cannot make anything of this case. Carrick also believes that he woke up the brain of a comatose patient, and offers us only anecdote.
The studies he has published are all terrible – not compelling evidence for anything.
As I said – there is no body of scientific evidence that establishes chiropractic neurology, or that they have anything specific to offer. It is classic pseudoscience.
micheleinmichigan:
Our oldest son was seen by a pediatric neurologist when he was younger due to his history of seizures and lack of speech. He did a series of tests (EEGs, blood test for a metabolic disorder) and several in office examinations. The visits were often about an hour long.
Here is the one thing I got from him and his staff: they were willing to admit that they did not know everything, that neurology was still evolving and brains are very complex. I especially learned this when the final diagnosis was not Landau-Kleffner Syndrome, but “static encephalopathy.” His physician’s assistant told me that there is something, they don’t know what, but it is not changing.
Which is in stark contrast to a woman I met who claimed to be a neurologist, but revealed what kind when she suggested I should get my son cranialsacral therapy. She seemed quite offended when I told I did not thing gentle head massages would repair the damage in Broca’s and Wernicke’s areas of my son’s brain. She avoided be for the duration of the function we were both attending.
@Steven Novella – Very interesting and understandable article. Vestibular therapy was a good example of how some of these practitioner may happen upon an effective therapy without a full understanding of it’s evidence or applications. It seems to me, one problem is, without understanding the evidence or how that therapy is working, the chiropractic neurologist can not research or apply that therapy to it’s best effect. Then, also, the occasional effective therapy gets mixed in with other ineffective therapies, taking up more time and resources with less results.
@Chris, I would have thought the one thing worse than being avoided by a chiropractic neurologist is being sought out by one.
Back story here that some readers may be unfamiliar with:
Carrick’s protégés Robin Pauc (UK), Robert Melillo (US) and Gerry Leisman (US) have ginned up the (false) notion of something called “developmental delay syndrome”. In their minds, ADHD, autism (including Asperger Syndrome and PDD-NOS), dyslexia, OCD, and Tourette Syndrome as discrete syndromes or conditions don’t exist — they are just differing manifestations of “Developmental Delay Syndrome”. They explain this by claiming that the left and right hemispheres of the brain are not developing in appropriate synchrony, called by Melillo “functional disconnection”.
Of course, Melillo has a fix: his franchise empire of Brain Balance emporia, usually purchased by (what else?) chiropractors.
Harriet Hall published a critical evaluation of Melillo’s theory of functional disconnection here on September 14, 2010, here Brain Balance.
Steven Novella published another critical evaluation of the Brain Balance program at Neurologica on November 18 2010, and concluded:
The Brain Balance program is essentially a movement program, with some other bells and whistles (such as aromatherapy) thrown in. Earlier this year, the journal published by the International Dyslexia Association published an issue on questionable therapies, which included the article Physical Exercise and Movement-Based Interventions for Dyslexia
As Citizen Deux wrote about Brain Balance earlier:
I don’t fault parents for falling for this stuff. The marketing is pretty slick.
@Dr. Novella
“The rest of the so-called “errors” are not. I quoted a chiropractic source which states that straight chiropractors believe all illness comes from the spine. So at least some believe this. I had already stated that there is a variety of views and practices under the umbrella of “chiropractic.”
You cited a website, the ICA. Straight chiropractors, in 2011, do not believe all illness comes from the spine. I provided you a reference with that, in a text published in 2011. Your statement is inaccurate. You should own up to your mistake. See Villanueva-Russell 2011 for a more balanced, objective sociological look at the profession. She is a PhD and not a DC and does not work for a chiropractic school.
I maintain there is no scientific basis for chiropractic neurology. Incorporating mainstream functional practices does not count – because they are not “chiropractic” nor developed by or unique to chiropractic neurologists.
If chiropractic neurology incorporates established, scientific based functional practice, alongside with SMT, which is clearly established at having value for spinal pain, in addition to the emerging research which suggests it alters sensorimotor function, is perfectly chiropractic. It’s simply a neurological rehabilitation using manual techniques combined with a holistic paradigm.
“Their practice seems to be based on pseudoscientific principles with some functional interventions thrown in. That doesn’t make them science-based. This is similar to naturopaths throwing in some basic nutritional advice and calling it “naturopathic.”
You make this declaration without having read the functional neurology text, not having spoken with Dr. Carrick or his associates nor having read the Macleans article. Seems? RTFA!
The defense of Crosby’s anecdote is absurd. It’s still just anecdotal. I would note that in the interview Carrick said Crosby’s function was “supernormal”, but when he was formally examined he was just mildly improved. Never underestimate the power of delusional marketing.
It may be anecdotal, and the article did not state he was “mildly improved”. The quote was “the best we’ve seen” which is attributed to Dr. Michael Collins. You are deliberately misquoting the article. Also from the article “Carrick had a very prominent role Sidney’s current recovery process” (pg 66). What’s absurd is your flat out denial that a DC could play a prominent role in the rehabilitation in one of the hockey players of the last 25 years.
“The studies he has published are all terrible – not compelling evidence for anything.”
Why are they terrible Dr. Novella? You offer no specific critique or rebuttal because you didn’t read them. You claim something is terrible without even reading it. Is this the type of scientific investigation your promote here? Sad. You failed to address the majority of my arguments, which is par for the course here. If you had even read the Macleans article, you would have seen that it stated Dr. Carrick’s name was Frederick. It’s more proof that you have no clue of what you’re talking about. And that is just bad science.
@Dr. Hall
Your rebuttal of Dr. Carrick’s article was rebutted quite thoroughly on an earlier post. You have offered to rebuttal to his critique. I agree, the “psychotic” remark was not appropriate, but your rebuttal of his work was half-assed and he thoroughly deconstructed your rebuttal proving his case quite clearly, and he referenced it as well. Why didn’t you take him up on his offer to speak to him directly? Why didn’t you publish your rebuttal? Debate is important in science, but the debate has to to be fair and objective. None of commentary I’ve read here at SBM regarding chiropractic medicine approaches any level of objectivity. Why?
The rest of the posts are white noise, posturing really, that gets away from Dr. Novella’s main argument. He did not research this topic and I’ve proven that. His rebuttal which is one big anecdote in itself full of special pleading, straw man arguments and circular logic. I await your replies.
NMS-DC
@Chris
What makes Chiropractic unique? Well, the emphasis of spinal manipulation and it’s role in health. The effects of SMT is neurological. That the holistic paradigm is superior to the conventional biomedical paradigm.
PTs replacing DCs are the main provider of SMT when DCs perform >90% of SMT in North America? Ok there.
We are not talking about Hulda Clark nor are we talking about your personal opinion of the Mayo Clinic. You are critiquing the integrity of Mayo Clinic? On what basis? Inclusion of proven techniques for specific conditions? Do you follow the literature Chris regarding SMT?
@GladOS
Prohypothesis
a) differentiates it from the current scientific consensus
b) can be subjected to some test that might prove it false.
So good luck with that.
The current consensus for vestibular rehabilitation with respect to concussions is the wait and see approach. DCs favour a more active approach.
The testing of the gyrostim with respect to balance is currently being done. The study will be published in 2012. The gyrostim was a component of Sidney’s rehab, but it was multi-modal. Basic sciences in neurology and concussion treatments will be furthered with this type of research.
Regards,
NMS-DC
@nobs
It’s amusing to see the senior SBM editors wither under the spotlight when their assertions are challenged with research. It proves that they are far from objective but have a genuine xenophobia of any natural healing arts. I looked back at my posts on chirotalk circa 2005-2006 and they actually proved to be prophetic. The same will happen here in 5-10 years when the research accrues and many of the fundamental principles of chiropractic have been validated by scientific investigation. The profession has developed the capacity to conduct research and have made affiliations and partnerships with universities. It’s already crossed the tipping point, SBM just refuses to admit it. Mainstream chiropractic research is not only scientific, but contributes to health care by gaining a better understanding of how the human body functions. I look forward to debating them and I’m still waiting for Dr. Homola to make an appearance (5th request). I bet these guys think that Dr. Haldeman is quack. Just goes to show how fringe their thinking really is (just like their hero Ernst).
Regards,
NMS-DC
@NMS-DC
If a chiropractor takes a half-assed 300 hour course at the motel down by the airport and can call himself a neurologist then I demand, having just finished 300+ hours of legitimate neurology (with actual patients), to be able to call myself a neurologist.
Seriously, you can’t be defending what is such a clearly shoddy course of study. It is actually bordering on fraud that these people call themselves “neurologists” or “radiologists” despite having basically zero exposure to the real thing. Actually, given that, I feel completely comfortable saying that they (DC “neurologists”) are quacks or, at least, lack the humility and self-reflection to realize that they probably shouldn’t hold themselves out to the (ignorant) public as something they aren’t.
If anything, you ought to feel embarrassed by these people who clearly aren’t neurologists and shouldn’t hold themselves out as such.
As for Sidney Crosby, who cares? Professional athletes do stupid things all of the time; have you seen how many of them wear those idiotic “hologram” bracelets?
I did read the Mcleans article. They call him “Ted Carrick” at the top of the article and “Carrick” from then on. I read back and still don’t see any reference to “Frederick Carrick.” If there is anything further in the print version that is not online I did not read it. I maintain it’s unprofessional not to use your real name, the name under which you publish. I managed to read a dozen articles about Ted Carrick (including his own website) without there being any mention of “Frederick.”
But after you pointed it out I went back and read his articles. They are not compelling. I’m not going to go into a detailed analysis in a comment – perhaps I will do a follow up in a later post. I agree with Harriet’s analysis of his blind spot mapping article. The claims is simply absurd, his evidence is not adequate to support his claim, and there are no replications. There is no body of research, with independent corroborative evidence, etc. There are a few studies by a lone researcher promoting an extreme claim – that is the pattern of pseudoscience, not legitimate science. He references a lot of studies, but none support his claims. They are mostly case reports printed in a chiropractic journal.
The core criticism of his study holds – it is unblinded and uncontrolled. Given the extreme nature of his claims, it is absolutely unscientific to base clinical claims on such flimsy and notoriously unreliable evidence.
Carrick claims he woke up a comatose patient – where is the science behind this. This claim demonstrates he is disconnected from reality, or simply not interested in rigorous science. The other example I gave is that he claims Crosby was “super-normal” after his treatment. This claim was contradicted by examination. All they could say is that he was improved (I acknowledge they did not say “mildly”, I misremembered that) We can’t know from the article how much improved he was, and if it was only subjective. The uncritical Macleans article is not an adequate source of information.
I’m afraid you have proven nothing but your own bias. You make many distracting points that have nothing to do with the core claim – there is no established body of science behind chiropractic neurology. It is at odds with modern science. It is a marketing scheme, nothing else. And stop assuming you know what I have read or researched – you don’t.
NMS-DC:
Cranialsacral therapy is just a homeopathic head massage. I noticed you did not mention it.
If you have any evidence that spinal manipulation can improve oral motor dyspraxia with functional dysarthria and some dysphasia due to damage to mostly Broca’s area, and some of Wernicke’s area of the brain (which may or may not have been caused by seizures, especially the one suffered during a now vaccine preventable illness) then…
… please post the journal, title, date and authors of the papers. Thank you.
“What makes Chiropractic unique? Well, the emphasis of spinal manipulation and it’s role in health. The effects of SMT is neurological. That the holistic paradigm is superior to the conventional biomedical paradigm”.
You know, you had me going there what with the “nothing here but us little science-based back cracking” routine. I actually took you kinda seriously for a while and then your belief in the good old subluxation comes out.
Kudos though, that you were able to hide it that long.
@NMS-DC, “Your rebuttal of Dr. Carrick’s article was rebutted quite thoroughly on an earlier post. You have offered to rebuttal to his critique. I agree, the “psychotic” remark was not appropriate, but your rebuttal of his work was half-assed and he thoroughly deconstructed your rebuttal proving his case quite clearly, and he referenced it as well. Why didn’t you take him up on his offer to speak to him directly? Why didn’t you publish your rebuttal?”
It appears that you have fallen hook, line, and sinker for Carrick’s misrepresentation and distortion of what I wrote. Before you judge me, it would only be fair for you to read my SRAM article with my complete analysis of his blind spot study. I plan to publish it here on SBM in the near future so you will have that opportunity. Carrick’s attack on me was not responsive to my specific criticisms of his study, and as an offensive and irrational diatribe it does not deserve any further response from me. He and I had a long e-mail exchange. I can provide copies of the e-mails to anyone who is interested. You will find that they don’t sound at all like Carrick’s portrayal of them. In them, I politely asked a number of questions about his research and he failed to answer, and he made no effort to understand my point about the difference between a reproducible measurement and a validated one (think two identical but falsely high blood glucose readings from a malfunctioning or uncalibrated glucose meter). I “spoke” to him directly and at length through our e-mail discussion. I chose not to speak to him on the telephone because I generally find telephone calls less useful than communicating in writing, and there would be no record of it.
I Googled “Ted Carrick gyrostim,” and got this page:
http://www.drtituschiu.com/neuroessene/Blog!/Entries/2010/10/9_A_Magical_Time_in_Atlanta.html
Where I read,
Which is pretty funny in light of the pics of ol’ Ted on that page.
Also he magically cures cortical blindness, lol.
@DrNovella
I did read the Mcleans article. They call him “Ted Carrick” at the top of the article and “Carrick” from then on. I read back and still don’t see any reference to “Frederick Carrick.” If there is anything further in the print version that is not online I did not read it. ”
Therefore you missed 3/4 of the article. You’re basing opinions on a article which you just admit haven’t fully read. His full name is on pg 66, Frederick R. Carrick. But if you had read the full article you would have known this.
His research is preliminary and should be judged according its content. It’s not a double blinded RCT, but that’s not what he was researching. Double standards though, par for the course here.
What claim are you specifically saying that Dr. Carrick is making? Do you have a specific quote or reference? Because you’re losing me here with your line of argumentation. His research is not published just in a chiropractic journal as you claim. Of the 6 articles I found at PubMed, two were in JMPT, which is a chiropractic journal (which has seen it’s impact factor double in the last 5 years, just saying…)
“Carrick claims he woke up a comatose patient – where is the science behind this.”
The family had witnessed this. Also, new research suggests that 20% of “vegetative” patients are aware. He claims he used stimulation techniques to areas of the brain which were inhibited. This was done by doing a neurological exam (muscle tone, reflexes, eye movement patterns, asymmetries, etc..)
All they could say is that he was improved (I acknowledge they did not say “mildly”, I misremembered that) We can’t know from the article how much improved he was, and if it was only subjective.
This is patently false and if you read the article you would have realized that Dr. Collins put Crosby though the same baseline tests that he had done throughout his treatment and ran computerized tests called IMPACT which compared his neuro-cognitive abiilties prior to Carrick’s treatment. Dr Collins’ quote “the best we’ve seen since Crosby got hurt” Playing with the facts Novella is not good science either and it discredits your argument. You should have at least told readers you had not read the full article.
More from you
“I’m afraid you have proven nothing but your own bias. You make many distracting points that have nothing to do with the core claim – there is no established body of science behind chiropractic neurology. It is at odds with modern science. It is a marketing scheme, nothing else. And stop assuming you know what I have read or researched – you don’t.”
I presented to you a textbook, that goes into detail of exactly what is chiropractic/functional neurology. It’s published by Beck DC/PhD. You can even glimpse a few pages online for free at amazon.com. This book is the foundation of the principles and the scientific manner at which a DC would look at diagnosis and treatment of neurological cases. It’s not at odds with modern science, it’s just a different perspective than modern science. There you go with the false dichotomy again. If it doesn’t come from an MD, it’s terrible. Science is a two headed coin, it can be viewed by conventional/orthodox methods and be viewed by holistic/traditional methods. We differ in our approach to healing, but our intent is the same: good outcomes for the patient. Re: marketing scheme, that’s a nice copy of Edzard’s take on chiro, so come up with an original thought of your own. And, I do know what you read and researched with respect to this article, because you’ve been wrong the whole time about facts!! RTFA!
Regards,
NMS-DC
Fascinating. I assume you are referring to areas within the cerebral cortex?
@NMS-DC
Dr. Novella said “Carrick claims he woke up a comatose patient – where is the science behind this.”
You answered: “The family had witnessed this.”
Oh, wow! Hearsay, second-hand anecdotal testimonial evidence from a patient’s family = science? Since when?
And since when does a single textbook chosen by you get to trump all the evidence from other sources? I have a copy of a chiropractic textbook entitled “Somatovisceral Aspects of Chiropractic: An Evidence-Based Approach” – it doesn’t contain anything that a scientist would call “evidence-based,” only poor quality uncontrolled studies and case reports. It falsely claims that chiropractic manipulation is effective for all sorts of non-musculoskeletal ailments. It has sections on “Practical Vitalism: An Emerging Paradigm,” “The Ergonomics of Neurologic Holism,” “Subluxation and the immune system,” “Subluxation and the pediatric central nervous system,” etc. It’s really pretty funny: for instance, a patient with MS had a long list of symptoms that all vanished within minutes of diversified adjusting. Another piece of “evidence” for chiropractic’s effectiveness for MS is that a report of a literature review described a 35 year old man who “apparently responded well to unspecified cervical and upper thoracic adjusting.”
And before you accuse anyone here of parroting Edzard Ernst’s take on chiro, do some research into the history of criticisms of chiropractic. You will find that Ernst has only come to the same conclusions that many others had previously reached for the same reasons.
Oh strike the above. I’m too busy to play cat-and-mouse at the moment.
NMS-DC, you are arguing that 300 hours of study in something you call “neurology” which strangely does not involve any neurologists, is just as good as a medical education and a residency program in neurology. Your position is stupid. Just stop before you embarrass yourself further.
If chiropractors would use the term “chiropractor” in their business name, and if they would avoid calling themselves “neurologists,” I could go back to largely ignoring them. But fooling vulnerable patients, this doesn’t sit well with me.
@Harriet
I simply was referring to what was presented. The family claimed that Dr. Carrick helped awaken a “comatose” patient. Maybe the patient wasn’t really comatose afterall. Like I alluded to in my most, preliminary research by EEG demonstrated in an albeit small sample, 20% of patients who were diagnosed as “vegetables” where actually conscious. Please see the link here for the story
http://www.cbc.ca/news/health/story/2011/11/09/vegetative-eeg-research.html
Your rant regarding the Somatovisceral Effects of Chiropractic, is a red-herring and is not pertinent to our discussion on chiropractic neurology. I’d be more than happy to purchase the book and objective critique it, if you provide me the author(s). But for now let’s stick to the topic at hand.
You write
“And since when does a single textbook chosen by you get to trump all the evidence from other sources?”
This article is specifically discussing the merits, or lack thereof of chiropractic neurology. There is a text that is specific to chiropractic neurology, that discusses the principles and practice of chiropractic neurology and which is written by a DC/PhD with a foreward by Dr. Carrick. This book does trump all other sources provided in this thread because it is the only source that specifically addresses the topic of chiropractic neurology in its entirety and not an opinion based commentary written by Dr. Novella who didn’t read the Macleans article, didn’t conduct a proper PubMed Search, did not read the studies by Dr Carrick and was not aware of the textbook which is centre of this discussion. RTFB!
Also, I call ‘em as I see ‘em. The majority of SMB editors and posters are parrots of Ernst and it doesn’t take a genius to figure out the talking points that you espouse are directly from his plethora of anti-chiropractic articles. Even the phrasing of the “rebuttals” here are either direct or very close to the same language used in Ernst papers.
Being a DC Harriet, I am intimately familiar with the criticisms of my profession both from internal and external sources. In gauging the criticisms, I look for objective and valid criticisms that are fair and balanced which take into account the both historical and contemporary practices of chiropractic. The criticisms here are of such hyperbole with parrots and lemmings parading it who mostly have 0 expertise in neuromusculoskeletal medicine its virtually impossible to have a reasonable debate with any of you who are on the fringe, much like Ernst, when it relates to complementary medicine.
And to be specific about Ernst, his obsession and witch hunt about chiropractic (65 articles published about chiropractic in the past 14 years, the majority coming from 2003 onwards , see here http://www.ncbi.nlm.nih.gov/pubmed?term=Ernst%20and%20chiropractic) has done more to discredit as a serious, objective scientist. His conclusions regarding chiropractic, ranging from effectiveness of SMT, to cost effectiveness of SMT, to safety including outrageous conclusions that “the risks of cervical manipulation including death outweigh the benefits” are merely an attempt to distort and misinform the public, policy makers and the ignorant. He can write all the systematic reviews he wants, but they are a house of cards waiting to crumble. His lit search omits any supportive papers and chooses papers espoused by “straight” DCs to make the majority of the profession to look as though it is stuck in 1895.
But, thankfully, there will be a concluding chapter into the safety of SMT, particularly with cervical manipulation, that one that gets so much attention around here. This paper will be the gold standard and will settle the matter once and for all: patient safety and SMT.
http://www.research.ualberta.ca/en/VP%20Research%20News/2011/05/Researcherstaketeamapproachtopatientsafetyduringspinalmanipulation.aspx
Good night,
NMS-DC
Wow. So, where is the evidence that chiropractic neurology has anything to help my kid’s issues? I laid it out for NMS-DC, but I did not see anything resembling journal articles with solution via spinal manipulation.
Screw the difference between the 300 hours for a chiropractor to get qualified as a “chiropractic neurologist” compared to the years Dr. Novella spent to become a real neurologist. I have a feeling I know more about neurology as a parent of kid with neurological issues. And I am only an engineer (okay, I used to be a “rocket scientist”… but having a kid with medical issues put an end to that).
And all I did was check books out of the library (like Conversation With Neil’s Brain by Ojemann and Calvin), and go on the internets. One of the best articles was on the uselessness of Doman/Delcato patterning by Dr. Novella. I should also add, I also learned lots from my son’s pediatric neurologist, especially his twelve page report on my son after his initial visit.
Unfortunately the neurological issues have taken a back seat to the kid’s heart. I’ve now had to learn too much about a genetic heart condition, which has involved more visits to the cardiac clinic in the last two months since he was initially diagnosed eight years ago. I really hate riding in ambulances with a kid.
So what miracles does spinal manipulation provide for damaged mitral valves caused by excessive heart muscle growth due to genetic manifestation of hypertrophic cardiomyopathy? Don’t bother since that would be off topic.
off-topic post
@Chris, sorry to hear about your son’s heart condition. That completely sucks. My thoughts will be with him, you and your family.
The Mcaleans article is a lay press article – and very poor quality. I did not rely upon it for scientific information – I used the information that was in the version I read. You are not contesting the quotes that I pulled out. So what’s your point?
My point remains – Carrick, who presents himself as a professional, an expert, with a published record – should use his professional name consistently, and if he uses his nickname should put it in parentheses. It is just odd how much I was able to read about him without running across his real name.
Obviously in the last two days I have not read a print textbook I don’t currently have access to. I almost never read textbooks these days anyway. They are hopelessly outdated, even if they are originally high quality. The published literature is the place to go to see if the science supports any claim.
My other points remain, unrebutted:
Carrick overstates his claims and any alleged effectiveness of his treatment. It is highly unprofessional, unethcial, and pseudoscientific to claim that you can treat a serious condition like coma based upon a single unverified anecdote.
Carrick also overstated the response of Crosby. His claims of “super-normal” had to be specifically contradicted by his doctors. Saying “the best so far” is another way of saying “improved” and is compatible with the slightest improvement. And – this is all heresay – how about at least a published case report.
The evidence I was referring to above was in the rebuttal to Harriet’s criticism. Carrick reference almost exclusively from the journal of manipulative therapy, and his specific references often did not even support his claims. His rebuttal was classic diversion and character assassination.
The bottom line is this – the basic claim that functional interventions can significantly affect brain recovery, so as to reverse damage and even “wake up the brain” from a coma is pure hokum. It is based on ideas that were disproved decades ago. There is no published clinical evidence to back up such claims. It seems that chiropractic neurology is mostly based on this flimsy premise.
Please point me to references in the published literature that establish any of Carricks claims – where is the basic science, where is the clinical science?
You claim it’s not fair to judge his preliminary studies for being preliminary. This completely misses the point. Preliminary exploratory studies should not be used as the basis for clinical claims and practice. That is what Carrick is doing – another sign of pseudoscience. Even as preliminary studies, they are highly dubious.
The general experience is that such results will be like N-rays – they will vanish the moment double-blinding procedures are put into place.
Shouldn’t we determine scientifically that SMT has a role in health to begin with before we base an entire profession around it? Please provide research outlying some of these claims. And please don’t fall prey to the age old “I don’t have time, go find them yourself!” I’m specifically looking for good quality studies published in peer-reviewed medical journals with sound methodology and statistical reporting. The burden of proof is on the claimant.
If my personal opinion of the Mayo Clinic doesn’t matter (which it probably doesn’t in this sort of discussion, I’ll admit) then don’t use YOUR opinion of those facilities offering Carrick’s “treatments” as support of your argument against Dr. Novella. Only fair. And yes, I am critiquing the integrity of the Mayo Clinic when it allows unproven, unscientific nonsense to proliferate inside it’s doors, nonetheless offering it to patients and giving it an un-earned air of legitimacy with their organization’s name.
I do follow the literature for SMT. I have found almost nothing to date worthy of even being called “scientific”, aside from the Cochrane Collaboration’s findings that SMT is as effective as other modalities for treatment of lower back pain. If that’s the only headway a profession has made in it’s long history of establishment, well…
Again, I’m not claiming this literature cannot exist. I’m simply saying in my years of research, I have never been able to find anything worthwhile. I’d gladly accept a source or two if you have them. I’m willing to admit I’m wrong.
@NMS-DC,
“I simply was referring to what was presented,”
Yes, that’s the point. Dr.Novella asked for science and you responded with hearsay.
“Your rant regarding the Somatovisceral Effects of Chiropractic, is a red-herring and is not pertinent to our discussion on chiropractic neurology.”
Yes, it is pertinent, as it is a chiropractic textbook that discusses the interface between chiropractic treatment and neurology. http://www.amazon.com/Somatovisceral-Aspects-Chiropractic-Evidence-Based-Approach/dp/0443061203
It’s also relevant in that it is an example of what passes for “evidence-based” in schools of chiropractic.
In his medical training in Germany, Ernst learned spinal manipulation along with homeopathy, acupuncture, and herbal medicine. He then turned to rigorous science and, through his own research as well as assessing the evidence published by others, tried to find out what worked and what didn’t in CAM. He was appalled to learn that the evidence failed to support what he had been taught. He eventually concluded that chiropractic offered some benefits and that homeopathy was a total crock. When he omits papers from his systematic reviews it is only because they do not meet the review criteria – many of the supportive studies are too poorly designed to pass muster. He doesn’t have any vendetta against chiropractic. If we seem to you to be “parroting” Dr. Ernst, it is only because we have all looked at the evidence in the same objective fashion so we have reached the same inescapable conclusions.
I had never heard of Ernst until long after I formed my own opinions of chiropractic. I started my investigation by reading everything I could find both pro- and anti- chiropractic and comparing the two sides. It was no contest: I found the “pro” information from chiropractors badly lacking in evidence and reasoning. I can honestly say that I learned almost everything I know about chiropractic from chiropractors themselves.
Your desperate efforts to defend chiropractic and chiropractic neurology are understandable, but you are hopelessly lost in confirmation bias. You are striking out in the only way you can, with ad hominems and diversions rather than evidence. You are not making any headway here. It’s really rather sad.
FWIW, I’ve never read anything by Ernst unless it was somebody else quoting him.
My own interest in understanding chiropractic came from an acquaintance who was trying to treat all his medical problems “naturally.” He claimed to me that he’d been cured of “chronic fatigue syndrome” by a chiropractor who found that one of his legs was longer than the other. (The myth of symmetry is used for so many odd things.) I found this explanation weird and set about looking into the world of chiropractic thinking and practice and concluded it was mostly based on pseudoscience and speculation wrapped up in the language of persuasion and marketing.
The efforts of nms-dc have only added to my original conclusion. (Assuming of course nms-dc is a chiropractor.)
@Dr. Novella
I’m contesting that you misquoted the article, then you attempted to correct yourself, only to misquote it again.
“My point remains – Carrick, who presents himself as a professional, an expert, with a published record – should use his professional name consistently, and if he uses his nickname should put it in parentheses. It is just odd how much I was able to read about him without running across his real name.”
You’re just embarrassed that you said in your original post that he had 0 publications and you didn’t even know his real name nor did you bother to even find out. Obviously Carrick and Hall have crossed paths, you could have easily found out through her. Your search was lazy.
“Obviously in the last two days I have not read a print textbook I don’t currently have access to. I almost never read textbooks these days anyway. They are hopelessly outdated, even if they are originally high quality. The published literature is the place to go to see if the science supports any claim.”
You made a post and a point to discuss chiropractic neurology without getting any facts. This is lazy journalism/editorializing on your behalf. You can writhe all you want about the utility of textbooks, but if you had any bit of credibility or objectivity on the topic of chiropractic neurology you would go the foundational textbook. Your comments and opinions remain uninformed, thus not credible nor reliable. And don’t try appealing to authority in your rebuttal.
“Carrick overstates his claims and any alleged effectiveness of his treatment. It is highly unprofessional, unethcial, and pseudoscientific to claim that you can treat a serious condition like coma based upon a single unverified anecdote.”
Please show me the reference, or quote where Carrick claims that he can “effectively treat” a coma. Also, even though it is anecdotal, it did allegedly occur. What is unprofessional Dr. Novella is to profess knowledge of a subject and not even bother to research it, like the case here with your rant on chiropractic neurology and then making unfounded conclusions based on your terrible methodology. Again, if you want to learn about chiropractic neurology, buy the text, and we can discuss points you may have an issue with and debate it accordingly. Otherwise this is a smoke show.
“Saying “the best so far” is another way of saying “improved” and is compatible with the slightest improvement.”
Slippery slobe Dr.Novella. You can’t try to interpret Dr. Collins words so suite your own personal bias’. Also, the quote “best so far” and the quote from Sidney Crosby’s agent was “Carrick had a very prominent role in Sidney’s recovery status. he progressed extremely well under Carrick”. These are the actual quotes. Your reasoning is “best so far” = “improved” = “slightest improvement”. What a joke. Stick to the actual quotes. Your personal interpretation is worthless. It’s just a pathetic attempt to minimize the “prominent” role Carrick played in which Crosby “extremely well”. Not slightest improvement. Extremely well.
“The evidence I was referring to above was in the rebuttal to Harriet’s criticism. Carrick reference almost exclusively from the journal of manipulative therapy, and his specific references often did not even support his claims. His rebuttal was classic diversion and character assassination.”
That was not the case whatsoever. And you got the journal title wrong (another factual error). It’s JMPT, Journal of Manipulative and Physiological Therapeutics. It wasn’t character assassination. It was a thorough, referenced rebuttal of Harriet’s half-assed, poorly researched and referenced reply. She is embarassed by it because she bit off more than she could chew. Just like what you’re going through right now by doing a lazy, half-assed post and I’m pointing out all the flaws.
The bottom line is this – the basic claim that functional interventions can significantly affect brain recovery, so as to reverse damage and even “wake up the brain” from a coma is pure hokum. It is based on ideas that were disproved decades ago. There is no published clinical evidence to back up such claims. It seems that chiropractic neurology is mostly based on this flimsy premise.
“Please point me to references in the published literature that establish any of Carricks claims – where is the basic science, where is the clinical science?”
What claims are you referring to?
“You claim it’s not fair to judge his preliminary studies for being preliminary. This completely misses the point. Preliminary exploratory studies should not be used as the basis for clinical claims and practice. That is what Carrick is doing – another sign of pseudoscience. Even as preliminary studies, they are highly dubious.”
Did you even read the studies Dr. Novella, oh, that right you didn’t. Carrick didn’t make any claims with his research. What he did do was to test out the validity and reliability of equipment to measure posture and balance. For the record, 2 of the 6 studies were in non-chiropractic journals. Do you consider Biomed Sci Instrum, Int J Adolesc Med Health, and Disabil Rehabil. to be unscientific journals?
Regards,
NMS-DC
@Chris
I’m sorry to hear about the health of your son. It’s not a matter for debate, I hope he gets the care that he needs and hope he makes a good recovery.
@Chris R
“Shouldn’t we determine scientifically that SMT has a role in health to begin with before we base an entire profession around it?”
SMT, at a minimum is effective for back pain, neck pain and certain forms of headache. Manual therapy, which includes many other hands-on techniques that aren’t HVLA have been found to useful for MSK disorders. Please see a literature review on effectiveness of manual therapies published in 2010:
http://www.ncbi.nlm.nih.gov/pubmed/20184717
Scientifically there is effectiveness for manual therapy and DCs are the experts at manual therapy. Chiropractic literally means “done by hand”. MSK disorders are a huge health issue. DCs are experts in diagnosing and managing MSK disorders.
Regarding the Mayo clinic, we will have to agree to disagree. If you think that the Mayo clinic would bring in useless therapies that have no benefit and that are potentially unsafe, to somehow appease CAM, I think that’s grasping for straws.
“I do follow the literature for SMT. I have found almost nothing to date worthy of even being called “scientific”, aside from the Cochrane Collaboration’s findings that SMT is as effective as other modalities for treatment of lower back pain. If that’s the only headway a profession has made in it’s long history of establishment, well…
Again, I’m not claiming this literature cannot exist. I’m simply saying in my years of research, I have never been able to find anything worthwhile. I’d gladly accept a source or two if you have them. I’m willing to admit I’m wrong.
You want RCTs. Ok, I will provide them. I took the liberty of doing a PubMed MeSH and shortening the url because it was really, really long. Take a peak, and we can discuss afterwards.
http://1.usa.gov/ujkJ49
Regards,
NMS-DC
@NMS-DC
Weak sauce man, trying to make someone read a textbook. If there is enough literature to write the textbook why don’t you just give us a salient reference from each of the chapters; I’d be happy to read some of those.
And you still can’t be defending “Chiropractic Neurology”. The “training” (if you can call it that) is so superficial and limited it doesn’t even rise to the level of a junior college, let alone that of a physician. So sorry, but Drs Novella and Hall are right, it is just a marketing ploy to prey on patients.
Finally, who really cares about Sidney Crosby? Time probably has more to do with his “recovery” than anything else; the real test will be to see how he handles playing an actual game.
“Regarding the Mayo clinic, we will have to agree to disagree. If you think that the Mayo clinic would bring in useless therapies that have no benefit and that are potentially unsafe, to somehow appease CAM, I think that’s grasping for straws”.
Uh, its just a low-risk money grab for the clinic/university. They usually have some cheesy “whole-person wellness” angle although the needles are really treating anything at all except the practitioner’s pocketbook. Even my own university/medical center has a CAM clinic (thankfully it is PsyD and nursing driven so at least it isn’t directly connected with the docs).
@NMS-DC
“It was a thorough, referenced rebuttal of Harriet’s half-assed, poorly researched and referenced reply. She is embarassed by it because she bit off more than she could chew.”
How dare you say that when you have not even read what I wrote!
I am not embarrassed, I am proud. A real neurologist agrees with my analysis. It is Carrick who should be embarrassed by his inability to reply to my valid criticisms or answer my questions and by his need to resort to distortions and ad hominem attacks.
If you are going by the article I wrote on blind spots for Quackwatch, the only one that is available online, it only briefly alludes to the defects in Carrick’s work. Carrick’s tirade was in response to the article I wrote in Skeptical Inquirer: have you read that? It was a humorous version of my SRAM article, written for the general public. I don’t know if Carrick has even seen my SRAM article, but my main points were explained in the SI article and he has failed to understand or respond to them appropriately. He is defending his turf with emotion, not responding as a scientist would to valid criticism.
Please do me the common courtesy of reading my SRAM article and then explain exactly what you think is wrong with my analysis. I don’t think you will be able to persuade anyone here that it was half-assed.
“You want RCTs. Ok, I will provide them. I took the liberty of doing a PubMed MeSH and shortening the url because it was really, really long. Take a peak, and we can discuss afterwards.
http://1.usa.gov/ujkJ49”
Nice shotgun blast of all sorts of things, many of which are irrelevant. Some are simply test reports, indicators of further proposals, feasibility studies, reports of what’s in the literature. A selection from the first couple of pages of the conclusion sections of some of the papers:
“Neck manipulation is not appreciably more effective than mobilization. The use of neck manipulation therefore cannot be justified on the basis of superior effectiveness.”
“Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care.”
“Further investigation of the possible benefit of chiropractic maintenance care (extended schedule) for balance and pain-related disability is feasible and warranted, as well as both limited and extended schedules for patients with idiopathic dizziness.”
“Although the sample size was smaller than initially required, a statistically significant and clinically important effect was obtained for the combined treatment group. There are considerable difficulties with recruitment of subjects in such a trial. This trial should be replicated with a larger sample.”
“It is important that complementary and alternative medicine (CAM) research can be successfully conducted at CAM institutions. However, the costs associated with recruitment efforts for studies conducted at CAM institutions may be higher than expected and many self-identified participants are users of the CAM therapy. Therefore, strategies for efficient recruitment methods and targeting nonusers of CAM therapies should be developed early for CAM trials.”
Not exactly a ringing endorsement of chiropractic. Be that as it may, since there is no fundamental scientific basis for most of what chiropractic claims, all the dodgy studies available can’t suddenly find it, not even in a perfect post hoc word.
@Quill
I read the papers and know the conclusions. Your point? Besides acknowledging that you didn’t read the studies and just skipped through the first 2 of 9 pages? I was asked before to provide evidence of RCTs because the basic sciences papers I provided “were worthless” and “bad and backwards science”. I guess that’s a step up from pseudoscience. We’re making progress here, let’s keep it up!
Important point to consider: HVLA manipulation is not the only manual therapy DCs provide to our patients. Mobilizations can also be done and should be done in the appropriate circumstances. No reasonable clinician would ever say it’s SMT or bust. But, nice try to again steer the debate away with yet another red herring.
I also heard from SBM senior editors that there were no good RCTs showing SMT and manual therapies were good for anything. Proven wrong, once again. Here has been a summary of how slippery the slope is for you anti-chiropractic bashers
DCs are quacks and are useless charlatans -> patients who improve under DCs are all being placeboed –> it’s all a cult –> it’s all pseudoscience –> there is no research –> there is no good research –> there is no basic science research –> the basic sciences research is worthless, terrible, backwards and bad –> there are no RCTs –> the RCTs are bad.
The medical profession has actively sought to contain, discredit, eliminate and destroy the chiropractic profession. This has been proven by Wilk vs. the AMA. Now the same type of BS is happening in the literature, attempts to discredit, misrepresent, distort, etc. Good thing that DCs have DC/PhDs and objective MDs who truly want to further science by understanding the mechanisms behind manual therapies and their effects on MSK specifically and general health, broadly.
Time to work out,
NMS-DC
@Harriet
Please provide me a link to your SRAM and I will read it following my work out. I will be objective and honest.
Regards,
NMS-DC
@NMS-Dc
“It’s not chiropractors ‘inventing’ neurology, it’s chiropractors interpreting neurosciences in a functional way. We (DC and MD) are both using the same pool of information, we’re just applying it differently.”
If the DC neurologists’ interpretation/application of neuroscience had any validity then obviously MD neurologists would be employing the same interpretation/application and using the same therapies. It would be well within their scope of practice. You can quibble all you want about citations to textbooks and journal articles, but basically you seem to be arguing that somehow DC neurologists are better at interpreting and applying neuroscience than MD neurologists. You’re not going to get anyone to agree to that — I doubt even a DC neurologist would agree.
@NMS-DC,
“Please provide me a link to your SRAM and I will read it following my work out. I will be objective and honest.”
You haven’t been paying attention. It is not available online and I have promised to post it here on SBM in the near future, tentatively scheduled for Nov 29. Stay tuned. By the way, I think an apology is in order for insulting me before reading what I wrote.
“The medical profession has actively sought to contain, discredit, eliminate and destroy the chiropractic profession.”
Oh dear, nms-dc. Playing the conspiracy card now? That’s pretty bad. What’s next, claiming Pfizer is tapping your phone? (And still no acknowledgement let alone apologies for your vile scriblings here, your juvenile personal attacks and your constant use of ad hominems and lashing out instead of rationally and logically attempting to persuade. You are, as they say about preachers who scream at people, a poor witness for your cause.)
@NMS-DC
I have repeatedly seen a different slippery slope in my discussions with chiropractors.
Chiro: X works.
Me: How do you know X works?
Chiro: Quotes article.
Me: Article isn’t acceptable evidence because….
Chiro: Yeah, I admit it is poor quality evidence, but we’re working to get better evidence.
Me: What if better studies show X doesn’t work?
Chiro: I know it works on my patients.
Me: You could be mistaken; that’s what science is for – to test our beliefs.
Chiro: You’re prejudiced and ignorant and I’m not talking to you any more.
I still want to hear the justification for allowing DCs to call themselves “neurologists” after a shoddy 300 hour course at the La Quinta next to the airport.
@Cowry1: That’s easy, you see, as their holistic, meta-cognitive paradigm is superior to the ol’ stodgy, knowledge-based medical one. Which therefore gives them special and rapid insight into things and that requires only 300 motel-hours instead of 15,000 clinic-lab-classroom hours. It’s all in the paradigm!
Questions for @NMS-DC:
1. Do you consider a chiropractic neurologist to be the equivalent of an MD or DO neurologist in education, training, and expertise?
2. The program offered by the Brain Balance franchises advertises itself as “clinically proven to help children overcome unique challenges”. I am particularly interested in dyslexia. How does chiropractic neurology characterize dyslexia and how can spinal manipulation improve reading?
More for @NMS-DC:
You wrote:
My word, chiropractic has been around since 1895, and still needs another 5 to 10 years to be validated by research?
You wrote:
You are implying she is objective. Oopsie. She is married to a chiropractor who was named Head of the New Zealand College of Chiropractic last year. I think that would have an impact on her objectivity.
@NMS-DC
Thank you for responding to me. I apologize it took me a while to respond and review the literature, I just got home from class.
I was beginning a write-up of my findings, but Quill addressed a number of concerns I had with what I found. Just so I don’t completely ride on Quill’s coat-tails, I included the first few remarks I had in my review I was penning:
These trials contained no placebo control group. Therefore, it’s impossible to determine whether or not the method works better than sham intervention, which I believe is very important.
The patients in this trial received their manipulation along with other conventional treatment modalities. Therefore, it would be wrong to attribute any measured benefit to just one of the given treatments.
This study also did not have a placebo group. However, it did find that manipulation was not superior to simple mobilization.
These sorts of things were the problems I mentioned I was finding over and over again when it comes to the literature. That’s part of my problem, is that I’m trying to find something that meets the criteria, but keep coming up short.
You know NMS…
Can I call you Neims?
Anyway, Neims, around these parts we like to keep our posters as honest as they’ll come. So, Neims, since we’re pals now, I’d like you to answer the following questions as truthfully as you can. There’s no wrong answer, so don’t worry about getting any wrong. Just, you know, be truthful.
1) Some people think that Apex Digital makes shitty products, but I think that if you want a TV on the cheap, they’re really not bad. Would you agree?
2) Who’s better on Friends, Chandler or Joey?
3) What’s your favorite flavor of Arizona Ice Tea? (Mine’s green with plum.)
4) Is the program at Palmer College hard, or would you say it’s more of a party school?
Pencils down!
In addition to their party-school education, chiropractors are suckers. Many subscribe to practice management firms run by Scientologists –e.g., Singer Consultants, Sterling Management, Hollander Consultants, Silkin Management Group, Stellar Consultants, BackTrack, etc. There’s a bunch of spin offs with new names, to avoid the Hubbard tech association.
NMS sounds a lot like a Hubbard Admin tech head to me. He hits that “always attack; never defend” note hard, and he’s got that delusional level of unwarranted self importance. Even though both strategies are very self-defeating from a PR perspective, the tech is the tech and the people who buy into it can’t deviate from it.
Here’s another little test, NMS. See if you can say the following out loud:
“I am not actually a neurologist. Neurologists have far more training and experience with diseases of the nervous system than I will ever have.”
“The medical profession has actively sought to contain, discredit, eliminate and destroy the chiropractic profession.”
Oh dear, nms-dc. Playing the conspiracy card now? That’s pretty bad.
Actually NMS is correct. See Wilk v AMA.
Actually, GLaDos, he’s not. It was not “the medical profession” as a whole but a group that was doing the litigating. Had he wrote “the AMA” then he’d be right. (The AMA’s own current data says that less than 20% of us doctors belong to the group.) So it’s not a conspiracy of the entire medical profession (which as commonly used would also include nurses, NPs, dentists, etc.) but only one group.
I agree that not every doctor was against chiropractic back in the day. But you could get in trouble with your medical society if you referred patients to chiros. So it wasn’t just AMA members hatin’ on the chiros.
The chiros (not all of them, just most) really do do a lot of bad stuff, like pretending you can fight a scientific battle using political shenanigans, law suits, and dead agent tech. That is not ok. As long as they do things like that, I will want them to go away.
Chiropractic is like astrology (actually in many ways), but in one particular way relevant to this discussion – they are varied in belief and practice. So when science trashes sun-sign astrology, the stellar astrologists claim that’s not “real” astrology.
NMS-DC is playing the same game.
Some chiropractors use vitalistic philosophy to treat non-neuromuscular disease. There is zero science behind this.
Some chiropractors treat childhood disorders without evidence. The BCA defended this, but was unable to defend the practice with actual evidence. They, in fact, inadvertantly demonstrated that the evidence does not support such practices.
Some chiropractor use a host of unscientific modalities, like homeopathy (the #1 prescribers of homeopathy in the US are chiropractors).
Some chiropractors limit their practice to functional and manipulative therapy for neuromuscular conditions, and do so in a deliberately science-based manner. By all accounts, this is a small minority (a few percent). They end up being a combination of physical therapist and sports medicine specialist. This is the only legitimate and evidence-based chiropractic, in my opinion.
And then there are chiropractors like Carrick, who are pushing the envelope of dubious marketing, creating fake specialties, making claims that are not evidence-based, desperately trying to build a pseudoscience by going through the motions of science.
NMS-DC actually demonstrates this by saying that evidence will validate chiropractic in the future. That’s putting it backwards. To be science-based, you have to already have the evidence to support your claims, not use science to back fill in claims and practices you already have. Classic pseudoscience.
So, the reason that you hear different kinds of objections from us at different times is because we are talking about different aspects of chiropractic. Some of it violates basic science. Some of it uses poor science. Some has no evidence, some uses bad evidence. And some (spinal manipulation for acute uncomplicated lower back strain) actually has evidence of efficacy (but not superiority to other options) It depends upon what specific chiropractic claim or practice you are talking about.
So – let’s see the published scientific evidence adequate to establish that any chiropractic practice can improve traumatic brain injury or wake someone from a coma. I’ll wait.
And one more type of chiropractor of less renown but a major source of chiropractic income in some spheres:
The chiropractor who is linked casually to plaintiff attorneys (some MDs do this also) and in auto insurance PIP states where there is the first 10,000 dollars in medical bills available ripe for the pickings, no questions asked…the auto accident with subjective complaints gets treated 3 times a week with every modality available in the office, each report after the visit describes improvement. When the 10K runs out, the lawyer gets the plaintiff back and files a suit for permanent injury, with the chiropractor a witness that there is permanent injury to this disc space and that disc space, etc. and with most MRI studies of the spine in adults showing disc abnormalities, and with no pre-accident MRI to compare, combined with the awareness of the plaintiff that permanent injuries are more handsomely compensated….you can see where this is going. Be aware that the science of rating permanent spine injury in order to come up with an objective numerical figure for compensation purposes is equivalent to magic and is basically subjective. Then add that for a plaintiff under such circumstances to be challenged or doubted regarding pain (which cannot be measured in another) results in an escalation of subjective symptoms, often described as catastrophizing, or symptom magnification…and voila! a permanently impaired invalid is created. Next step: application for SSI or other disability claim. What an awful system. Some auto accident claimants embroiled in this system report two or more simultaneous claims under litigation, presenting an impossible situation for analysis.
In some arenas, this scam is a major source of income for chiropractors. A similar scam was recently uncovered in New York involving some MDs and union officials, as I recall, perhaps with the Long Island RR?
I just read this awesome post by Dr. Novella, Thank you again. I am only about halfway through the comments and this may not be that profound of a thought. But I just sat down and made a rough estimate of my anesthesiology training, including call and normal days of the week. This comes to roughly 10,000 hours of providing anesthesia to patients. I also did a fellowship which focused specifically on acute pain/regional/ nerve blocks and that was an additional 3000 hours. As a new anesthesiology attending for the last six months a few times a week I am consulting my more experienced colleagues regarding specific patient problems, different anesthetic approaches, and different managment decisions. It is a challenge everyday. I could not imagine performing as a board certified anesthesiologist on 300 hours of training. To say it would be dangerous is an understatement. The practice of any medical or surgical specialty is so varied and complex. Reading the American Chiropractic Neurology Board website provided a good laugh. I look forward to the day when chiropractors want to lay claim to my chosen specialty with dread.
The auto accident routine is being translated into a VA service connected disability routine, with chiropractic neurologists hoping to position themselves as TBI experts. They’re actively inserting themselves into brain injury networks. So it’s really important that we educate the public about the difference between chiro neurologists and real neurologists ASAP.
@ chris repetsky
“Again, I’m not claiming this literature cannot exist. I’m simply saying in my years of research, I have never been able to find anything worthwhile. I’d gladly accept a source or two if you have them. I’m willing to admit I’m wrong.”
here are a few studies:
http://www.ncbi.nlm.nih.gov/pubmed/20053720
http://www.ncbi.nlm.nih.gov/pubmed/21334541 (this one is preliminary and has limitations which are fully stated but interesting nonetheless)
http://www.ncbi.nlm.nih.gov/pubmed/21407100
http://www.ncbi.nlm.nih.gov/pubmed/20889389
I would also like to add that most LBP studies to date are suffering from a serious design flaw as LBP is not a specific diagnosis, it is a symptom. When studies using clinical prediction rules and subgrouping of LBP patients come along the efficacy for SMT will be better understood. Most of the studies to date would be equivalent to taking patients with abdominal pain and randomly perfroming appendectomies. It will work for those with appendicitis, some will have benefit via placebo and some it will not help at all.
@ lizditz
“1. Do you consider a chiropractic neurologist to be the equivalent of an MD or DO neurologist in education, training, and expertise?
I can not speak for NMS DC but would like to address your first question and the answer is an unequivocal no. Furthermore, if a chiropractic neurologist is using the term neurologist without chiro before it then this person should be reported to their respective state board.
@ cowy1
“There are also Chiropracty Internists (http://www.councildid.com/index2.html) and radiologists (www.dabcr.com). Kind of hilarious.”
The radiology program is actually a 3 to 4 year residency with a minimum of 4000 hours on top of the 400 hours of radiology in chiro school. Are chiro radiologists the same as MD radiologists? No. The chiro radiologists focus on MSK imaging.
Here is an iteresting little study:
http://www.ncbi.nlm.nih.gov/pubmed/12221360
A lot of commentary has been added since my visit yesterday, if I forget to address specific questions, please remind me and I’ll get to it
@Harriett
I was referring to your rebuttal of Dr. Carrick’s 1997 paper on blind spot mapping. I believe I read it at QuackWatch. I do apologize for my tone towards you, we can disagree and not be disagreeable.
You wrote:
I have repeatedly seen a different slippery slope in my discussions with chiropractors.
Chiro: X works.
Me: How do you know X works?
Chiro: Quotes article.
Me: Article isn’t acceptable evidence because….
Chiro: Yeah, I admit it is poor quality evidence, but we’re working to get better evidence.
Me: What if better studies show X doesn’t work?
Chiro: I know it works on my patients.
Me: You could be mistaken; that’s what science is for – to test our beliefs.
Chiro: You’re prejudiced and ignorant and I’m not talking to you any more.”
I understand your argument and agree how those types of conversations can degenerate and be unproductive. If I could make a constructive suggestion it would be that you engage these debates with chiropractic academics, or chiropractic scientists (DC/PhDs). We will discuss chiropractic sciences critically, objective and unemotionally. I do appreciate your reply though. I look forward to Nov 29th post.
@Quill
“Oh dear, nms-dc. Playing the conspiracy card now? That’s pretty bad. What’s next, claiming Pfizer is tapping your phone?”
Quill, with all due respect, I was referring to the Will vs. AMA case antitrust case. Have you not heard of it? In fairness I didn’t either until my first year in my history of chiropractic course. Please see the link provided http://en.wikipedia.org/wiki/Wilk_v._American_Medical_Association
@Jann
“If the DC neurologists’ interpretation/application of neuroscience had any validity then obviously MD neurologists would be employing the same interpretation/application and using the same therapies.”
Well, MDs generally don’t perform spinal manipulation, and generally aren’t interested in conservative therapies. I would like too add that chiropractic neurology is more than just applying manipulative techniques to neurological cases. The Crosby case I was referring to was multi-modal and didn’t involve anything controversial like homeopathy or other alt-med approaches.
“basically you seem to be arguing that somehow DC neurologists are better at interpreting and applying neuroscience than MD neurologists. You’re not going to get anyone to agree to that — I doubt even a DC neurologist would agree.”
I did not state that Jann. I do not think DC neuros are better at interpretation and application of neuroscience. I just think that they have a different way of looking at rehabbing neuro cases, and that their approach might broaden the spectrum of how science understands and treats neuro conditions, and specifically to this article, vestibular rehab.
Regards,
NMS-DC
“most LBP studies to date are suffering from a serious design flaw as LBP is not a specific diagnosis, it is a symptom. When studies using clinical prediction rules and subgrouping of LBP patients come along the efficacy for SMT will be better understood. Most of the studies to date would be equivalent to taking patients with abdominal pain and randomly perfroming appendectomies. It will work for those with appendicitis, some will have benefit via placebo and some it will not help at all.”
Why is it that chiropractors doing these studies have not defined what kind of LBP they can treat successfully?
I don’t have the reference handy, but I believe the existing clinical prediction rules for SMT were developed by non-chiropractors. Why have chiropractors not studied their various techniques in comparison with each other and rejected those that are less effective? Can you imagine surgeons continuing to lump all abdominal pain patients together and doing appendectomies on them all? After over a century of study? This really highlights the difference between the scientific approach and the chiropractic approach.
@NMS-DC ” If I could make a constructive suggestion it would be that you engage these debates with chiropractic academics, or chiropractic scientists (DC/PhDs). ”
Do you know who Stephen Perle is? We had a long discussion with him on the Quackwatch Healthfraud list. He was courteous and rational, but ultimately could not support his claims with satisfactory evidence and he gave up and exited the list.
GLaDOS,
Thanks for the info re the chiropractic neurologists infiltrating the VA to provide TBI “expertise”. I’d like to hear more about the VA connection.
@lizditz
1. Do you consider a chiropractic neurologist to be the equivalent of an MD or DO neurologist in education, training, and expertise?
No I do not.
2. The program offered by the Brain Balance franchises advertises itself as “clinically proven to help children overcome unique challenges”. I am particularly interested in dyslexia. How does chiropractic neurology characterize dyslexia and how can spinal manipulation improve reading?
I am not familiar with the BB franchise so I can’t directly comment on it. I can provide you with a bit of information however regarding some of the concepts (not proven) regarding conditions like ADHD/autism/dyslexia. Here in the exerpt:
“We outline the basis of how functional disconnection with reduced activity and coherence in the right hemisphere would explain all of the symptoms of autistic spectrum disorder as well as the observed increases in sympathetic activation. If the problem of autistic spectrum disorder is primarily one of desynchronization and ineffective interhemispheric communication, then the best way to address the symptoms is to improve coordination between areas of the brain. To do that the best approach would include multimodal therapeusis that would include a combination of somatosensory, cognitive, behavioral, and biochemical interventions all directed at improving overall health, reducing inflammation and increasing right hemisphere activity to the level that it becomes temporally coherent with the left hemisphere. We hypothesize that the unilateral increased hemispheric stimulation has the effect of increasing the temporal oscillations within the thalamocortical pathways bringing it closer to the oscillation rate of the adequately functioning hemisphere. We propose that increasing the baseline oscillation speed of one entire hemisphere will enhance the coordination and coherence between the two hemispheres allowing for enhanced motor and cognitive binding.” Here is the link http://www.ncbi.nlm.nih.gov/pubmed/19774789
Anyways, the take home point was that the treatment isn’t only manipulative therapy, but also ” somatosensory, cognitive, behavioral, and biochemical interventions” I can’t go too deep in this subject (ADHD/dyslexia/autism and related disorders) as my professional interests are more in NMS rehabilitation/sports medicine.
Your 2nd post
ore for @NMS-DC:
“My word, chiropractic has been around since 1895, and still needs another 5 to 10 years to be validated by research?”
True, scientific research into chiropractic has only really been around since the late 70s, early 80s, and it only now starting to reach a level of maturity and capacity that would be considered to be at the mainstream scientifically acceptable levels. That being said, some core concepts such as the identifying precisely the specific biomechanics/kinematic markers of joint dysfunction are well underway with the technology allowing us now to get a much better idea of spinal biomechanics and how this affects neuromuscular responses. Also, the specific biological effects behind SMT are further being elucidated, research looking into how mechanical forces on tissues is tranduced into a therapeutic effects (this covers joint and soft tissue techniques) as well as getting a better understanding of the role of joint dysfunction and specific reflexes that occur segmentally in the spine, other autonomic reflexes such as somato-visceral responses. There are also many RCTs that are currently underway but that will have to be for another thread.
“She is married to a chiropractor who was named Head of the New Zealand College of Chiropractic last year. I think that would have an impact on her objectivity”
I was not aware that she is married to a DC, and I do think that’s a relevant point. But having read both her papers (2005, 2011) she is not a chiropractic cheerleader. I personally found her most recent article to be almost sympathetic to the plight of subluxation-based chiropractors (how the CCEI and chiropractic academics are “steering” chiropractic into a limited specialty as manual NMS experts) who are seeing their clout and vision of dissipate in the EBM era. Thanks for information though, learned something new.
Regards,
NMS-DC
Regards,
NMS-DC
@Harriet
Yes I know of Dr. Perle. Can you provide me a link to your discussions? What claims was he making?
NMS-DC
@NMS-DC,
The discussions took place a long time ago. I don’t know if they would still be available in an archive. The details are hazy this long after the fact, but his main claim was that chiropractic was reforming and becoming scientific, and he did convince me that he was sincerely involved in reform efforts, but he didn’t convince me that chiropractic as a whole was reforming or even was listening to him. And if I remember correctly, he advocated the use of activators.
@ NMS-DC
“Well, MDs generally don’t perform spinal manipulation, and generally aren’t interested in conservative therapies.”
Absolutely false statement. Regarding back pain in specific one never immediately jumps to laminectomy, diskectomy, fusion, etc. You may find some neurosurgeons or orthopedic surgeons that may jump the gun on spinal surgery, any surgery for that matter but most will consult PT for treatment, utilize NSAIDS and acetaminophen, recommend excercise and weight loss. Most physicians realize that low back pain is a self-limited disease/symptom that will eventually resolve on its own. If a patient develops chronic low back pain they then may be sent to Chronic pain physicians that may try some invasive techniques to avoid spine surgery. If all of that fails then if the surgeon feels the problem may be treated successfully with spine surgery (by using RCT’s and science based medicine) then they may operate. There may be some conditions-spinal trauma, severe scoliosis, or discs impinging nerve roots causing neurologic deficits, that must be treated with surgery to minimize neurologic deficit. If you as a DC ever recommend against surgery in spinal trauma, scoliosis, etc then you are fooling yourself and commiting malpractice my friend.
It is nonsense that physicians never try the conservative therapies first. Smoking cessation, weight loss, excercise, healthy diet is always reccomended to prevent risk of COPD/Lung CA, CAD, PVD, etc. Many patients will not make these adjustments and treating the diseases with medications would be the next on the list.
One more thing, I occasionally see “RTFA” or “RTFB” pop up in your posts. I am assuming you are saying “REad the fucking article” and “read the fucking blog” as I googled these abbreviations and they seem to fit in context. If I am misinterpreting I apologize but if I am correct is derogatory language really necessary?
@Harriet
I will see if I can comb through the archives. Would be interesting to see. As far as chiropractic becoming scientific you and I have divergent views and contexts. What I mean by that is there are only 2 Canadian chiropractic schools, both of whom make no reference to the VSC and whose educational curricula is centred around neuromusculoskeletal practice. Both these institutions I would argue are “scientific chiropractic” as both are either in universities or have affiliations with universities and have a conducting scientific research into manual therapy, SMT and things there are pertinent to chiropractic clinical practice. These schools do not promote DCs as a PCP, and the professors there have PhDs and are from health related disciplines. For example, my neuroscience course was taught by a PhD in neuroscience and not a DC. Same goes for anatomy, neuroanatomy, immunology, microbiology and all the other basic sciences courses I took at my time of study (2002-2006). I had previously received my Honors Bachelor of Science degree. I feel very comfortable in discussing the literature and know had research methods courses in both my chiropractic and undergraduate degrees. I will always cite peer-reviewed literature in debating here. It’s a standard I hold myself up to and expect the same from others here that I debating with. Bottom line is I want you to feel like you can communicate with me in an honest and open manner and I won’t be a mindless chiropractic defender. I acknowledge the limitations of my profession in certain domains and am not a “true believer” which implies that I am a mindless drone who is part of cult and am unable to critically think. I would hope that you could extend me that courtesy until proven otherwise.
I also understand, however, your context, where there are schools in the US such as Sherman and Life who are promoting a subluxation-based, philosophy-heavy, straight/Palmer view of chiropractic which is rightfully the target of skeptics and critics. I realize that my post is anecdotal, but if you would indulge me and visit the CMCC and UQTR websites, you could give me your impression of the research occurring at these schools and the limitations that you see and perhaps what specific evidence you require as a chiropractic skeptic that might make you “accept” that, in some limited form, perhaps, there is a scientific “branch” of the profession that strives for genuine integration in the “conventional” health care system.
http://www.cmcc.ca/Page.aspx?pid=355
https://oraprdnt.uqtr.uquebec.ca/pls/public/gscw031?owa_no_site=722&owa_no_fiche=1&owa_apercu=N&owa_imprimable=N&owa_bottin=
Unfortunately the second school is in Quebec and it’s in French (I am bilingual but assume that you are not fluent in French). I was hoping that they would have a page in English. Anyways, if you would indulge me and perhaps make quick list of specific scientific criticisms of chiropractic I might be able to gain a better understanding of your POV. Is your main critique regarding the concept of joint dysfunction/subluxation or is it broader than that? I’d like us to focus, if we can, on spinal manipulation and not debate paradigms which are philosophy-driven which is not really the purpose of your website.
A long winded reply, but I’m just trying to clarify certain things so we can have productive discussions.
Regards,
NMS-DC
Regards,
NMS-DC
@NMS-DC,
I have always agreed that SMT is effective for certain types of musculoskeletal pain: I have seen it work, and the literature confirms that it is effective for LBP (although not more effective than other treatments). It is unfortunate that the effective contributions of chiropractic have been discredited by association with all the nonsense that the majority of chiropractors have engaged in. I would love to know what happens on an anatomical and physiological level during a chiropractic adjustment. After a century of practice, it is far past the time when chiropractors should be figuring out just what it is they have been doing. I acknowledge that there are scientific-minded people in chiropractic who are trying to figure that out. I strongly support good scientific research on SMT, but the quality of research so far has varied wildly. Carrick’s study that I critiqued was not good science and should never have been published. We need more solid science, preferably published in mainstream (not chiropractic) journals and verified independently by different groups of researchers.
By the way, you assume wrong. I read French fluently, although I do not speak it well.
@ harriet hall
“Why is it that chiropractors doing these studies have not defined what kind of LBP they can treat successfully?”
I am not sure as I was not involved in designing these studies.
“After over a century of study? This really highlights the difference between the scientific approach and the chiropractic approach.”
RCT outcome studies are extremely expensive and need funding of which mostly comes from NCCAM. NCCAM didn’t break a 10 million budget until the late 1980′s. So, it is more like 30 to 40 years of study not a century.
Also, it seems as though you are implying allopathic medicine has been engraved in EBM since its beginnings and we both know this is not true. I will be generous and give you since the 1950′s.
@jhawk,
The fact remains that chiropractors have been doing something they don’t understand for over a century without any attempt to discriminate who should be treated and which treatments to use. The selection of patients for appendectomy and the choice of surgical procedure were established long before the term EBM was coined, although research has continued and diagnosis and treatment have been refined. The diagnosis and treatment of “subluxation” has not made any significant progress, and chiropractic has never given up on anything except perhaps the nerve tracing nonsense of BJ Palmer. And chiropractors did not have to wait for NCCAM to do research. RCT outcome studies may be expensive, but other less expensive kinds of studies were possible.
@jhawk
Thank you for the response. I took a little time to check these out, and had the following comments jotted down on my notepad:
I often am skeptical of studies that utilize subjective responses from patients only (IE: a visual pain scale, word of mouth reporting, etc.) because the subjective sensation of pain can differ vastly between people in a wide variety of ways.
That being said however, I could see the results of this study being plausible, since I did mention before that the Cochrane Collaboration did find SMT for lower back pain to be at least equal to other interventions.
For this study, the limitations you suggested are there, yes. However, it would be interesting to see follow up to this with more stringent methodology. I wonder if they are planning on doing so? I’d imagine one would just have to wait and watch the website of the facility to see if any research is in the works.
For this one, I couldn’t find out whom was reporting the outcomes of each patient and how they were measured. Perhaps one of you guys could help me out here?
This study is one of the ones I had looked at above when NMS-DC responded to me. The issue I had with this study is that SMT was being delivered along with conventional treatments. Therefore, it would be difficult to attribute results to any one of those treatments alone. Also, they compare that treatment grouping to “family physician directed-usual care”, but I was unable to find exactly what that means.
I agree with you concerning LBP. It’s going to be very tricky, as there are so many different possible underlying causes. It will be interesting to see how research proceeds once more headway is made into the exact specifics concerning LBP.
@ Harriet Hall
“The fact remains that chiropractors have been doing something they don’t understand for over a century without any attempt to discriminate who should be treated and which treatments to use.”
I disagree as many chiro’s are discriminating who should be treated and which treatments to use everyday in practice by taking a history, perfroming a physical exam, arriving at a diagnosis and then performing any number of manual therapy procedures. Hopefully the research will catch up.
“And chiropractors did not have to wait for NCCAM to do research. RCT outcome studies may be expensive, but other less expensive kinds of studies were possible.”
Yes, but would you even consider these less expensive studies evidence? If responses to posts of non RCT on this website are any hint, then I would have to say no.
@NMS-DC
I’ll give you credit for refining your argument over time as I read your posts.
And when Steven Novella says,
“…science-based, you have to already have the evidence to support your claims, not use science to back fill in claims and practices you already have. Classic pseudoscience.”
Don’t take him seriously. By this definition, the evolution of alchemy to chemistry and the evolution of astrology to astronomy could both be dismissed by prior biases. Classic SBM bias. I think science can overwrite beliefs in a profession over time and with a willful minority.
I hate speaking up here, but this seemed an unusually unscientific dismissal even for this forum.
@jhawk,
“many chiro’s are discriminating who should be treated and which treatments to use everyday in practice by taking a history, perfroming a physical exam, arriving at a diagnosis and then performing any number of manual therapy procedures. Hopefully the research will catch up.” You believe they can discriminate, but many chiros are diagnosing subluxations in every patient and treating every patient with their preferred modality: for instance NUCCA. “The research will catch up” sounds like “we are right and the science will prove that what we are doing works” which is a pseudoscientific approach rather than the scientific “Maybe some of what we are doing doesn’t work, let’s find out what works.”
“would you even consider these less expensive studies evidence?”
Yes, we would; preliminary evidence. If non-RCT studies had been well done and were very promising, mainstream scientists would have been spurred to do more definitive studies.
@JPZ, I don’t understand your point about not taking Dr. Novella seriously. Pseudoscience typically would try to prove beliefs about astrology were true; science would test those beliefs to find out if they were true. There was once a bias towards believing in astrology, but it was quickly overcome by the evidence. “Classic SBM bias”? By definition, SBM does everything possible to minimize bias.
@HH
If members of what you define as a pseudoscientific group, test their beliefs to find the scientific truth of them, that is not to “back fill in claims” as Steve claims (you could call me Dr., I could call you Col., there are titles aplenty here – and it doesn’t cut him any slack for you to call him “Dr. Novella” to defend his point of view – I suspect that “Dr.” insistance is hospital bias – I used to insist on it too when I was quite a bit younger – how about we go for science bias?).
The people who looked at astrology and tested its tenents created the “evidence” you speak of that led to astronomy (Da Vinci notebooks I think). Do you think outsiders attacked unscientific beliefs in alchemy and astrology? I will need some evidence of that given the pervasiveness of alchemy in the 1500′s during the Royal Society’s formative period. I think I got that from the discovery of phosphorus, but I would need to check into it more. As much as I would like to, you can’t just cite everything willy-nilly here with a limit of 2.
Science overcame belief from within, as NMS-DC is claiming for chiropractery now. I have no idea if that is true, but I read his CMCC website reference and found maybe 10% of their science directly addressing whether chiropractic principles are real. NMS-DC also called me a troll, so I am disinclined to speak up for anything s/he says.
If you can say that SBM minimizes bias, I am going to guess that you have missed my posts in the last week. If one takes the Baysean prior and makes the SBM subjective assumption that certain kinds of scientifically-valid data (e.g. even though they are meeting Bradford-Hill criteria for example) do not meet the SBM standard of evidence due to biases against unpopular fields of study on SBM, then there is a systematic bias here, the SBM bias. The Baysean prior cannot be determined based on exclusion of relevant data; therefore, the concept of using the Baysean prior as a dismissal of any unpopular discussion on SBM is flawed based on the SBM bias. Wow, that one just came to me as I typed it. It overreaches a bit because some fields are flawed en face (homeopathy, reiki, etc.), but I am attempting to argue from a middle groud.
You might need to read my previous posts for more details, but here is an example of a dietary supplement study that meets my standard (http://www.ncbi.nlm.nih.gov/pubmed/20434961). The subsequent JAMA study was specific to Alzheimers not cognitive decline in otherwise healthy people.
So, no. I do not take Steve’s comments seriously. They are flawed, en face.
@JPZ,
“the SBM subjective assumption that certain kinds of scientifically-valid data (e.g. even though they are meeting Bradford-Hill criteria for example) do not meet the SBM standard of evidence due to biases against unpopular fields of study on SBM”
You have set up a straw man to knock down. This does not accurately represent what SBM is all about.
@HH
Not straw man. I presented evidence that Scott Gavura ignored evidence that he mis-interpreted VAS measures and misinterpreted why the drop-out rate is so high in pain studies. I also discounted his evidence that the EU has rejected probiotic supplements, and I rejected his one review based on expert evidence that it was unscientific. I mean to say to avoid further dismissal, WOO science on SBM.
SBM reinforces what I have said. What other evidence do I need to provide?
@JPZ,
Straw man. You said “What I don’t understand is the default dismissal on SBM of any case where there is some but incomplete evidence.”
SBM does not just dismiss any case where there is some but incomplete evidence. Any of our regular readers will recall many examples where an SBM article says there is some but incomplete evidence and that accepting the claim is not justified without further evidence. That does not constitute dismissal. I think you are reading “dismissal” where we are writing “insufficient evidence for acceptance.”
@JPZ
Just a few things I’d like to mention before getting to bed. First, sorry for calling you a troll. I’ve come to see with your posts that you, like me, try to strive for the middle ground and I can say that you’ve approached this debate with an open mind, which all I ever wanted. Second, you stated that you “found maybe 10% of their science directly addressing whether chiropractic principles are real”. That brings up a couple of questions if you don’t mind
1) which science are you referring to when addressing chiropractic principles? SMT? Because there is a lot of studies IMHO that may not be directly related to SMT but address neuromuscular, stabilization, and other topics pertinent to clinical chiropractic practice. Where does the 10% number come from
2)Which principles to you personally have problems with or find to be scientifically reputable. I often hear of discussion here regarding chiropractic principles and I’m not entirely sure we are talking about the same things. It’s worth clarifying. I am not referring to the 33 principles that was part of traditional straight/subluxation-based chiropractic but underlying principles that forms the basis of contemporary chiropractic practice.
Also, I appreciate your ability to call a spade a spade. I refer to many posters here trolls, lemmings and parrots, because they really ever challenge the editors even though, at times, like this post by Novella, there’s some egregious errors ranging from not reading the material, to not performing valid PubMed Search and then arriving at a conclusion that did not support his hypothesis then trying to pin the whole of Sidney Crosby’s recovery on placebo and cheerleader effect without knowing what specific treatment Crosby did get (I had to tell him afterwards as I have the full article and not merely a snippet online which was used in as part of this argument.
I also agree 100% on your perceived bias at SBM and agree with your statement. But perhaps Harriet can enlighten us otherwise.
@Harriett
I have read your reply and will reply in kind tomorrow. I’m very impressed that you can read in French; a pleasant surprise. I was born and raised near Quebec and my mom is from there so I’ve been lucky enough to live the two cultures. I am also happy to hear you would like to read some basic science research into SMT and its effect on tissue mechanics and neurophysiology. Kawchuck, Pickar, Descarreaux, Triano, Blouin, Szerbely are all DC/PhDs studying this at the present (that I know of in Canada anyways).
This study looks interesting: http://www.ncbi.nlm.nih.gov/pubmed/21708042
We can finish up our discussion, there a few other topics that I’d like to get your opinion on.
Regards,
NMS-DC
@ NMS-DC
“I did not state that Jann. I do not think DC neuros are better at interpretation and application of neuroscience. I just think that they have a different way of looking at rehabbing neuro cases, and that their approach might broaden the spectrum of how science understands and treats neuro conditions, and specifically to this article, vestibular rehab.”
I didn’t say you stated that, I said it appears to the basis of your argument, because you said DCs and MDs “are both using the same pool of information, we’re just applying it differently.” Dr. Novella’s post argues that the DC interpretation is not just “different,” it is, in fact, incorrect. You think the DC position is correct. So, in essence what you are arguing is that DC neurologists are better at interpreting and applying neuroscience than MD neurologists.
However, now your comment indicates that this is not true, that MDs are in fact better than DCs in interpretation and application of neuroscience. Yet you continue to insist that the DCs just have “a different way of looking at rehabbing neuro cases.” But if an MD neurologist says it’s not just “different,” it is “incorrect,” and MD neurologists are better able to interpret and apply the neuroscience, why do you support the DC interpretation over the MD interpretation?
As I pointed out, if the DC neurologists’ treatments had any validity MD neurologists would employ them. Your answer was that “MDs don’t generally perform spinal manipulation.” That fails to address my point: they could use any of the DC treatments they thought valid, but they don’t because they don’t think they are valid. The second part of your answer was that MDs “generally aren’t interested in conservative therapies,” an assertion that you pulled out of thin air and, again, fails to address my point. In any event, MDs neurologists don’t eschew “chiropractic neurology” because it is a “conservative treatment,” they do so because they don’t think it’s valid.
In sum, although you deny that DC neurologists are better at interpretation of the neuroscience, you continue to support their interpretation over that of an MD neurologist.
@NMS-DC,
“This study looks interesting: http://www.ncbi.nlm.nih.gov/pubmed/21708042”
The link is to a study protocol, not a completed study. It supports the claim that chiropractic is being studied. It doesn’t support anything else.
@ JPZ
“Don’t take him seriously. By this definition, the evolution of alchemy to chemistry and the evolution of astrology to astronomy could both be dismissed by prior biases.”
Those evolutions happened several hundred years ago. This is the 21st century, and I’d like to think that society would no longer tolerate the attitude that “hopefully the research will catch up” (per jhawk). While the “research” is “catching up” millions of chiropractic patients are being diagnosed each year with joint dysfunctions/manipulable lesions/subluxations/vertebral subluxation complex, are being treated for same. This has been going on for over 100 years. It is my understanding that you are a scientist. I would hope that you are appalled at the idea of attempting to back-fill in the science, while at the same time treating patients (and charging them for it) based on (at best) woefully incomplete and (at worst) implausible “theories” of human physiology.
@ Jann bellamy
“Those evolutions happened several hundred years ago. This is the 21st century, and I’d like to think that society would no longer tolerate the attitude that “hopefully the research will catch up” (per jhawk). ”
Yet another snipped sentence taken out of context. A commom theme on SBM. I was referring to the clinical prediciton rules being set up. The research on SMT for LBP is there. I posted some evidence previously and no one responded to the pubmed articles. Another common theme here, ignoring evidence when it doesn’t fit your belief and attacking after thought opinions.
While the “research” is “catching up” millions of chiropractic patients are being diagnosed each year with joint dysfunctions/manipulable lesions/subluxations/vertebral subluxation complex, are being treated for same.
Yes, we are a MSK specialty. We see people with MSK problems including but not limited to joint dysfunction.
This has been going on for over 100 years. It is my understanding that you are a scientist. I would hope that you are appalled at the idea of attempting to back-fill in the science, while at the same time treating patients (and charging them for it) based on (at best) woefully incomplete and (at worst) implausible “theories” of human physiology.
Are you implying that the medical profession does not back fill in science? Please tell me why one of the most common analgesic and antipyretics used today, acetaminophen, still has a mechanism of action that is not completely understood. Here in lies your bias.
@jhawk,
“one of the most common analgesic and antipyretics used today, acetaminophen, still has a mechanism of action that is not completely understood.”
You’re missing the important difference. We have overwhelming evidence that acetaminophen is effective. We don’t have that for chiropractic.
@ Harriet Hall
“You’re missing the important difference. We have overwhelming evidence that acetaminophen is effective. We don’t have that for chiropractic.”
In a previous post you said “I have always agreed that SMT is effective for certain types of musculoskeletal pain: I have seen it work, and the literature confirms that it is effective for LBP (although not more effective than other treatments). ”
So SMT is effective for LBP and now research is being done to find out the exact mechanism of action. This is not back filling in science.
@jhawk,
SMT has only been shown to have a limited degree of effectiveness for certain types of LBP, and research is justified to figure out who benefits and how it works. “Chiropractic” includes SMT with a lot of other baggage. If either SMT or other aspects of chiropractic care had the same level of evidence for efficacy that acetaminophen does, science-based physicians would have adopted them just as enthusiastically as they adopted acetaminophen.
@jhawk
studies showing the efficacy of IV APAP in perioperative and inpatients, I can provide many more for you.
http://www.ncbi.nlm.nih.gov/pubmed/22008309
http://www.ncbi.nlm.nih.gov/pubmed/21975764
http://www.ncbi.nlm.nih.gov/pubmed/21353105
http://www.ncbi.nlm.nih.gov/pubmed/21296248
http://www.ncbi.nlm.nih.gov/pubmed/21134123
This interesting study included in its Chiro treatment arm Acetaminophen. The family practice guided arm did not specify and there was no statistically significant difference between the groups. Whose to say the effectiveness in the SMT arm was not just APAP. >>>
http://www.thespinejournalonline.com/article/S1529-9430%2810%2901114-9/abstract
IN all the studies above supporting chiro for low back pain they show no better than other therapies. Though acetaminophen does not yet have a clear mechanism of action discovered yet there are a plethora of studies supporting it for all types of pain-perioperative, low back pain, chronic pain, and inpatient pain. It also has a very well defined opioid sparing effect ranging from 30-50% depending on the study (mostly perioperative pain). I have not found any studies demonstrating an opioid sparing effect of chiropractic manipulation. If you have any please point me in the right direction, I will then promptly add it to my acute perioperative pain toolbox like I did acupuncture (tongue implanted in cheek).
I responded to you with some of my thoughts above. Sorry, for some reason every time I post, my comment sits with “pending moderation” and loads of other comments jump in front of it. I don’t know why this is the case.
@ Chris Repetsky
Thanks for responding. Sorry it took me so long to get back to you but somehow I missed your response when I was reading the thread earlier.
“I often am skeptical of studies that utilize subjective responses from patients only (IE: a visual pain scale, word of mouth reporting, etc.) because the subjective sensation of pain can differ vastly between people in a wide variety of ways.”
I agree that the sensation of pain can vary widely but they used the Roland Morris Disability questionnare which has been shown to be a reliable way to measure progress of functional improvement.
“For this study, the limitations you suggested are there, yes. However, it would be interesting to see follow up to this with more stringent methodology. I wonder if they are planning on doing so? I’d imagine one would just have to wait and watch the website of the facility to see if any research is in the works.”
I was listening to an interview with the director of this clinic some time ago and if memory serves me right they are planning on more studies or at least hoping other sources will build on their model.
“For this one, I couldn’t find out whom was reporting the outcomes of each patient and how they were measured. Perhaps one of you guys could help me out here?”
They used work comp disability claims data. I would assume they used standard disability ratings but I could not find it either. Not sure if this answers your question?
“This study is one of the ones I had looked at above when NMS-DC responded to me. The issue I had with this study is that SMT was being delivered along with conventional treatments. Therefore, it would be difficult to attribute results to any one of those treatments alone.”
Agreed.
“Also, they compare that treatment grouping to “family physician directed-usual care”, but I was unable to find exactly what that means.”
Patients assigned to the UC group were referred back to a PCP who then treated at his/her own discretion. So opiates, nsaids, advice, physical therapy, massage, etc.
Hope this helps.
@ chris repetsky
“I responded to you with some of my thoughts above. Sorry, for some reason every time I post, my comment sits with “pending moderation” and loads of other comments jump in front of it. I don’t know why this is the case.”
I hear ya. I think it happens when you post more than one or two links.
Chris–It appears I have the same issue as you…my comments are always pending moderation! It appears that one of the studies I found was discussed. I think it is still interesting that the chiro arm included APAP since that topic was mentioned.
I think pain is a very difficult thing to study. It is very subjective and experienced very differently by different patients. One good method is to use opioid consumption as a gauge of pain instead of a VAS score – but this still has problems. Some people do not push PCA buttons bc it makes them feel nauseated or drowsy and they find those symptoms more unpleasant. I deal everyday with trying to get an adequete measure of pain from patients. A very difficult to assess symptom indeed.
@ Harriet Hall
“Chiropractic” includes SMT with a lot of other baggage.”
Somewhat true but this baggage is getting smaller and smaller via research.
“If either SMT or other aspects of chiropractic care had the same level of evidence for efficacy that acetaminophen does, science-based physicians would have adopted them just as enthusiastically as they adopted acetaminophen.”
Once again in a previous post you said “I have always agreed that SMT is effective for certain types of musculoskeletal pain: I have seen it work, and the literature confirms that it is effective for LBP (although not more effective than other treatments). ”
Acetaminophen is one of these other treatments. So SMT for LBP has at least the level of effectiveness of acetaminophen for LBP.
@jhawk,
Acetaminophen has been proven effective for relieving all kinds of pain. SMT has limited effectiveness for one kind of pain, and we don’t even know how to predict which patients are likely to respond. It is unfair to compare them.
@jhawk,
“Somewhat true but this baggage is getting smaller and smaller via research.”
Really? What practices has chiropractic eliminated because of research?
@jhawk:
“Yet another snipped sentence taken out of context. A commom theme on SBM. I was referring to the clinical prediciton rules being set up.”
Actually, from the “context” you were referring to “who should be treated and which treatments to use in everyday in practice:” Here’s what you said: “I disagree as many chiro’s are discriminating who should be treated and which treatments to use everyday in practice by taking a history, perfroming a physical exam, arriving at a diagnosis and then performing any number of manual therapy procedures. Hopefully the research will catch up.”
“The research on SMT for LBP is there.”
The fact that there is some moderate evidence for SMT for LBP does not justify chiropractors diagnosing and treating “joint dysfunctions/manipulable lesions/subluxations/vertebral subluxation complex” a putative condition that you cannot demonstrate even exists. The effectiveness of a single therapy for a particular symptom does not validate your assumption as to the cause of that symptom nor does it validate the diagnostic techniques you are using to determine what you think might be the cause. Likewise, it does not justify extrapolating from the effectiveness of this single therapy that many other symptoms share this putative cause or that you are therefore able to find this putative cause with your diagnostic techniques.
“Are you implying that the medical profession does not back fill in science?”
I have no idea whether they are or are not, but it is not relevant to my point. My background is not in science and I find discussions about medicine difficult to follow. However, since you raise the point, I note that it is not hard to spot the deficiencies in many of the chiropractors’ arguments on SBM even without a background in science.
@ jhawk, HH
I posted some links about 8 posts back regarding APAP but it took forever to post b/c it was “awating moderation”
It reinforces your Comment Dr. Hall->
“Acetaminophen has been proven effective for relieving all kinds of pain. SMT has limited effectiveness for one kind of pain, and we don’t even know how to predict which patients are likely to respond. It is unfair to compare them.”
@ intraneural
Thanks for posting those studies. I did not mean to imply that acetaminophen is not effective. I was just pointing out the exact mechanism of action is not fully understood.
“Whose to say the effectiveness in the SMT arm was not just APAP. >>>”
Maybe but not the point of the study. The point was to see if CPG based care including SMT was more effective than family physician usual care and they found it (CPG) to be superior. Whose to say every physician in the UC group did not prescribe acetaminophen? This is a preliminary study with limitations as I mentioned earlier.
@ Harriet Hall
“Really? What practices has chiropractic eliminated because of research?”
I was thinking of the old vitalistic concepts that I guess used to be taught at chiropractic schools and might still be at Sherman or Life college. This concept is very foreign to me as I was never taught anything about it at my school. These chiro’s (vitalistic) seem to be in the minority though.
@jhawk,
“These chiro’s (vitalistic) seem to be in the minority though.”
A much larger minority than medical doctors who practice bloodletting to balance the humors.
Scientific medicine has given up many practices when they were proven not to work; chiropractic and the rest of CAM seldom if ever give up doing anything.
@ Jann Bellamy
“The fact that there is some moderate evidence for SMT for LBP does not justify chiropractors diagnosing and treating “joint dysfunctions/manipulable lesions/subluxations/vertebral subluxation complex” a putative condition that you cannot demonstrate even exists. The effectiveness of a single therapy for a particular symptom does not validate your assumption as to the cause of that symptom nor does it validate the diagnostic techniques you are using to determine what you think might be the cause. Likewise, it does not justify extrapolating from the effectiveness of this single therapy that many other symptoms share this putative cause or that you are therefore able to find this putative cause with your diagnostic techniques. ”
First of all, I never said any of this. Obviously not all LBP is due to joint dysfunction. This is why you take a history, perfrom a physical exam and arrive at a diagnosis. Joint dysfunction is not a chiropractors only diagnosis and SMT is not the only therapy as you imply.
@ Harriet Hall
“Scientific medicine has given up many practices when they were proven not to work; chiropractic and the rest of CAM seldom if ever give up doing anything.”
The majority in chiropractic have given this vitalistic theory up and hopefully the minority will soon follow. It is ashame they have not already.
“A much larger minority than medical doctors who practice bloodletting to balance the humors.”
Harriet Hall, not only a medical doctor but a comedian as well!!
Here’s a chiropractic neurologist who helps personal injury attorneys win big after someone gets a bonk on the head with or without loss of consciousness. Now, these are legitimate cases. And remember, you must get an MRI which will show where the lesion is or evidence of shearing forces upon the brain.
http://www.youtube.com/watch?v=Azn5-NRBe5w
I would like to know:
1) How come chiropractors are allowed to order MRIs?
2) Why does that chiro in the video need a stethoscope around his neck?
lizditz,
In 2004 several VA hospitals began offering chiropractic services (West Haven VA is one; maybe Steve knows how this is working out?). For veterans not near these facilities, the VA insurance plan will pay for a certain number of visits per year with a chiropractor of the patient’s choice.
The past couple of years I’ve seen chiros networking through organizations like the Wounded Warrior Project and a few chiropractic neurologists promoting themselves as TBI experts with an interest in vets returning from Iraq and Afghanistan.
I Googled to find some examples for you. My first result isn’t what I was looking for but it’s so precious that I must use it:
http://www.ehow.com/how_8155371_treat-tbi-chiropractor.html
Just a taste:
Tips & Warnings
While there is no scientific proof of TBI treatment by chiropractors, decreases in symptoms and pain medications and an increase in function are common results following chiropractic care in those who have suffered from TBIs.
If a TBI is expected, seek a diagnosis from a neurologist.
@jhawk:
“First of all, I never said any of this. Obviously not all LBP is due to joint dysfunction. This is why you take a history, perfrom a physical exam and arrive at a diagnosis. Joint dysfunction is not a chiropractors only diagnosis and SMT is not the only therapy as you imply.
I imply neither. Let’s review the chronology of the comments: In response to Dr. Hall’s criticism that “chiropractors have been doing something they don’t understand for over a century without any attempt to discriminate who should be treated and which treatments to use,” you disagreed, saying that “taking a history, perfroming a physical exam, arriving at a diagnosis and then performing any number of manual therapy procedures. Hopefully the research will catch up.” I then pointed out (in a comment to JPZ) that “this is the 21st century, and I’d like to think that society would no longer tolerate the attitude that ‘hopefully the research will catch up’ (per jhawk). While the ‘research’ is ‘catching up’ millions of chiropractic patients are being diagnosed each year with joint dysfunctions/manipulable lesions/subluxations/vertebral subluxation complex, are being treated for same. This has been going on for over 100 years.” Next, you claimed that you were referring only to the clinical prediction rules being set up, and that I had taken your comments out of context, a mischaracterization we’ve previously cleared up. In any event, you also criticized the veracity of my comment by stating, “the research on SMT for LBP is there” the only research you reference in your response. I followed up by pointing out that chiropractors can’t legitimately use the fact that SMT is moderately effective for LBP as a justification for the existence of the dysfunction/manipulable lesion/subluxation/vertebral subluxation complex.
But, since you bring it up, as to the assertion that “not all LBP is due to joint dysfunction” let’s be clear: there is no evidence that any LBP is due to “joint dysfunction” as the term (synonymous with subluxation, manipulable lesion, etc.) is defined (to the extent it has been defined) by chiropractors.
@Jann Bellamy
“I would hope that you are appalled at the idea of attempting to back-fill in the science, while at the same time treating patients (and charging them for it) based on (at best) woefully incomplete and (at worst) implausible “theories” of human physiology.”
I think your particular characterization is just a matter of perspective. I don’t think chiropracters should be making money by claiming to treat health conditions they have no evidence they can treat, if your proposed legislation can stop them from doing that – more power to you. What you call back-fill science could also be seen as building an evidence base for the limited portion of chiropractery that someone feels actually works. If that is what they are actually doing (like discovering chemical principles that work in the midst of alchemical principles that don’t), more power to them.
But, I could try to make a joke about why it took chiropracters 100′s of years to get to their own scientific evolution… but I don’t think funny is the way to go right now.
So just to be clear: You are, right now, in the year 2011, saying many things which have not yet been validated by scientific investigation… and those things are fundamental principles of chiropractic?
@HH
I said, “What I don’t understand is the default dismissal on SBM of any case where there is some but incomplete evidence.”
You said, “SBM does not just dismiss any case where there is some but incomplete evidence.”
Ah, my use of “any” may be the problem. Let me rephrase to more accurately convey my opinion and correct my error. In my experience, if a valid scientific case is presented here in favor of an unpopular subject, many SBM commentators and contributors will not accept evidence short of two RCTs (even if they fulfill Bradford-Hill criteria to provide supporting evidence for a scientific case, for example). This is a pervasive bias on SBM, and this bias impairs the group’s ability to reach scientifically sound conclusions.
Example 1 (This thread):
When Steve says,
“To be science-based, you have to already have the evidence to support your claims, not use science to back fill in claims and practices you already have. Classic pseudoscience.”
Which means what? That chiropractors should not try to test the tenants of their profession because they are already doing it wrong? There are a lot of bad things I hear about chiropractic practices, but “don’t even try to do science” seems pretty dismissive to me.
Example 2 (Alpha Brain – What’s Wrong with the Supplement Industry? thread)
Steve says,
“Usually the claim is implied in the name of the product itself – sleepwell, or brainboost.”
“The popular product Airborne fits this mold. It is essentially a multivitamin with the unfounded claim that it will prevent infection by boosting the immune system.”
“In the US, regulations (under DSHEA) specifically allow “structure/function” claims without any requirement for evidence to back up the claims.”
To which I replied that these were illegal names for products, a fraudulent product prosecuted by the FTC, and an outright false statement (I provided links there). I think this could be called dismissal of the whole dietary supplement industry (regardless of ANY evidence) based on three false examples.
Example 3 (Constipation Myths and Facts thread)
Scott says,
“For constipation, their effectiveness hasn’t been demonstrated though. A systematic review published in 2010 examined the data supporting their use in adults and children. Five high quality trials were identified and the results were unimpressive:”
These were five trials on five different genuses or species of probiotic organisms. Professional groups and EFSA have all said that data from different organisms cannot be combined in determining efficacy (links in that thread), but this review did. It is an invalid basis for dismissal of probiotic efficacy.
Scott also says,
“…little reason to recommend their use. That’s the opinion of some regulators, too. The European Food Safety Authority has largely rejected general health claims for probiotics.”
As I pointed out to Scott in that thread, they rejected 170 of 180 requests for probiotic health claims due to incomplete paperwork. So, this is not an opinion of the regulators, and Scott has no remaining basis for dismissing the efficacy of probiotics in constipation.
Example 4 (Collagen: An implausible supplement for joint pain thread)
Scott says,
“The body doesn’t treat amino acids derived from collagen any differently than any other protein source. For this reason, the idea that collagen supplementation can be an effective treatment for joint pain, osteoarthritis, or any other condition, is highly implausible, if not impossible in principle.”
There is data supporting selective uptake of radiolabeled oral collagen into mouse cartilage (PMID 10498764) and a human imaging technique can detect increases in knee cartilage after collagen hydrolysate feeding (PMID 21251991). Proof? No. Proof enough to counter a claim of impossible? Easily.
Scott says,
“Setting aside the grandiose claims, statistical significance isn’t enough — we want clinical significance. A tiny change in pain may be enough to be statistically significant — but is it relevant in the real world?”
Dismissal by moving the goal posts? I walked him through why VAS scales don’t pick up “tiny change[s] in pain” (details in that thread) – especially when physician and patient scores agree like in the Penn State study. And, unless clinical significance is coming from a practice guideline, clinical significance is an opinion that differs between physicians.
Scott says,
“…but there’s certainly no persuasive evidence to suggest that’s the case. Based on what collagen is, how it’s absorbed, and how we know collagen is actually synthesized in the body, it’s highly implausible that 1200mg of additional protein consumed daily will have any meaningful therapeutic effects.”
I have said many times, there is not enough evidence to recommend collagen hydrolysate as a treatment for OA. Are there human clinical efficacy trials? Yes, a few, (PMID 18416885) and (PMID 19212858), but some junk trials too. Is calling this small amount of evidence “highly implausible” or “impossible” a dismissal due to SBM bias?
Those are four recent examples where I spoke up and supported my contention with evidence and data. The lack of scientifically engaged replies might also fall into the realm of dismissal of counter evidence.
So, when you said,
“SBM does not just dismiss any case where there is some but incomplete evidence. Any of our regular readers will recall many examples where an SBM article says there is some but incomplete evidence and that accepting the claim is not justified without further evidence. That does not constitute dismissal. I think you are reading “dismissal” where we are writing “insufficient evidence for acceptance.”
In reply, I cite the four most recent examples of SBM bias in posts where I have participated in the comment thread. Actually, your hoodia post was the most science and fact focused dietary supplement post I have seen here recently. If you can find something other than SBM dismissal in what I presented, I am more than open to finding where the golden mean may lie.
Whilst I have not (and will not) be my usual prolifically logorrheic self, I have been following my usual fora and these comments as well.
First, I would also like to commend NMS-DC on his change of tone and tack (well, save the RTFA comments which I was also puzzled about but didn’t look up). Now if only his understanding of science can make a commensurate shift….
Second, it is edifying to see that completely without my input, the chiro argumentation is exactly the same and the other science based commentators are all chiming in similarly as well. Makes me feel like I wasn’t crazy, despite NMS-DC’s insistence. Also, my creationist analogy is still very much apt at this point.
Jann said it very well:
Lastly, it seems that mon ami JPZ is still stuck on the basic sciences/clinical sciences issue.
As a scientist, JPZ, I find it strange you would say such a thing. You don’t “feel [something] actually works.” You have evidence for it or you don’t. The only aspect of chiro that has any evidence of actual efficacy is for chronic LBP – not any other kind. The mechanism for that is actually fairly straightforward and has to to with massage, expectancy effects, motivational encounters, and placebo responses to pain. That is why it is no more effective than any other treatment, including sham acupuncture. To try and hang the hat of chiropractic on that tiny of a nail is simply a fail.
The rest of chiropractic has extremely limited, if any, evidence for efficacy. Trying to find a mechanism by which such chiro interventions might have putative effects, without having first proven that they even have effects in the first place is precisely the back-fill bad science I had spent much time explaining in the very first thread where NMS-DC made an appearance.
To try and make a sort of tu coque argument wherein we as SB medical practitioners use acetominophen with knowing the precise MOA is a complete straw man. Doing the basic science to demonstrate why tylenol works is not bad science because there is robust evidence for and a good Bayesian as well – the subsequent science is not seeking to justify the use of it but merely to explain why it works. Chiropractic “science” does not seek to determine mechanisms for why something works, since they have no evidence that any of it works. They are seeking basic science mechanisms to string together a “just-so” type story in order to justify their continued use of what they already think works. There is a vast difference, that is entirely lost upon the chiro contingent here.
So no, that is not what they are actually doing, no matter how vehemently they try and assert it.
As for your criticsm of SBM – I agree with Dr. Hall that it is misplaced. You aren’t wrong but the sum of your arguments does not, IMO, add up to what SBM is looking for. You claim that SBM has moved goalposts on you and that your references to basic science were dismissed and that we need at least two RCTs for everything. That really is not true. As Dr. Gorksi pointed out in his FSU talk, the point of SBM was to add to the facet of EBM that led to the increase of methodolatry – taking into account basic sciences. But from an SBM perspective, basic sciences are very good at disproving things but not proving them (i.e. lowering the Bayesian prior, but not increasing it). The reason for this is that highly improbable priors, like homeopathy and reiki, are much more easy to identify than more probable priors (like collagen for OA). As I had said in our previous discussion, the post has always been the clinical application of any treatment. SBM observes that even the best bench research has a very limited clinical application and actually very rarely pans out into something clinically useful. So when you cite the bench science demonstrating collagen peptide uptake, that (from our perspective as clinical medical scientists/practitioners) actually doesn’t really change the prior all that much. We could be wrong, but to the best of knowledge as we have it today, that is a valid assessment. If bench and clinical research continues, and demonstrates that our assessment of the Bayesian prior was incorrectly low, then we here would be the first to accept that, admit our error, and correspondingly change our view. But, once again IMO, nothing you presented in the OA discussion offered cause to change that assessment. Nobody said further research shouldn’t be done (like we do for homeopathy). From a basic science perspective it looks very interesting and promising. But from a clinical medicine perspective it is still genuinely unimpressive.
So it wasn’t dismissal of evidence – it was an SBM perspective assessment of the magnitude of said evidence. Not a changing a goalposts but an explicit statement as to where the goalposts are, which indeed are very different from a bench sciences perspective (I don’t like calling them “basic” sciences, since they really are not very basic, even though that is the common parlance and I fall into it frequently).
At least, that is my opinion on the matter. I’d be happy to have Drs. Novella and/or Hall offer any corrections.
(oh, and BTW, at least for me, referring to them by title is a sign of respect for the level of knowledge and education they have. It absolutely dwarfs mine and was very hard earned. I don’t feel it is demanded of me, but I do it because I feel they deserve it. I do the same IRL, even with physicians that I worked with extensively and have had drinks with. It depends on the situation, of course, but I do not know these physicians well enough to feel comfortable calling them by first name – it was mentioned somewhere up on the thread, so I thought I’d kick in my two cents on the matter).
I’ll check back on this at some point, but I am actually quite busy running errands and seeing family and whatnot, but had some time and desire to chime in.
Thanks, nybgrus. You have explained it very nicely. As I said, he was reading “dismissal” where we are writing “insufficient evidence for acceptance.”
As for using titles, I do know my colleagues well enough to call them by their first names, but I think it is a courtesy to use their titles when referring to them in a discussion with third parties. It’s a cultural thing, and I am not always consistent. It really is unimportant and irrelevant to the discussion. Our critics frequently use diversions like that when they can’t find anything more substantive to say about the topic under discussion.
For future reference, I don’t care what people call me as long as it is polite and is not intended as a subtle put-down. I have been called “Ms. Hall” by people who didn’t know any better and didn’t intend any disrespect and also by those who wanted to insult me.
@ Jann Bellamy
“But, since you bring it up, as to the assertion that “not all LBP is due to joint dysfunction” let’s be clear: there is no evidence that any LBP is due to “joint dysfunction” as the term (synonymous with subluxation, manipulable lesion, etc.) is defined (to the extent it has been defined) by chiropractors”
Actually, two of the known pain generators in LBP are the facet joints (http://www.ncbi.nlm.nih.gov/pubmed/8059268) and the SI joints (http://www.ncbi.nlm.nih.gov/pubmed/7709277). These two structures can be painful due to irritation or scar tissue lay down. Either way these structures can have limited motion due to this irritation or scar tissue and this equals joint dysfunction.
You could justify calling LBP “joint dysfunction” because there are joints in the back and if a patient is in pain, something is obviously not functioning normally. “Joint dysfunction” can be used as a replacement for “subluxation” to justify manipulating anything a chiropractor wants to manipulate. Like subluxation, it is not meaningfully defined.
Awr, I feel a little bad now that I called Steve, “Steve” instead of “Dr. Novella” a few comments up. But I have to blame too many hours spent listening to The Skeptic’s Guide to the Universe,” which is awesome btw.
Speaking of podcasts, Brian Dunning did a really good job on this one, which you all should listen to:
http://skeptoid.com/episodes/4283
JPZ, don’t be sad that nobody cares about rat level evidence –and by “nobody” I mean working physicians.
It is good that researchers care and invest a lot of time into sorting out potential novel treatments. Keep at it. More power to ya. Just don’t expect busy doctors to pay any attention to the rat stuff.
Kinda cool about the mice eating Jello and having bits of it getting into their cartilage. I wonder what percentage of the gelatin placed in the mouse gut is getting absorbed as amino acids verses small peptides.
I eat a lot of Trolli worms but my nails are crap. What is up with that?
@ Harriet Hall
“You could justify calling LBP “joint dysfunction” because there are joints in the back and if a patient is in pain, something is obviously not functioning normally. “Joint dysfunction” can be used as a replacement for “subluxation” to justify manipulating anything a chiropractor wants to manipulate. Like subluxation, it is not meaningfully defined.”
ACA’s definiton of subluxation:
A motion segment, in which alignment, movement integrity, and/or physiological function are altered although contact between joint surfaces remains intact.
Before joint dysfunction is diagnosed you must have ruled out sinister pathology as well as other causes of LBP (instability, disc herniation, internal disc derangement, sprain /strain, etc.). Then you must also have tenderness/pain, range of motion abnormality, assymetry and or tissue texture change. This is how it is taught in chiro school not LBP equals jont dysfunction equals adjust.
@jhawk,
“Before joint dysfunction is diagnosed you must have ruled out sinister pathology as well as other causes of LBP (instability, disc herniation, internal disc derangement, sprain /strain, etc.). Then you must also have tenderness/pain, range of motion abnormality, assymetry and or tissue texture change.”
I’m not convinced that chiropractors can objectively and reliability do all that. I’m not convinced that chiropractic’s “joint dysfunction” is a valid diagnosis. I’m not convinced that making that diagnosis discriminates which patients will benefit from manipulation.
Thank you Dr. Hall. I am still very much learning, so thank you for taking the time to comment on my post.
I really think that is the sole issue JPZ has been having – that bridge between the bench and clinical sciences. I guess a simpler way of putting it would be that even the absolute best bench science findings have a sort of “capped” upper limit for the prior – which is still relatively small. I don’t think we can reasonably assign an actual value to it, but no matter what, bench science can never be justifiably used in a clinical application (don’t misread me – that can mean that it should be quickly and robustly assessed in clinical trials, but just not rushed into clinical practice). My step father is a critical care doc and we were chatting just the two days ago and his take is that he always waits at least 12-24 months before beginning to use new drugs. Hence, his practice was little affected by the whole Xigris thing that Dr. Crislip wrote about (that and he thought the evidence was slim). I think that also reflects the SBM ethos regarding early studies and the decline effect.
As for titles, of course – if someone doesn’t know better then why would one be offended? But it certainly CAN be used as a derogatory. I’m sure if I started calling you by first name on this forum you wouldn’t be offended, but from my end I don’t know you well enough to do so, and even if I did I probably still would use your title. As I said, your knowledge (and those of the other contributors here) absolutely dwarfs mine and I think it is a reasonable sign of respect that is hard earned and well deserved, despite not being demanded.
Hey, I remember that! Indeed, you even cited a specific law. Wasn’t I the one who pointed out that your own citation included an explanation for how a product name could get away with it so long as they played the non-disease game, and how the page you cited even provided an example for it?
Weren’t you also informed at that time that the same product, in spite of the prosecution, is still sold under the same name and as a product which “supports the immune system” because the ruling only required them to stop referring to diseases directly?
MEEEEEEEMMMMORY all alooOOOoone in the mooOOonlight
I can smile at the ooOOOoold days
I was beautiful then
I hope the singing wasn’t too much.
@ConspicuousCarl
And did you read my replies? You pointed out very pertinent aspects of the law that require cross-referencing with other laws to properly understand. I believe I provided those cross-references.
@nybgrus
“As a scientist, JPZ, I find it strange you would say such a thing. You don’t “feel [something] actually works.”
Sure you do, it is called a “hypothesis.” You don’t start off with proof of your hypothesis, so you test it. If a chiropracter believes a procedure has real health benefits but knows that there is no proof of efficacy, what is wrong with testing the hypothesis that the procedure works? One guy is developing a sham control for a neck procedure at CMCC, which sounds like a step in the right direction for better procedure validation.
“Trying to find a mechanism by which such chiro interventions might have putative effects, without having first proven that they even have effects in the first place is precisely the back-fill bad science I had spent much time explaining in the very first thread where NMS-DC made an appearance.”
My assumption was that a procedure is hypothesized to have a beneficial effect, and the procedure is tested to determine if the benefit is real. If chiros don’t know how to best test a procedure but they hypothesize a potential benefit, what is the harm in looking for more sensitive biomarkers before you begin your efficacy testing? I think you are having NMC-DC’s conversation with me.
“So no, that is not what they are actually doing, no matter how vehemently they try and assert it”
OK, and I have always said that you know more about it than I do on this topic. Just some of the comment here against chiro science seem to violate some fundamental aspects of the scientific method.
@nybgrus and HH
“But from an SBM perspective, basic sciences are very good at disproving things but not proving them (i.e. lowering the Bayesian prior, but not increasing it). The reason for this is that highly improbable priors, like homeopathy and reiki, are much more easy to identify than more probable priors (like collagen for OA).”
Yes! SBM citing the Baysean prior to toss out reiki and homeopathy is easy. But, the Baysean prior is only valid where all available are taken into account to set the prior. Weighing all the data would raise the prior proportionally to the amount of supporting data (I diagree that you can’t raise the prior with animal and pilot data since it may address Brandord-Hill criteria or other measures). SBM can’t seem to overcome its own bias to raise the prior. I don’t accept that pilot studies, mechanistic and animal studies have NO or infintesimal weight in the Baysean prior because that violates the assumptions of the statistic.
“As I had said in our previous discussion, the post has always been the clinical application of any treatment.”
But, wait a minute, a paragraph before you said,
“You claim that SBM has moved goalposts on you and that your references to basic science were dismissed and that we need at least two RCTs for everything. That really is not true.”
So, what are the research standards for the clinical application of any treatment if not 2 RCTs?
“So when you cite the bench science demonstrating collagen peptide uptake, that… from a clinical medicine perspective it is still genuinely unimpressive.
I didn’t cite it for a proof of efficacy (getting tired of repeating myself). Scott said that peptide uptake into cartilage from collagen hydrosylate after digestion is impossible. I provide direct proof in rats and indirect proof in humans that it is taken up. Don’t move the Baysean prior – toss out your assumptions!
@HH
And this comes back to the 500 lb. gorilla in the room, most of what I discussed in my examples above were cases of dismissive conclusions drawn by SBM commentators using false statements or examples. When data or evidence to the contrary is presented, there is no revision of the conclusion. If you are not willing to revise your opinion based on new scientific data, then you have a systematic bias (SBM+ bias?).
@JPZ, “When data or evidence to the contrary is presented, there is no revision of the conclusion.”
When evidence to the contrary is presented but is insufficient to alter the conclusion, there is no reason to revise the conclusion.
There may be some confusion when a statement intended as a provisional conclusion or an opinion is read as a dogmatic statement of fact. We need to exercise caution to distinguish between these, and our readers need to exercise caution in interpreting what we write.
@HH
The examples I listed in this thread quoted the commentators as making unqualified statements of fact or conclusion based on their own opinion or based upon a quoted piece of information. I presented data showing that the basis for their unqualified statement was either disproven, false interpretation of the law, or a fatally-flawed review. If you and I were playing ‘gothca bingo’ with words like “any” (that I misused earlier), I could somewhat better understand your soft sell of the differences. This is why I took the time to document some fairly clear-cut examples.
‘The hardest thing to explain is the glaringly evident which everybody had decided not to see.’ – Ayn Rand
Regarding the SBM clinical vs research dispute. I’d like to add a laymen’s opinion. I’ll be clear, that I only think I understand about half the discussion (which means it’s more likely I understand a quarter,) but here goes.
While SBM does focus on the clinical application of therapies, some articles do cover therapies that are currently being research that may be promising, but are not ready for prime time. It is suggested that patients should not participate in these therapies, since they are unproven, but they should be research further. Also, there have been occasional complaints about NCCAM wasting money on reasearching implausible treatments. In fact I think I recall some article that talked about how SBM is, in part, built to exclude researching implausible treatments that can sometime result in papers that prove the impossible (I think there was some Poe on prayer as an example.)
So, from a laymen’s perspective it does seem important, in term of research, if SBM is claiming a particular therapeutic avenue is “implausible or impossible” rather than say…not promising or not ready for prime time (clinical application).
As a laymen, who sometimes needs to rely on others to say whether something is scientifically impossible or not, I find it quite confusing for a SBM writer to use the word implausible to describe both homeopathy and something that has a remote possibility of working, but needs a bunch of research before we have an idea if it might work (collagen for OA).
I would appreciate it if writers made the distinctions within the implausible to plausible spectrum clear when discussing the clinical (or research) aspects of the therapies.
Just my two cents.
@JPZ,
“I presented data showing that the basis for their unqualified statement was either disproven, false interpretation of the law, or a fatally-flawed review.”
I’m not going to get into a fight about your examples: I’ll leave the writers to defend themselves. As for myself, if you think something I write is disproven, false interpretation or fatally flawed, I’ll gladly look at your evidence and if you can convince me, I’ll gladly correct my errors.
@HH
“I’m not going to get into a fight about your examples: I’ll leave the writers to defend themselves.”
I agree, that would be unfair for you to defend the validity of their statements. I presented the examples as evidence that your previous statement
“SBM does not just dismiss any case where there is some but incomplete evidence.”
was falsifiable. Even without going into the validity of the statements (which the authors should defend), we see a pattern. If a SBMster makes a statement based on a falacious opinion or fact; a commentator replies with verifiable, appropriate, scientific evidence countering the falacious opinion or fact; and the SBMster dismisses the contrary evidence by ignoring it. I could certainly continue to collect examples of scientifically-flawed SBM-bias beyond these four, but to what end? If the SBMster won’t face the fact that they got the facts wrong, they only discredit themselves over time until they become the Mercola they hate.
“As for myself, if you think something I write is disproven, false interpretation or fatally flawed, I’ll gladly look at your evidence and if you can convince me, I’ll gladly correct my errors.”
Gladly, I haven’t seen one from you. I enjoy reading your posts, and you refrain from overstepping what the science says. I may differ with your interpretations at times, but that is opinion and not any fault in the facts.
@JPZ,
“SBM does not just dismiss any case where there is some but incomplete evidence.” is true in general, even if there are rare exceptions.
As simplistic as my view may be, I simply don’t trust anything a chiropractor says. Their entire practice is based on scientific nonsense. If they’ve devoted 4 years of their life to studying this nonsense, why on earth would I trust their opinion regarding anything. There’s a strange trend where people have started to believe that chiropractors know a lot about nutrition. If someone believes that all of disease comes from mystical subluxations of vertebrae why on earth would I trust their opinion on anything else?
JPZ,
If someone writes something that you feel is too dismissive, rather than claim that everyone at SBM is biased, I would comment on the particular author’s post. If that author doesn’t see eye to eye with you, go ahead and hate them for being unfair, if you must.
Anyway, I think you and I might not agree on the meaning of “dismissive.” For a new drug, yes I want two clinical trials showing safety and efficacy before I start recommending it to patients. For other stuff, it depends.
Chiropractic back rubs for adults who get something out of the experience? Fine. I don’t care. Whatever floats your boat.
Craniosacral therapy or gluten free diet for kids with autism? GTFO and DIAF.
“As a laymen, who sometimes needs to rely on others to say whether something is scientifically impossible or not, I find it quite confusing for a SBM writer to use the word implausible to describe both homeopathy and something that has a remote possibility of working, but needs a bunch of research before we have an idea if it might work (collagen for OA).”
Collagen is a protein. A protein is a chain of amino acids arranged like beads on a string. There are 22 different amino acids.
When you eat protein, your gut secretes proteases which chop the individual beads from the string. It is these beads, not the string, that gets transported from the gut lumen into your blood stream.
So there exists a plausibility hurdle for anyone claiming that eating collagen will do more for your joints than, say, eating a steak (myosin). Myosin and collagen chopped up are the same 22 amino acids as far as your urea cycle is concerned.
The plausibility hurdle is this: how are big assed collagen molecules nearly the size of a bus getting into someone’s blood stream? And why is that person not yet dead?
If you say, only a little tiny bit of the collagen is getting into the blood, ok maybe that is true. But then I would guess that only a little tiny bit of one tiny little joint is noticing any benefit.
@GLaDOS
“If someone writes something that you feel is too dismissive, rather than claim that everyone at SBM is biased, I would comment on the particular author’s post. If that author doesn’t see eye to eye with you, go ahead and hate them for being unfair, if you must.”
I addressed each individual false claim in the original thread with relevant facts but no response. Now I am up to four examples of this occurring in the last 2 weeks, I have a pattern. The two commentators who won’t face up to facts are SBM staff. If you can’t step up and discuss the science even when you are wrong, then you have a bias – the SBM bias.
These are not differences of opinion. An exampe is that you claim oral collagen can’t get into cartilage in any significant amount (define significant) because it is completely broken down. Based on your well-educated opinion, correct? When I take your well-educated opinion and contrast it to selective uptake of macromolecular radiolabeled oral collagen into mouse cartilage (PMID 10498764) and a human imaging technique that can detect increases in knee cartilage after collagen hydrolysate feeding (PMID 21251991), do you feel your opinion still wins out over data? Do you feel you should revise your opinion – even provisionally?
This isn’t about being “unfair” it is about the deliberate proliferation of lies by not addressing contrasting data. Scott Gavura dismisses the use of probiotics for constipation based on one review and by saying EFSA also doesn’t support probiotic claims. The review tried to compare five different genus and species of probiotic organisms to form one conclusion. EFSA and ISCAPP have both said you cannot compare efficacy studies across different organisms to draw more general conclusions – fatal study flaw. And, the only reason EFSA threw out 170 of 180 probiotic claims was due to incomplete paperwork. So, with the only two pieces of support in the posting, a fatally-flawed review and a total misinterpretation of EFSA actions, somehow the statement that probiotics don’t work in constipation still makes perfect sense? Is how chiros feel when they won’t let go of subluxations despite the evidence against it?
GLaDOS, I appreciate the attempt to engage the softer vocabulary of “feel” and “unfair,” but this is a scientific discussion and we can occasionally separate truth and fiction based on facts.
@HH
“SBM does not just dismiss any case where there is some but incomplete evidence.” is true in general, even if there are rare exceptions.”
Could you link me to 1-3 examples of where the SBM discussion gave a favorable impression of a potential treatment that had less than 1 full RCT completed? I think I would learn a lot by actually seeing one of those, and it might give me a better insight into the selection bias that I perceive.
Thank you!
They don’t have a hypothesis. They have a claim that it works. Look at what they all write – particularly NMS-DC. They each state something to the effect that the science is finally catching up to what chiropractic has been doing all along. Very different things.
That is a very rare exception to what we actually see from the chiros. Actually testing to see if the intervention works is fine. But to use the intervention without that evidence is questionable at best. And the evidence they have been putting up is all bench science and animal studies. As we’ve discussed, that does not explain nor justify the use of an intervention at a clinical level. Telling me that pinning a guinea pig’s knee joint is proof for the use of SMT on humans for low back pain is…. bad science.
The point is that we all agree (well, save the chiros of course) that the surrogate biomarkers and endpoints are not adequate.
True enough. It was to tie it all in to illustrate the SBM point.
I’m sure not everything is 100% spot on. But close enough.
Yes, we agree it would raise the prior. We disagree as to how much.
I never said that you can’t raise the prior. I said that bench science can only raise it to a non-insignificant but small value. Having piles and piles of bench science that gives as much plausibility and Bradford-Hill as you could hope for only means that a decently powered and well designed RCT will be enough to convince me. Less than that means highly powered or repeat RCTs. But anything else is a stretch. To put it plainly, what truly excites and tittilates a bench scientist is usually quite less dramatic for a clinical scientist – and both are right to have that reaction.
Once again, I never said no weight. I never even said infinitesimal. But the one consideration you aren’t taking into your account in the Bayesian prior is that historically and with good reason the vast majority of bench science breakthroughs lead to zilch in clinical application. Even really good, very plausible, well done, super-awesome bench science. The assumptions of the statistic must take that into account as well. So the most a bench science finding(s) can do for me is make me quite interested in future work. That’s about it.
Convergence and concordance of evidence is good enough as well. We don’t have RCTs on smoking and lung cancer, but I feel pretty confident telling my patients they should quit. We don’t have RCTs on use of lidocaine and epinephrine in full arrest, but I’ll still order and push the drugs. But those require at least some good retrospective studies, maybe some case-controls, prospective cohort studies, etc and bench science to back it up. It is possible to clear those SBM goalposts without 2 RCTs, but it is certainly much tougher. But bench science alone cannot clear them.
Actually, as I pointed out, you did not offer such proof. You offered plausibility that it might happen to some undefined extent. You like to cite the DHEA uptake of less than 1% being enough to effect a response in the brain – that has no bearing on this discussion. Hormones and structural peptides are inherently and vastly different in their potencies. And even then, comparing uptake and bioavailibility of similar compounds is only moderately interesting at best.
The articles demonstrates a relative increase in radiolabeled density – that means it could have gone from .0001% to .0026% for all we know. It tells us nothing clinically useful. It also used rat gut-sac product protein electrophoresis. That tells us that in a rat gut sac some of the polypeptide gets through as a macromolecule. Besides the fact that they are using a cut piece of rat gut (as opposed to an intact human gut) it merely tells us that the macromolecule can exist outside the gut-sac to some extent. It does not inform us as to whether that is a 1:1 relationship between the radiolabel signal in the cartilage. The notion that human guts can absorb larger than just single amino acids or short oligopeptides is nothing new BTW – I knew about that from my high school days.
The point is that this is all very interested from a bench science perspective. But has so many assumptions and leaps, plus the inherent implausibility of a relative drop in the ocean of collagen, combined with the ever present fact that bench science rarely pans out, plus the really equivocal human studies means that nothing has changed with our Bayesian prior. The goal posts didn’t move and our assumptions were not flawed (perhaps amongst some of us they were in need of some refinement) – the additional data just didn’t reach the posts is all.
@JPZ,
You appear to be moving the goalposts. First you accused us of dismissing things and now you ask “Could you link me to 1-3 examples of where the SBM discussion gave a favorable impression of a potential treatment that had less than 1 full RCT completed?” Not giving a favorable impression does not equate to dismissing.
It would not be good science to give favorable biases to untested treatments, and we shouldn’t be doing that. What we should do and do do is not dismiss a treatment just because it has not been tested with RCTs, and to acknowledge when a treatment seems to have promise and deserves further testing. Here are just a few of many examples:
http://www.sciencebasedmedicine.org/index.php/hash-oil-for-gliomas-what-would-you-do/
http://www.sciencebasedmedicine.org/index.php/protandim-another-kind-of-antioxidant/
http://www.sciencebasedmedicine.org/index.php/amish-home-burn-treatment-bw-salve-and-burdock-leaves/
Could you link me to 1-3 examples of where the SBM discussion gave a favorable impression of a potential treatment that had less than 1 full RCT completed?
Wat.
“Favorable” in the sense that further research is justified, or “favorable” in the sense that working doctors ought to promote some supplement to their patients. Cuz if you mean the latter, then no, that is not okay.
These are not differences of opinion. An exampe is that you claim oral collagen can’t get into cartilage in any significant amount (define significant) because it is completely broken down. Based on your well-educated opinion, correct? When I take your well-educated opinion and contrast it to selective uptake of macromolecular radiolabeled oral collagen into mouse cartilage (PMID 10498764) and a human imaging technique that can detect increases in knee cartilage after collagen hydrolysate feeding (PMID 21251991), do you feel your opinion still wins out over data? Do you feel you should revise your opinion – even provisionally?
Mouse abstract:
Several investigations showed a positive influence of orally administered gelatin on degenerative diseases of the musculo-skeletal system. Both the therapeutic mechanism and the absorption dynamics, however, remain unclear. Therefore, this study investigated the time course of gelatin hydrolysate absorption and its subsequent distribution in various tissues in mice (C57/BL). Absorption of (14)C labeled gelatin hydrolysate was compared to control mice administered (14)C labeled proline following intragastric application. Plasma and tissue radioactivity was measured over 192 h. Additional “gut sac” experiments were conducted to quantify the MW distribution of the absorbed gelatin using SDS-electrophoresis and HPLC. Ninety-five percent of enterally applied gelatin hydrolysate was absorbed within the first 12 h. The distribution of the labeled gelatin in the various tissues was similar to that of labeled proline with the exception of cartilage, where a pronounced and long-lasting accumulation of gelatin hydrolysate was observed. In cartilage, measured radioactivity was more than twice as high following gelatin administration compared to the control group. The absorption of gelatin hydrolysate in its high molecular form, with peptides of 2.5-15kD, was detected following intestinal passage. These results demonstrate intestinal absorption and cartilage tissue accumulation of gelatin hydrolysate and suggest a potential mechanism for previously observed clinical benefits of orally administered gelatin.
Based on this, I’m supposed to recommend collagen supplements to people with arthritis? Is this what you are saying?
If you give a mouse just proline but no other amino acids, how is the poor thing supposed to make any new proteins to stick in its joints or wherever?
Protein digestion involving protease and the gut barrier against the absorption of large molecules by diffusion isn’t really a personal opinion on my part.
http://www.chicagotribune.com/health/la-heb-chronic-fatigue-syndrome-xmrv-20110922,0,6289303.story
How much did that wild goose chase cost?
People who say “favorable” things about some potential medical intervention based on research from one group without independent replication are bad people who should feel badly about themselves.
@HH
“First you accused us of dismissing things and now you ask “Could you link me to 1-3 examples of where the SBM discussion gave a favorable impression of a potential treatment that had less than 1 full RCT completed?”
Goal posts didn’t move – just being open to counter-evidence. I do feel SBM dismisses certain classes of data and when I provided examples, you said it does not. I asked for examples to support your counter-claim, you gave them. I will read them with as open a mind as possible and comment favorably or unfavorably as fairly as I can as to whether I see your point of view more clearly. So far, this portion of our conversation has not tested a goal post. Actually, I fear it will be personal definitions of the words “favorable,” “dismiss,” and “untested” where goalposts are in danger of being moved.
“It would not be good science to give favorable biases to untested treatments, and we shouldn’t be doing that.”
I thought the discussion was about treatments supported by some data just not 2 RCTs. It sounds like negative bias to call them “untested,” unless that was unintentional. Although, It is a given that a treatment with NO data gains no favorable bias – I am totally on board with that aspect of SBM.
“What we should do and do do is not dismiss a treatment just because it has not been tested with RCTs, and to acknowledge when a treatment seems to have promise and deserves further testing.”
I lost you in the “do and do do”‘s typo, but it sounded like we were agreeing there.
@GLaDOS
Your patient-centric viewpoint makes perfect sense in terms of “show it to me in a practice guidline and I will see if it is worthwhile in my patients.” Nothing short of 2 RCTs is good enough for your patients. Also, you derive schadenfreude when a CAM treatment fails.
As I have said, repeatedly, there is not enough data to support collagen as a treatment to prescibe for OA patients. Period.
Pardon my transforming your previous comments into a wall of text. You said,
“Collagen is a protein. A protein is a chain of amino acids arranged like beads on a string. There are 22 different amino acids. “When you eat protein, your gut secretes proteases which chop the individual beads from the string. It is these beads, not the string, that gets transported from the gut lumen into your blood stream. So there exists a plausibility hurdle for anyone claiming that eating collagen will do more for your joints than, say, eating a steak (myosin). Myosin and collagen chopped up are the same 22 amino acids as far as your urea cycle is concerned. The plausibility hurdle is this: how are big assed collagen molecules nearly the size of a bus getting into someone’s blood stream? And why is that person not yet dead? If you say, only a little tiny bit of the collagen is getting into the blood, ok maybe that is true. But then I would guess that only a little tiny bit of one tiny little joint is noticing any benefit.”
I provided two references, one showing SELECTIVE uptake into rat cartilage (mechanism via radioisotopes) and the second showing empirical increase in human cartilage in a pilot randomized trial. nybgrus can explain the macromolecular part better than I (he put it quite well). This is not to say “go prescribe it now” this is to say that the mechanism you thought was true is not, and that you should consider revising it and your bias against other data here.
“Mouse abstract”
Well, I suppose we could bring you by the lab a shoot you up with C14-proline labeled collagen fragments as long as you don’t mind giving up some cartilage, liver, adipose, etc.
Some medical interventions are difficult to study using methods of blinding and randomization. But in the case of oral supplements for common conditions, I don’t really see the problem with using the same standard that we want for drugs: two RTCs. That is not dismissive. That is just practical.
Even with the two RTCs, we still get a lot of treatments to market that turn out to be disappointing in some way. If we lower our evidential bar further, we will be up to our ears in spam medicine.
Oh wait. We did lower our bar, thanks to DSHEA. And we are up to our ears in spam medicine.
So back to two RTCs for little things that you put in your mouth. Is that so wrong?
JPZ:
We are clinicians (some in training
) practicing on actual human beings. Bench science = untested. 1 million guinea pigs agree that testing on them means untested from an SBM perspective.
I do too, to be honest. If I was in a genuine scientific discussion with someone where we were both intellectually honest and I were vindicated I would not. But when people are swayed away by dishonest political and ideological tactics from actual science and those doing the swaying trip and fall, yes, I will happily derive some schadenfreude. One of my favorite words, BTW.
I will actually be forced to agree here and say that GLaDOS was either misinformed or taking a shortcut for brevity. Macromolecules of decently large size can and are regularly absorbed through the gut. Not each and every single protein in chopped into mono- or oligo-peptides. However, exactly what those macromolecules are has not been determined. At best, they are in a similar size distribution as the original protein electrophoretic profile in question. That doesn’t tell us how much and where GLaDOS is right is that it is almost certainly rather small amounts. Furthermore, the rat studies you cite explicitly state that their methodology for determined said electrophoretic profile is flawed, but “the best available.”
In other words, all the data is tenuous at best. GLaDOS is not unjustified in ignoring it as noise from a clinical perspective. From a strict scientific one, he should be compelled to change his verbiage a bit, but the overall conclusions stay the same. I can understand his shortcut though – I am in a position where I can delve into such bench science studies. He, I am sure, is much busier. And until good data comes about that demonstrates that such macro-peptide absorption is actually a clinically significant entity (and so far it only has in cases of the development of pediatric allergy, but that is a different topic altogether), then he can reasonably continue with the “bias” you ascribe to him, which, IMO, is more of a rounding error than a systematic bias. We all have to take shortcuts sometime.
“Well, I suppose we could bring you by the lab a shoot you up with C14-proline labeled collagen fragments as long as you don’t mind giving up some cartilage, liver, adipose, etc.”
The study mice got C14-proline labelled collagen and the control group got C14-proline only, is this correct?
So the control mice could not manufacture cartilage using the meals they were given over the few days they participated in this study, while the study mice could.
I don’t understand how the researchers could differentiate radiolabelled collagen molecules that the mice made themselves using amino acids from the collagen meals they were given verses radiolabelled collegen that strangely passed intact from their gut and somehow got into their joints.
nybgrus, I’m not saying that big things are never absorbed from the gut. That’s obviously false. For example, viruses.
But you are mostly protein because you have that DNA transcription machine in all your cells. That machine uses amino acids, not peptides. You don’t need peptides as building blocks. And a gut that lets a lot of kilo Dalton sized things through is not a healthy gut.
“Also, you derive schadenfreude when a CAM treatment fails.”
That is incorrect. I would be very happy to learn that I might delay my own progression toward osteoarthritis by simply adding collagen supplements to my diet.
A fine glass of shadenfreude cannot be enjoyed without first tasting a serving of moral outrage, which itself is rather bitter.
@nybgrus
The first part of your message seems to say that chiros are never practicing the scientific method, and that they only use pseudo-research wrapped in the trappings of science to back-fill beliefs that they don’t plan to change. You know more than I on this topic, and I trust your superior knowledge base. If a chiro tried to present actual science here, I am not sure it would have a snowball’s chance in hell of getting heard (of course their would need to get a LOT better at presenting the science).
The second part of your post seems to say that pilot and animal data should not be discounted in establishing the Baysean prior, but they should not influence it much. In the absence of prior data on expected versus actual outcomes, the Baysean prior is established subjectively using all available evidence. If you and I discuss all available evidence and agree on a prior we feel best fits the data, then we have used the model appropriately. Others on SBM have resorted to dismissing data to include in the model based on false assumptions and therefore violate the model (SBM bias). Perhaps another reason I am not so quick to dismiss pre-clinical findings is that the change of a drug candidate getting through pre-clinical models is 1:250. For a nutritional product, it is 1:5. The chance of getting through clinical testing is 1:5 for a drug and 1:2 for a nutritional product. That might inflate my estimates of the Baysean prior as well.
It isn’t DHEA, it’s DHA (docosahexaenoic acid), a structural lipid in the brain much like collagen is a structural protein in cartilage.
Regarding collagen, those are all standard, highly validated techniques – and you do not seem to understand the models. If one organ takes up more of a orally-dosed compound (except the liver or adipose sometimes) than other organs, somehow that organ has an affinity for the orally administered compound. The everted gut sac model has long history of validation in multiple labs as well and is a much more complete test of the various factors that might break down a set of molecules before absorption (as opposed to CACO2 cell cultures or artificial gut models). The newer technology, dGEMRIC, showing increased cartilage deposition in human knees after collagen treatment is the empirical piece of the puzzle. Selective uptake, macromolecular absorption and empirical evidence of deposition indicating that the metabolism is not what it was assumed to be.
@GLaDOS
“A fine glass of shadenfreude cannot be enjoyed without first tasting a serving of moral outrage, which itself is rather bitter.”
LOL!
@GLaDOS:
I’d have to re-read them in detail (which I am not keen to do), but my impression was that they had reasonable cause to assume that at least some of the radiolabel in the cartilage was from the original collagen hydrosylate. My point to JPZ was they had no way of telling how much was actually there – they could ONLY cite a relative change. How much of that was from the radiolabeled AA’s being incorporated and how much was direct from the macromolecule uptake of the gut is anyone’s guess (though ours would be “very little”). That is why I made the comment about 1:1 absorption – there is no way to verify that. But from a very strictly pedantic scientific standpoint JPZ is right – but what I feel gets lost upon him is how little that means to us clinically.
@JPZ:
Never is always a strong word. I am sure I used it or at least implied it. But of course chiros do practice some real science – just not very often at all and damned near none of it has proven useful in any way. Everything is very preliminary.
I think Dr. Hall’s statement still fits well – we do not “dimiss” we simply think that the evidence presented simply doesn’t add up to much. But I suppose we could get into semantics and rounding error here. Is me saying that “piece of evidence [X]” only increases the Bayesian by 0.1% “dismissing” it? I suppose it could be – I would be saying, essentially, that it is positive, it does improve the Bayesian prior, but it may as well not have existed since it does so to no appreciable degree. So yes, we “dismiss” the evidence in that sense, but we aren’t really being dismissive.
Mea culpa. I was going off memory and did not look up the quotes. That does change things a bit…. but as I said in my original comment “And even then, comparing uptake and bioavailibility of similar compounds is only moderately interesting at best.”
I am sure I don’t fully. However:
I do get that. However – why the affinity? What does that affinity mean? And is that affinity clinically relevant? None of those questions are answered by the studies.
The affinity could be simply because a collagen like macromolecule will stick in a collagen matrix better. It could simply mean that it is hanging around that area longer, producing a stronger signal without interacting at all with the chondrocytes. And it could mean that 26 such macromolecules vs 10 proline residues are absorbed, which means pretty much nada clinically speaking (it could also, as GLaDOS pointed out, mean that the radiolabeled residues are being incorporated preferentially into cartilage since the proportion of amino acid residues used in collagen production is higher in… collagen!)
In other words, as I have said repeatedly – very interesting from a bench science perspective and certainly I wouldn’t begrudge some further study. But nothing that makes me feel the Bayesian has changed significantly.
@nybgrus
“In other words, as I have said repeatedly – very interesting from a bench science perspective and certainly I wouldn’t begrudge some further study. But nothing that makes me feel the Bayesian has changed significantly.”
Missed the point again. Scott Gavura and GLaDOS both said eating collagen can’t put collagen in the knee. This is SBM dismissal. The data say feeding collagen increases cartilage in the human knee as measured by dGEMRIC, and there is a supporting animal study showing labeled oral collagen preferentially accumules in the cartilage. If this is evidence that eating collagen can put collagen in the knee, how can someone continue say that it can’t happen without presenting counter evidence? The counter evidence you have presented amounts to hypothetical speculation about how proteins might be metabolized or just saying “I don’t believe it.”
Again, this is not to prove any clinical benefit, it is to prove that the SBM bias is insoluble when exposed to evidence to the contrary. The Baysean prior is a larger and slightly corollary point about accepting limited data in determining the probabiliy of better describing the underlying relationship before the next experiment. SBM bias is the willingness to ignore counter evidence in order to maintain one’s opinion about a subject that is unpopular on SBM.
Let me see if I can simplify this discussion. If you tell me than A cannot exist, and I show you B and C as evidence A exists. Do you,
- Yell louder that A cannot exist
- Turn you back, fold your arms and pout
- Find every fault you can with B and C with addressing A (even though none are fatal flaws)
- Admit B and C provide some evidence of A, but D and E would be better evidence
- Say that B and C do indeed provide partial support for the existance of A, but A alone is not enough for clinical practice
I take B and C and say that it still doesn’t materially change A. I think that has basically been what the SBM line has been here and that everything else has been a very nit-picky sort of discussion. I certainly don’t think I have said anything different.
I think we have also called into question just what exactly and how much B and C prove anything about A. And I think that is a valid criticism. In other words, it isn’t that the evidence is contrary and we aren’t changing a stance on it. It is that we already knew that evidence (in general, as GLaDOS pointed out) and find it unimpressive. In other words, we knew the general concepts of B and C and you giving us specific examples just fit in with what we’d already been saying. I don’t see a bias there – it has nothing to do with popularity.
As GLaDOS said – yes, we all have known that macromolecules do permeate the gut in toto from time to time. But that a gut which accepts a large amount of such macromolecules is undoubtedly diseased. So citing a specific example of bench science that shows collagen specifically can do that doesn’t change our understanding.
Demonstrating it selectively accumulates in cartilage also doesn’t really demonstrate anything either since it is a relative change and there are many mechanisms by which that may reasonably happen (once again, as GLaDOS pointed out as well).
So there isn’t a bias you are finding, nor a shifting of goal posts. Merely a lack of absolutely explicit and incredibly detailed discussion on the very fine specifics of each case. Which once again reflects the nature of this site as being clinically oriented rather then bench science oriented.
a few random thought.
One question I would be curious about is the concept of oral tolerization with collagen in patients with RA. Considering the speculation that some subsets of OA may have an autoimmune component, perhaps there’s a long shot for research in that direction. Although seeing if the RA research pans (panned) out would seem advisable. I can’t find a whole lot googling the topic. Maybe because it just didn’t work or maybe I’m not using the correct key words.
Guys, (and you too GLaDOS) It seems you are going round and round on this topic. GLADOS makes an excellent point that recommending unproven therapies is…bad. But having been on the otherside of that argument (doctors reluctant to prescribe medication for my autoimmune thyroid disease until TSH exceeded 10, because my subclinical hypothyroidism “couldn’t be causing symptom”.) I would suggest that it’s a pain to wait for science to catch up. When there is undocumented or questionable safety, certainly caution is best, but when the risks are well documented and the patient is advised of them, it seems reasonable to include the patient in the decision making process.
As Harriet Hall observed in the HPV thread, even from a clinical viewpoint it is useful to understand the research aspect of the subject. This way, as research develops, the patient/consumer may have some expectation of the form therapies will take. I’m perfectly happy to hear, “we’re working on it.” or “with the information we have now, this therapy looks like a very bad bet.” But if you tell me something is “implausible, nearly impossible” then I’ll certainly have a slap my forehead moment if it becomes a treatment standard five years later (maybe a little shad..she..gloating will result).
Oh shoot, not finished with my ramble, but must come up with some sort of lactose free, soft food dinner. Yum.
“Regarding collagen, those are all standard, highly validated techniques – and you do not seem to understand the models.”
Correct, I don’t understand the model. So help me out by explaining how the researchers can differentiate:
1. Collage in stomach with C14 labelled amino acids –> broken down into individual amino acids in the gut by protease –> collagen synthesized by chondrocytes using C14 amino acids absorbed from gut.
2. Collagen in stomach with C14 labelled amino acids –> exact same molecule incorporated into cartilage.
Michelle you are an adult and can take some risks with your own health if you want. The problem is, once parents think that hormones are useful outside the recommended therapeutic levels, then kids are given the hormones.
So there need to be a line between sufficient evidence verses not enough evidence yet.
@HH
Thank you for your examples, they once again demonstrate that you personally don’t overstate the science with any regularity that I have seen. I found your level of criticism inconsistent between the three examples, but I was open to calling that “editorialization.” If we were to disagree over those inconsistencies, I do not think it would illuminate the reader all that much.
@nybgrus
If anything less than 2 RCTs doesn’t significantly alter the Baysean prior in your eyes, then you effectively deny any data that is not a RCT can be of significant use in evaluating the Baysean prior. That is consistent with my contention of a SBM bias. More worrisome, it seems OK with you that your colleagues base their assumptions on false pretenses as long as those false pretenses are meaningless compared to clinical trials. Since two of your colleagues lied about laws surrounding dietary supplements (which I have shown 3-4 times now with references) to influence the audience here, I question the wisdom of your point of view.
@GLaDOS
If the gelatin substrate from the gut reaches the cartilage at 260% of the rate of any other tissues, why do you still think that feeding collagen can have no effect on the cartilage for the sole (false) reason that it is all amino acids? We can talk a lot about macromolecular absorption and radioisotope dilution and substrate affinity, but that original fact is the bottom line, right?
JPZ, you were saying collagen, not amino acids, were getting absorbed from the gut, into the bloodstream, then into the joints.
Are you now saying amino acids are getting absorbed rather than collagen?
GLaDOS
“Michelle you are an adult and can take some risks with your own health if you want. The problem is, once parents think that hormones are useful outside the recommended therapeutic levels, then kids are given the hormones.
So there need to be a line between sufficient evidence verses not enough evidence yet.”
Yes, I agree, although I would speculate that the decision process falls along a black, gray white spectrum, with adults having more (but not complete*) control over the risks they take for themselves over the risk they accept for their children.
I would guess that black areas would generally be therapies where the risk is high or unknown, the risk of not treating is low, or the therapy is implausible and unproven and inaccurately presented. Gray areas might include off label medications or modified surgeries for adults or children for whom the risk of not treating is high, low risk therapies or interventions that are plausible but lack evidence (the lack of which the patient or parent is informed). White would be therapies sported by good evidence.
I only dwell on this because I’ve had to deal with finding therapies for my son with a low researched condition as well as comparing newer less proven surgeries to older more invasive surgeries. So it helps me to come up with concrete decision making criteria that include other variables besides RCT.
I know zilch about endocrine issues or inappropriate hormone use for children. Does that spectrum I outlined provide the potential for adequate protection for kids, while providing the ability to treat rare or under researched conditions?
*not a lot of use having a prescription system if doctors just prescribe whatever the genera adultl population wants.
On an individual, case-by-case basis, potentially any action is justified. Shooting someone may even be justified –e.g., Hitler throwing babies off a cliff. Best to shoot him, IMHO.
So yes, there’s always a gray zone. If the day comes when practice guidelines have erased the gray zone, the humans are dead and have been replaced by robots. Or maybe some very powerful managed care company.
In someone with a known history of hypothyroidism, I would have a lower threshold for treating than in someone first presenting with a TSH of 8-9 without any symptoms where I might simply repeat the test in 3 months.
Yeah, that part was pretty funny. Your own source actually provided instructions on how to do what you said could not be done, and then you switch from it being a clear source to something which can’t be understood.
@GLaDOS – I apologize if it sounded like I was saying that you practiced dogmatically evidence based medicine. That was not my intention at all. I don’t think you are a robot (although if you were, you would have some incredible software, sense of humor is almost impossible to program, I understand) and I certainly don’t think you are anywhere as evil as the typical managed care company (I only suggest you are a little evil, cause I’ve never meet anyone who wasn’t a little evil, except for my grandma…)
I was genuinely just thinking aloud to figure out what sort of evidence/therapy reasoning process I look for in a healthcare practioner. So my comment was more tertiary to your previous comment, not a direct response.
Going back to the original topic of this post, chiropractic neurology:
From the website of the American Chiropractic Association, which bills itself as:
Here is the ACA public statement (in part) on attention deficit hyperactivity disorder (ADHD):
Helping Children with Attention Deficit Disorder
What evidence do chiropractors have that this approach is as effective as researched treatments?
Oh, woops (emphasis added):
So they don’t have any evidence that “the chiropractic approach”, as they mis-label it, is more effective than tested treatments, but the chiropractic profession is fine with selling it anyway.
I have more questions:
What is the evidence that postural muscles have anything to do with ADHD?
What training do chiropractors have in postural changes not connected with spinal manipulation?
Why should a parent pay for advice on “nutrition and lifestyle changes” from a chiropractor?
What specific training do chiropractors have in nutrition?
One of the distinctions between doctors (and science-based medicine in general) is the insistence on testing before implementing. Nowadays, you want to approve a new drug, you test it beforehand to demonstrate effectiveness – to the point that it’s illegal to charge money for it while clinical trials are still underway. Only once effectiveness is demonstrated can it be sold.
The contrast with chiropractic care is pretty obvious – a single manipulative intervention and they’re still evaluating the data over a century later? And that data mostly comes from non-chiropractors?
And chiropractors accuse doctors of massive collusion to support the profitability of the pharmaceutical-industrial complex. Pot, kettle, except the kettle isn’t actually black.
WilliamLawrenceUtridge wrote on 24 November 2011 at 13:58 “One of the distinctions between doctors (and science-based medicine in general) is the insistence on testing before implementing. Nowadays, you want to approve a new drug, you test it beforehand to demonstrate effectiveness – to the point that it’s illegal to charge money for it while clinical trials are still underway. Only once effectiveness is demonstrated can it be sold.
And in the case of chiropractic…
“…if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.”
Beware the spinal trap
http://www.guardian.co.uk/commentisfree/2008/apr/19/controversiesinscience-health
@ WilliamLawrenceUtridge
“One of the distinctions between doctors (and science-based medicine in general) is the insistence on testing before implementing. Nowadays, you want to approve a new drug, you test it beforehand to demonstrate effectiveness – to the point that it’s illegal to charge money for it while clinical trials are still underway. Only once effectiveness is demonstrated can it be sold. ”
If comparing a drug (acetaminophen) to SMT is unfair per Harriet Hall then comparing drug trials to SMT tials is unfair. Medicine does test before implementation on drugs but what about the rest of medicine?
Example of testing after implementation in medicine. Pot, Kettle!
http://www.nejm.org/doi/full/10.1056/NEJMoa013259
What about the rest of medicine? Yep, knee debridement should have been tested before widespread implementation. Based on the reference provided in your post, the self-correcting nature of science has worked for the treatment of osteoarthritis of the knee. For nearly 20 years, debridement of the knee was practiced and found to improve functioning and pain. It was tested and failed, and now I doubt you’ll find any surgeons still performing it. The lesson to draw from this, naturally, is that surgical treatments should be tested the same way pharmaceuticals are (keeping in mind the enhanced difficulties like controlling for surgical skill and the far more complicated nature of cutting someone open versus giving them a pill).
I fail to see how this justifies chiropractic treatment of autism, allergies or acute infection. I fail to see how this justifies chiropractics practicing for over 100 years on the basis of a concept that was never tested (subluxations). In addition, surgical procedures have a grounding in a recognized body of knowledge that grants it a significan degree of prior probability (vis. anatomy, physiology, the germ theory of disease, biomechanics, and probably a lot more). It’s at least a reasonable conjecture that smoothing out the cartilage of the knee would allow it to function better. The idea that an invisible displacement of the vertebrae that can’t be demonstrated with any sort of medical imaging can affect the immune or central nervous systems – much less solid ground there.
Certainly, I would heartily support the implementation of an FDA-style clinical trial system that requires an evidence-base before the large-scale implementation of surgical interventions. The same way I would support chiropractors who support merging their discipline with physiotherapists to provide relief of musculoskeletal complaints. I would continue to oppose nutters who think manual manipulations can have some sort of impact on any bodily system beyond joints, bones, muscles and the occasional pinched nerve. The overall point is that flaws in one system do not justify flaws in another – it merely justifies eliminating or improving the flaw based on the best evidence available. There is some justification in saying surgeons have less right to criticize chiropractors than say, medical doctors. Of course, there’s the little asterisk next to this statement in that, as I said, surgeons are working within an empirical system that changes over time and is based on evidence. Most chiropractors do not appear to have said asterisk.
@WilliamlawrenceUtridge
“What about the rest of medicine? Yep, knee debridement should have been tested before widespread implementation. Based on the reference provided in your post, the self-correcting nature of science has worked for the treatment of osteoarthritis of the knee. For nearly 20 years, debridement of the knee was practiced and found to improve functioning and pain. It was tested and failed, and now I doubt you’ll find any surgeons still performing it. The lesson to draw from this, naturally, is that surgical treatments should be tested the same way pharmaceuticals are (keeping in mind the enhanced difficulties like controlling for surgical skill and the far more complicated nature of cutting someone open versus giving them a pill).’
I agree and would argue that SMT is tougher to study than a pill as well.
“I fail to see how this justifies chiropractic treatment of autism, allergies or acute infection.”
It does not and I did not imply such. Only a small minority of chiro’s would make this justification as there is evidence against. It is sad that there is this minority though.
” I fail to see how this justifies chiropractics practicing for over 100 years on the basis of a concept that was never tested (subluxations). ”
ACA’s definiton of subluxation:
A motion segment, in which alignment, movement integrity, and/or physiological function are altered although contact between joint surfaces remains intact.
“In addition, surgical procedures have a grounding in a recognized body of knowledge that grants it a significan degree of prior probability (vis. anatomy, physiology, the germ theory of disease, biomechanics, and probably a lot more). ”
SMT also has a major grounding in anatomy, physiology and biomechanics.
“It’s at least a reasonable conjecture that smoothing out the cartilage of the knee would allow it to function better. The idea that an invisible displacement of the vertebrae that can’t be demonstrated with any sort of medical imaging can affect the immune or central nervous systems – much less solid ground there. ”
I would argue that is also reasonable to take a patient with decrease ROM, pain/tenderness and tissue texture change and mobilize/adjust this area to allow it to function better.
“Certainly, I would heartily support the implementation of an FDA-style clinical trial system that requires an evidence-base before the large-scale implementation of surgical interventions.”
I would support as well but I think it will be tough to get implemented due to factors you mentioned previously.
” The same way I would support chiropractors who support merging their discipline with physiotherapists to provide relief of musculoskeletal complaints.”
I would argue this is the great majority of what chiro’s already do (treat MSK issues)
” I would continue to oppose nutters who think manual manipulations can have some sort of impact on any bodily system beyond joints, bones, muscles and the occasional pinched nerve. ”
Agreed.
“The overall point is that flaws in one system do not justify flaws in another – it merely justifies eliminating or improving the flaw based on the best evidence available. ”
I agree.
“Most chiropractors do not appear to have said asterisk.”
I think the prefession has been building this asterisk steadily over the past 30 to 40 years and will continue.
JHawk: and I would argue that your “motion segment” concept is just another name for subluxation, or for manipulable lesion or whatever and that it translates to “some region of the spine where there seems to be pain, tenderness, or muscle spasm. Obviously, several vertebrae and several joints are involved and no chiropractor or MD or DO or PT can tell which one is the source of the pain without exhaustive testing and expensive imaging and facet blocks with local anesthetic. By the time such extensive evaluations have been completed, most patients are over their original symptoms, since we are talking about a mostly self-limited affliction with a good natural history overall. So you are left with saying there is a region of the spine involving several vertebrae and their articulations which you think is “dysfunctional” and in your mind, cries out for your manipulation treatment. Like almost any treatment in medicine, including most surgical operations, about 70% of patients will record some subjective short term improvement. The trick is to show that some physiological significant result of the manipulation has been effected and that it has some lasting health benefit. I am unaware that there is any significant evidence of this.
@ marcus welby
“JHawk: and I would argue that your “motion segment” concept is just another name for subluxation, or for manipulable lesion or whatever and that it translates to “some region of the spine where there seems to be pain, tenderness, or muscle spasm.”
yes and usually a decrease in ROM as well. This is not my concept, this is how it is taught in manual medicine.
“Obviously, several vertebrae and several joints are involved and no chiropractor or MD or DO or PT can tell which one is the source of the pain without exhaustive testing and expensive imaging and facet blocks with local anesthetic.”
You may not be able to know 100% for sure what the pain generator/s is/are but you can come pretty close with a good history and physical exam. This is why it’s called a working diagnosis. Obviously, this is very case specific.
“By the time such extensive evaluations have been completed, most patients are over their original symptoms, since we are talking about a mostly self-limited affliction with a good natural history overall. So you are left with saying there is a region of the spine involving several vertebrae and their articulations which you think is “dysfunctional” and in your mind, cries out for your manipulation treatment.”
If other sources of LBP have been ruled out via history and exam a trial of spinal manipulation is warranted to decrease pain and duration of LBP as well as increase ROM.
“Like almost any treatment in medicine, including most surgical operations, about 70% of patients will record some subjective short term improvement. The trick is to show that some physiological significant result of the manipulation has been effected and that it has some lasting health benefit. I am unaware that there is any significant evidence of this.”
http://www.ncbi.nlm.nih.gov/pubmed/20053720 conclusion:Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.
@jhawk,
In the reference you provided, patients knew they were getting manipulations; without a sham manipulation control group, isn’t it possible that the apparent superiority of manipulation was due to the therapeutic ritual and other non-specific effects of treatment?
@ Harriet Hall
It could be possible but I would think unlikely as the PT group received exercise, passive mobilization (could be considered a sham HVLA to some degree) and soft-tissue treatment and the back school group (exercise, education/ ergonomics), both of which would be amenable to these placebo responses and the SMT cohort showed superiority to both groups.
Your thoughts?
@jhawk,
I think most patients would be aware of the difference between mobilization and HVLA manipulation, especially if there is an audible “crack” which patients have come to expect at the chiropractor’s office. Wouldn’t it be a better control to do something like a manipulation at the “wrong” level?
@ Harriet Hall
“I think most patients would be aware of the difference between mobilization and HVLA manipulation, especially if there is an audible “crack” which patients have come to expect at the chiropractor’s office”
I am not sure this is necessarily true as I see many patients that have never seen a chiropractor before and are unsure as to what a manipulation entails. (Obviously anecdotal and may not be generalizable to the public at large!)
“Wouldn’t it be a better control to do something like a manipulation at the “wrong” level?”
I think this would be tough as the research has shown we (manual medicine practicioners) are not as specific with our adjustment as we once thought. Therefore, we would probably end up mobilizing the “wrong” and the “right” level at the same time.
Also, It appears the audible crack may not be necessary for full therapeutic value. http://www.ncbi.nlm.nih.gov/pubmed/20170777
@jhawk,
Do you think there is some way to do a really effective placebo control for manipulation studies?
As to the control group using manipulation at the wrong level, there is abundant evidence for this model in the frequent use of the “hole in one” concept by which many chiropractors do their dangerous neck cracking as a treatment for literally every complaint. They embrace an ideology that all vital forces pass through the foramen magnum and therefore treat low back pain, shoulder pain, bed wetting, autism, coccidynia, high blood pressure, constipation, you name it, by high velocity neck manipultation and evidently report or think they experience, similar outcomes with about 70% favorable short term benefit. In a UCLA study with several chiropractors listed as co-authors, about a third of patients reported significant short term neck discomfort following the neck cracking, with no strokes, but this was a small study with minimal numbers of patients. I would think such embrace of neck cracking for treatment of all patient complaints would validate the observation that it is the therapeutic clinical encounter and placebo effect which results in reported benefit.
@ Harriet Hall
“Do you think there is some way to do a really effective placebo control for manipulation studies?”
I was re-reading over a study I had posted previously and it seems they incorporated aspects of both our comments for sham manipulation (decreased magnitude aimed to avoid treatable area’s of the spine ). It seems a reasonable sham manipulation to me. http://www.ncbi.nlm.nih.gov/pubmed/21245790
SMT was shown to perform better than the sham in this trial.
This trial is interesting to me as it sudies a group of patients with chronic non-specific LBP which is the 10% of LBP patients that have an extremely high cost on the healthcare system.
@ Marcus Welby
“As to the control group using manipulation at the wrong level, there is abundant evidence for this model in the frequent use of the “hole in one” concept by which many chiropractors do their dangerous neck cracking as a treatment for literally every complaint.’
Saying many chiropractors is definitely an enormous stretch. This is a small minority.
In regards to your dangerous neck cracking comment, I don’t think you understand how these manipulations (hole in one) are performed. The patient is usually side lying with no rotary or extension force being applied and therefore impossible to tear a vertebral artery.
I was re-reading over a study I had posted previously and it seems they incorporated aspects of both our comments for sham manipulation (decreased magnitude aimed to avoid treatable area’s of the spine ). It seems a reasonable sham manipulation to me. http://www.ncbi.nlm.nih.gov/pubmed/21245790
Was an exit poll performed to determine if patients could or could not tell the difference? How was conscious or unconscience practitioner “cueing” of the patient avoided? And, of course, there is no sham control group for the second phase of that study.
I have been following this discussion with interest. I suggest that no matter how carefully such studies are performed there will never be absolute certainty either way regarding the questions that are usually being posed. After review of all the studies there will be a partly subjective judgment concerning the likelihood/unlikelihood that some patients are benefiting beyond all the non-specific psychological influences of the treatment environment (for the record, I think some probably are but it is genuinely difficult to be sure from the evidence base).
I think we should go back to the beginning and consider the question from the practical medical viewpoint, that chronic low back pain is a difficult, costly condition. It causes much suffering, for which there are no entirely satisfactory conventional treatments.
SBM/EBM is mainly interested in whether SMT “works” or not i.e. via some direct physiological effect on the pathology of LBP. It will ignore it as a treatment option if it is “only placebo” even though most of its own approaches to LBP are also not shown to have real efficacy beyond moral support and sound advice.
Chiropractors desperately want vindication of SMT so they have been focusing on the same question. Yet that matters little for certain wider perspectives.
From the patient’s point of view, and from the point of view of employers, worker’s compensation agencies and taxpayers it does not matter one jot whether any benefits are mainly due to placebo and other non-specific influences, so long as they are gained in a reasonably cost effective way and they are meaningful and objective e.g. — back to work earlier? — less analgesic requirement?
So I suggest that it is pointless doing further “scientific vindication”/”better than palcebo” type studies if they will not change the possibilities/probabilities much. If chiropractors are game, they should look at studies that show more precisely what SMT can do in real-world practice and at what cost. It surely won’t matter if it is mainly placebo if can deliver the goods.
A nice and oblique tu coque argument. SBM has never claimed issue with using placebo effects in the treatment of patients. It has issue with using a therapy which is entirely based in placebo and/or equally as useful as another non-placebo based intervention. In the case of acupuncture, that is pure placebo – there is no mechanism behind the needles actually penetrating the skin vis-a-vis relieving the back pain. Telling patients anything else is, to a greater or lesser degree, fraud and lying to the patient. Contrast this with an antibiotic, for example.
In the case of SMT it is mostly placebo responses coupled with some “manual” therapy. There is absolutely zero indication that this is in any way different from a standard massage or PT exercises. So instead of having a chirorpractor claim some sort of otherwise unidentifiable hypomobile segments that they are “mobilizing” with SMT and utilizing “myofascial release” – which are both garbage that have no evidence and very little plausibility, SBM would demand that better motivating and massage techniques be used as adjuncts or in place of standard of care.
In other words, as I have said repeatedly, incorporating placebo effects and responses into actual medical care is perfectly reasonable. Using a therapy that only “works” by effecting placebo responses (even the “real” ones of Beneddetti’s neurophysiology) is unethical, counterproductive, and of very low utility. Hence, acupuncture and chiropractic have no place in medical treatment of any pathology.
SBM would demand that better motivating and massage techniques be used as adjuncts or in place of standard of care.
Thanks, Nybgrus, for yet again missing my point, with those muddled, dogmatic assertions. I was talking to how we should deal with the uncertainties that some treatment modalities pose and will almost certainly continue to pose for the future.
Your argument appears to be leaning towards denying patients possible benefits rather than risking that a treatment might be wholly placebo. I was suggesting that while there is any uncertainty the patient’s perspective should prevail.
Finally, how do you know massage is not a placebo? What placebo-controlled studies demonstrate that with any adequacy?
@pmoran
“Was an exit poll performed to determine if patients could or could not tell the difference?” Not to my knowledge but I think it would have been an interesting poll if it were done.
“How was conscious or unconscience practitioner “cueing” of the patient avoided?” It think they did the best they could by having a very standardized adjusment performed the same way on all patients but cueing could have happened.
“And, of course, there is no sham control group for the second phase of that study.” This would have been nice as well but I am not sure it was needed as the SMT group showed superiority over sham at all previous intervals.
“I have been following this discussion with interest. I suggest that no matter how carefully such studies are performed there will never be absolute certainty either way regarding the questions that are usually being posed. After review of all the studies there will be a partly subjective judgment concerning the likelihood/unlikelihood that some patients are benefiting beyond all the non-specific psychological influences of the treatment environment (for the record, I think some probably are but it is genuinely difficult to be sure from the evidence base). I think we should go back to the beginning and consider the question from the practical medical viewpoint, that chronic low back pain is a difficult, costly condition. It causes much suffering, for which there are no entirely satisfactory conventional treatments.”
I think I mostly agree with you here. Much of chronic LBP is probably multi-causal and trying to find one certain procedure to cure it is not going to happen. Just think of all the possible NMS contributors to LBP that are not even in the LB region. An example may be decreased ankle dorsiflexion leading to compensatory gait patterns which can increase load on the LB structures leading to pain . This is only one possible problem out of the whole lower extremity kinetic chain that could contibute to LBP. Furthermore, no LBP RCT will able to account for all these possible contributors. I think pragmatic trials for MSK medicine are a good way to go as they can at least demonstrate effectiveness of a treatment approach for such a multfaceted condition as chronic LBP.
“If chiropractors are game, they should look at studies that show more precisely what SMT can do in real-world practice and at what cost. It surely won’t matter if it is mainly placebo if can deliver the goods.”
If you have not already, take a look at some of those trials I posted earlier in response to chris repetsky about halfway up this thread. The second and fourth posted trial are both in line with your comment. The third study is interesting as well.
@nybgrus
“In the case of SMT it is mostly placebo responses coupled with some “manual” therapy. There is absolutely zero indication that this is in any way different from a standard massage or PT exercises.”
Interesting you say zero indication, as about 10 posts back there is a trial that directly contradicts your opinion. http://www.ncbi.nlm.nih.gov/pubmed/20053720 conclusion:Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.
“So instead of having a chirorpractor claim some sort of otherwise unidentifiable hypomobile segments that they are “mobilizing” with SMT and utilizing “myofascial release” – which are both garbage that have no evidence and very little plausibility, SBM would demand that better motivating and massage techniques be used as adjuncts or in place of standard of care.”
Myofascial release, hypomobile joints and mobilization are not spefic to chiropractic as you imply. They are used by all practicioners of manual medicine (PT, DC, MD physiatrist and sports med docs).
You were? Because it sounded a lot like your usual rhetoric in which using a treatment modality that depends entirely (or at least predominantly) on placebo responses for any effect is OK for medical doctors to turn a blind eye to in certain cases. None of the discussion in context related to anything where there was truly uncertainty – i.e. chiropractic or acupuncture. So forgive me, if I somehow misread your intended message.
My argument is not hinged on risk, as you frame it. If there is a risk that a treatment might be placebo that means we don’t reasonably know if it is or not. That is not the case with acupuncture, chiro, or pretty much all of CAM. However, toss in my general aversion to employing treatments for which there is no evidence (one way or the other) and yes, that does indeed limit what treatments may be offered to patients, regardless of what ephemeral benefit you or said patient may somehow perceive. That’s the whole point of basing medicine in evidence and science though – so we don’t just make things up that “sound good.”
And yes, as we’ve discussed before, the effect size and nature of placebo effects make them not useful as stand alone treatments.
In other words, I am not concerned with risk – we know acupuncture is placebo – and I am not concerned with denying patients possible benefits, because placebo only is, IMO, not a benefit to the patient. It would be a delusion to think otherwise.
This is often what you argue, but you offer no threshold. The nature of science is such that there will always be at least some uncertainty. There is no such thing as 100.00% certain. So at what point do you determine something is certain enough? From our discussions it seems you are quick to change that threshold depending on your own notions of the topic at hand.
Case in point is chiro vs acupuncture. You seem to be totally fine with acupuncturists and have consistently argued that it should be used for certain indications. Yet you don’t afford chiropractic the same degree of acquiescence.
Regardless, your threshold seems to be much high than mine (i.e. I am willing to be “certain” sooner than you are).
I don’t think I actually said it wasn’t placebo. However, besides the fact that Bradford-Hill criteria seem to support it as an active intervention, there is no mysticism or false claims associated with massage. And if there is, I would certainly be against that. Intent, presentation, and claims are also very important in determining the ethical standing of a treatment, especially when it may well include placebo elements. A chiro claiming that there are “hypomobile segments” that only they can detect and “mobilize” while doing nothing more intricate or directed than a good massage changes the game.
But the real point with the chiros is that the rest of their professional “package” beyond LBP treatment is hokum doing backwards science to justify its existence. So instead of recommending a chiro for LBP, the better answer is to incorporate the massage and manual aspects of the treatment into standard of care – I did after all say there was some actual effect there.
As an example, if the Memorial Sloan-Kettering Cancer Center (MSKCC) offered foot massages to its patients saying it would help them relax and de-stress, I would be all for it. Instead, they offer reflexology and call it “light touch massage.” Same exact actual treatment, framed differently. One I am certainly against and the other very much for.
@jhawk:
The article really doesn’t demonstrate anything I haven’t already known or written about at some point.
First off, the mean values have massive variance across each and every group and data point. Each and every group has a CI that is almost as big (and sometimes bigger) than the mean itself. Heterogeneous data like that puts a lot of noise in with any signal that may be there.
Secondly, the baseline (discharge) disability score mean for the SMT group was massively lower than the two other groups. It then proceeded to increase, whereas the other groups stayed the same. There was statistical difference but no real clinical difference in pain scores between any of the groups.
But more to the point, it can be explained by SMT being quite superior. Or it can also be explained by exactly what I have seen to be the case in many other studies – the novelty of being in the chiro group effects more placebo response. We also can’t discount that the randomization may have skewed the results because they baselines and then trend were so different.
But I will concede that my statement can’t really stand as is. PT may not be as effective. I will re-phrase myself to say that there is nothing in the chiro arsenal that can’t be employed by PTs equally as effectively with minimal additional training (basically, learning a couple new tricks but mostly sticking to evidence based guidelines). This is essentially what Marcus Welby has been arguing as well.
Interestingly enough, SMT patients were more prone to relapse and requiring further treatment. This further supports my assertion that SMT is mostly placebo since placebo responses are quite ephemeral in nature. The paper itself further supports this notion when it says: “spinal manipulation was given by a physician
while the other interventions by a physiotherapist, a patient’s different attitude to the two clinical categories may have influenced the results.” First off they are calling a chiro a physician. Secondly, nobody was blinded to any of this. In other words, many confounders in this study.
And as a further bit I found interesting because the chiro contingent here has been having a go at claiming cost-efficiency of their brand of treatment:
“, but long-term results were obtained at the price of returning more often for further treatment in the follow-up. Thus spinal manipulation seemed to be less effective than physiotherapy in promoting self-treatment”
The entire discussion section is an interesting read with all the drawbacks to the study.
In sum though, as I said, SMT is mostly placebo and studies such as this one with piles of noise don’t really offer persuasive evidence otherwise. I will be more careful in how I phrase things though, since I will concede that standard PT may itself be sub-optimal therapy for LBP.
sorry for the double post:
myofascial release may not be absolutely unique to chiros, but it most certainly started in the osteo/chiro camp and is BS no matter who uses it, so I fail to see your point about it being used by others.
@nybgrus
“Or it can also be explained by exactly what I have seen to be the case in many other studies – the novelty of being in the chiro group effects more placebo response.”
Both the back school and PT groups had 15 hours of contact time and the SMT group had 2 hours of contact time yet the chiro group had more of a placebo response?
“But I will concede that my statement can’t really stand as is. PT may not be as effective. I will re-phrase myself to say that there is nothing in the chiro arsenal that can’t be employed by PTs equally as effectively with minimal additional training (basically, learning a couple new tricks but mostly sticking to evidence based guidelines). This is essentially what Marcus Welby has been arguing as well.”
I will side with the WHO organization recommendations (2200 hours of extra training for healthcare professionals with a 1000 hours of supervised clinical experience) over yours and Marcus.
“Interestingly enough, SMT patients were more prone to relapse and requiring further treatment. This further supports my assertion that SMT is mostly placebo since placebo responses are quite ephemeral in nature.”
Or this could be due to the fact that SMT group was not allowed to give the exercises given in the other two groups to prevent recurrence.
@ nybgrus
As to cost effectiveness, http://www.ncbi.nlm.nih.gov/pubmed/21229367
“the better answer is to incorporate the massage and manual aspects of the treatment into standard of care – I did after all say there was some actual effect there.”
This systematic review blatantly states that massage is unlikely to be cost effective and that SMT is cost effective yet you espouse the opposite.
Sorry for the double post.
NybgrusFinally, how do you know massage is not a placebo? What placebo-controlled studies demonstrate that with any adequacy?
I don’t think I actually said it wasn’t placebo. However, besides the fact that Bradford-Hill criteria seem to support it as an active intervention, there is no mysticism or false claims associated with massage.
This is what I mean by muddled. Massage might also be placebo, yet you advised it as an alternative to SMT, which you oppose because it might be a placebo. — mysticism and false claims from some chiropractors? Been to a health spa lately?
If we are going to oppose mainly placebo treatments to the extent that you seem to wish (except, a little hypocritically, when your patients force you to confront them in the privacy of your consulting room) then let’s do so with some clarity of mind.
To my mind, massage by a practitioner who offers to produce relaxation and comfort is more acceptable than manipulation by a practitioner who claims to be correcting a poorly defined defect based on questionable evidence. IMHO placebo treatments are acceptable as long as they are provided without lying to the patient. I think certain SMTs are more effective than placebo for certain musculoskeletal conditions, and I am frustrated that chiropractors have not been able to figure out what they are doing or who is likely to benefit. SMTs are effective treatment in some cases and placebos in other cases.
JHawk: I think you are giving out misinformation. Re: neck cracking, the most recent surveys of chiropractors, as I recall, show some 2/3 or 3/4 of them using high velocity neck cracking, which is considered dangerous among ER physicians, neurologists, and neurosurgeons. Anyone with more than a passive knowledge of the anatomy understands the vulnerability of the vertebral arteries where they exit the safety of the bone in C-2 and twist around to enter the foramen magnum. That is exactly where one would expect the a artery to be torn by a sudden twist of the neck and that is exactly where the arteriograms demonstrate the artery dissection to occur. As to your claims that this is done with patients on their side, all the videos I see when I Google chiropractic neck manipulation are by chiropractors with the patient either supine or seated and the practitioner above the patient. The attempt to elicit an audible “pop” when nitrogen gas exits soluble form and becomes a bubble, so the patient is impressed that something important (a bone out of place, perhaps going back into place?) has taken place, has real dangers. As one who has spoken to the mother of a dead young girl whose neck was cracked by a chiropractor over 150 times as treatment for a tailbone pain, and who started having seizures immediately after the final manipulation while on the examining table…I understand the dangers and advise all patients to “never let them touch your neck.” I have also spoken to surviving patients in wheelchairs who were never to walk again after chiropractic neck manipultation for low back pain, and patients who needed craniotomy to treat the stroke which occurred immediately following neck cracking for shoulder pain treatment. I know the official chiropractic position is that the neck cracking is safe, but that is not the position of the medical practitioners who deal with strokes and their sequelae.
@ Harriet Hall
“I am frustrated that chiropractors have not been able to figure out what they are doing”
One of the major reasons SMT is thought to work is by disrupting articular and periarticular adhesions of the ZP joints by gapping and placing a quick stetch on the surrounding capsule. Here is a study that looks at this gapping via pre and post MRI on healhty subjects, http://www.ncbi.nlm.nih.gov/pubmed/12435975.
This same researcher is now doing a follow up study on acute LBP patients, http://nuhs.edu/media/185553/h0107.pdf
Hopefully this somewhat of an answer to your frustration.
Also, I am curious what you thought about the sham manipulation in the study I posted a few comments back in response to your question.
@ marcus welby
You said: “As to the control group using manipulation at the wrong level, there is abundant evidence for this model in the frequent use of the “hole in one” concept by which many chiropractors do their dangerous neck cracking as a treatment for literally every complaint.”
In response I said : “In regards to your dangerous neck cracking comment, I don’t think you understand how these manipulations (hole in one) are performed. The patient is usually side lying with no rotary or extension force being applied and therefore impossible to tear a vertebral artery”
Both of these comments are obviously talking about the hole in one/upper cervical technique which is almost wholly done in the side posture postion with no rotary component. So no I am not giving out misinformation.
Harriet: To my mind, massage by a practitioner who offers to produce relaxation and comfort is more acceptable than manipulation by a practitioner who claims to be correcting a poorly defined defect based on questionable evidence.
Agreed, more or less, but that is not an accurate refection of the stand-off that we seem to have reached.
I submit that there is insufficient difference in either the quality of the evidence for, or the plausibility, of massage, (or even of physiotherapy for that matter) and SMT as treatments for low back pain for there to be strong opposition or endorsement of either.
On both scientific and compassionate grounds we have no basis that would support such discrimination.
I, too, certainly like to point out the problems with the evidence when chiropractors get too pretentious about chiropractic’s scientific status, but in all scientific honesty the status of SMT is not clear. We do know its effects are not dramatic overall, but even those studies may obscure dramatic responses in a few that may not be obtainable any other way.
SMT is also not synonymous with chiropractic. It is used by many doctors without the least taint from traditional chiropractic mythology. Do we oppose that too, Nybgrus, or were the remarks that suggest that intended to refer to myofascial release and other dubious elements of chiropractic?
SMT to treat certain kinds of limited musculoskeletal low back pain is supported by evidence. SMT to correct subluxations is not.
“studies may obscure dramatic responses in a few that may not be obtainable any other way.” That’s the excuse CAM practitioners offer to discredit controlled studies. In a study of any treatment there might be a few patients who respond differently, but if they were more than a small minority it would show in the statistics.
I really didn’t think my comment was that cryptic. Very, very plainly it all boils down to what you tell the patient. Give them a massage and say that it will help them relax and relieve some tension which may well help their MSK complaint, no worries. Give them a massage and tell them you are mobilizing frozen segments which are causing some kind of nebulous impingement, and we have an issue.
And of course, not everyone will respond the same. Personally, I love massage. I actually have chronic joint paint since all my joints are slightly hypermobile since I have a mild form of Ehlers-Danlos (as diagnosed by my rheumatologist). So besides a massage being very helpful, the notion that a chiropractor would want to make my joints even more mobile seems, well, like a bad idea. But my girlfriend can’t stand massage – to her it is pure torture.
So now frame it in the sense of the utility and MOA of the intervention (a hypothetical). If my girlfriend has LBP and a chiropractor whom she believes to be a physician and have an actual evidence base for his treatments recommends some sort of SMT manipulation she would tolerate the discomfort thinking there was some sort of independent mechanism for relieving her pain. I would bet that she would be one of those that derive no improvement, subjective or otherwise, from chiropracty. Tell her its just massage and that the relaxation would probably help her, and she would turn it down stating that she knows it would not relax her.
And of course, Dr. Hall is spot on – there most certainly is some utility to SMT in certain pathology. We don’t have a good handle of what, exactly, is involved in the SMT (i.e. what are the necessary vs extraneous bits) and which pathologies it actually would be helpful for. But the parts that are somewhat useful lose utility when framed from the perspective of a chiropractor – because then you are lying about the MOA to heighten the putative effect.
So while SMT is not synonymous with chiro, the chiros are certainly saying that chiropractic is synonymous with SMT. So when used dubuiously, I am against it. When used within an evidence base, why would I be against it? The only difference between an MD and a DC using the evidence based parts of SMT is that the chiro will undoubtedly go much further than that, since otherwise their entire job would be reduced to something that a casual worker with a week’s training could do.
@jhawk:
As I have pointed out to NMS-DC, the WHO stance re: chiropractic is not something to hang your hat on or be proud of. It is purely a document derived from being forced to acknowledge you exist and trying to make sure you kill and harm as few people as possible. It in no way, shape, or form endorses chiropractic treatment as efficacious or evidence based. Since the WHO doesn’t have the power to simply expunge chiropractic from existence and since it cannot ignore the health seeking attitudes of people, no matter how uninformed they are, they created the document to try and assure some kind of minumum standard to try and protect people seeking out your services. It does a poor job at that, IMO.
[...] Novella recently wrote about so-called “chiropractic neurology” and its most outspoken proponent, Ted Carrick. In 2005 I published an article in The Scientific [...]
Telepathy , schizophrenia, paranormal scams, Homeopathic Medicine, million-man James Randi
Who is protecting those criminals and not publishing truth and what is truth?
There are houndred’s offices that sell paranormal scams(astrology, medicine…), can Uri Geller read peoples
mind? Why is James Randi offering one million when Internet is full with documents on Vinko Rajic and his telepathy.
What about this?
“Vinko Rajic can use telepathy , he is maybe the only person that can use telepathy all the time , send
and receive voice and video on distance of few kilometer. It works all the time and 100% correct.
I think it is important for science and human kind to make research on Vinko’s brain and find out how this works.
Vinko’s telepathy manifest itself exact like “Schneider’s first-rank symptoms”.
I think it would be extremely important to find out what kind of waves transmit my thoughts. Using
Vinkos brain I think it would be possible to find out how telepathy works and I think it would be possible to find out
if some Schizophrenics are telepathic to. ”
Who has interest to have telepathy “not existing”, and who has interest in sealing all those scams and show’s on
scam’s? Many people are loosing money because of all those scams, WHY?
I think that some perspective can be found in the knowledge that there remains no evidence in support of the majority of medical practice. Medical doctors throwing stones at chiropractic or any other practice should watch out for their glass house.
I think that some perspective can be found in the knowledge that there remains no evidence in support of the majority of medical practice. Medical doctors throwing stones at chiropractic or any other practice should watch out for their own glass house.
@gbove,
“there remains no evidence in support of the majority of medical practice”
This oft-repeated criticism of medicine is demonstrably false.
There is good evidence to support the majority of medical interventions. 78% of them are supported by some form of compelling evidence. 38% of them are supported by RCTs. Keep in mind that because of ethical and practical considerations, RCTs can’t be done for many interventions known to be effective, like setting broken bones and removing inflamed appendixes.
http://sram.org/media/documents/uploads/article_pdfs/5-2-06.Imrie-Ramey.pdf
Also keep in mind that medicine is constantly striving to become more and more evidence-based and has a solid track record of questioning itself, studying common practices and discarding those that are proven effective. Contrast that to the track record of CAM. What has chiropractic ever tested, found ineffective, and discarded?
Citation needed gbove.
Also, if there was no evidence supporting medicine, does that mean chiropractic “works”?
A lack of evidence for an intervention seems like nothing more than a lack of evidence for that intervention. I can’t see how a lack of evidence for medical interventions (if that statement is even true) can somehow validate chiropractic theory and practice. Seems like the answer is to test, abandon what doesn’t work and keep what does. Chiropractors can justifyably criticize medical practices, which means those practices should be tested or improved. But they’re hypocrites if they don’t also test their own.
Telepathy , schizophrenia, paranormal scams, Homeopathic Medicine, million-$-man James Randi
Who is protecting those criminals and not publishing truth and what is truth?
There are houndred’s offices that sell paranormal scams(astrology, medicine…), can Uri Geller read peoples
mind? Why is James Randi offering one million when Internet is full with documents on Vinko Rajic and his telepathy.
What about this?
“Vinko Rajic can use telepathy , he is maybe the only person that can use telepathy all the time , send
and receive voice and video on distance of few kilometer. It works all the time and 100% correct.
I think it is important for science and human kind to make research on Vinko’s brain and find out how this works.
Vinko’s telepathy manifest itself exact like “Schneider’s first-rank symptoms”.
I think it would be extremely important to find out what kind of waves transmit my thoughts. Using
Vinkos brain I think it would be possible to find out how telepathy works and I think it would be possible to find out
if some Schizophrenics are telepathic to. ”
Who has interest to have telepathy “not existing”, and who has interest in sealing all those scams and show’s on
scam’s? Many people are loosing money because of all those scams, WHY?
[...] me first say that chiropractic neurology is a new field with dubious validity. Stating that concussion is caused by injury to the cervical spine is [...]
Carrick’s back in the news, because Crosby is still not fully recovered:
NHL Today, 1/16/2012
Both hockey fans and chiropractors are spreading the news…The science-based medicine evaluation of “chiropractic neurology” or its other moniker, “functional neurology” not much in evidence.
Sadly, Sidney Crosby went back on the IR due to concussion symptoms only a few games after he returned to hockey. He’s still out and hoping to play again soon, but one has to wonder if his career is done.
Anyways, excellent article, I don’t know how I missed it. I think around this time I was distracted by Jaromir Jagr’s use of acupunture to treat his groin injury (ouch) and the local press that was receiving.
The original Sports Illustrated article gave too much credence to Carrick, but at least had this:
But the SI article today had exactly 0 criticism of Carrick or his pseudoscience:
Yahoo sports called Carrick “a concussion specialist” (!)
I’m at the point where I can’t be “politically correct” with chiropractors anymore. They are cranks. They are pure quacks. Tonight I’ve read how chiropractors “treat” concussions, how they can diagnose and treat “ileo-cecal valve syndrome” and how they can diagnose food allergies with applied kinesiology. There may be a couple of them out there that specifically treat only certain types of lower back pain and don’t give their patient radiation therapy (X-ray) in the process, but I believe they are few and far in-between. If such a person exists, I apologize, but your profession is just filled with disgusting quacks.
I was just mildly reprimanded by Dan Rosen (NHL writer) on Twitter. Rosen tweeted an article about Crosby… linked within there was another article that had a paragraph questioning Carrick (http://www.nhl.com/ice/news.htm?id=612050):
“Carrick specializes in a field called chiropractic neurology [..] The field is considered non-traditional, and some medical doctors have said that unorthodox treatments, such as putting a concussion victim into a tumbling chair, could be counterproductive and might actually worsen a patient’s condition.”
This is the response I got from Rosen when I tweeted an exerpt from this passage: “Pretty sure they wouldn’t put him at risk. I’m not a doctor. I have no idea if you are. But I know I’m not one to judge.”
Yup, let’s not judge, let’s just let people do whatever and not ask critical-thinking questions. Head in the sand. Lalalala.
We can “judge” if a coach should have pulled a goalie in a game, but asking questions about potentially dangerous health practices? WHY YOU BE ALL JUDGMENTAL.
@Enkidu, it’s a shame that main stream medicine isn’t more vocal in speaking out against these quacks.
Fact: chiropractic neurology is complete quackery.
According to a report in today’s Washington Post Pittsburgh Penguins hockey star is being treated by a chiropractic neurologist for his lingering symptoms from too many concussions
[...] Claims Cervical Cancer Is for Prostitutes | Straw Vulcan | Darwin Day | Oldest Known Primate | Chiropractic Neurology | Oxytocin and [...]
[...] Claims Cervical Cancer Is for Prostitutes | Straw Vulcan | Darwin Day | Oldest Known Primate | Chiropractic Neurology | Oxytocin and [...]