Dec 30 2011
Subluxation Theory: A Belief System That Continues to Define the Practice of Chiropractic
When I graduated from Lincoln Chiropractic College in 1956, I had come to the conclusion that chiropractic’s subluxation theory, that misaligned vertebrae can cause organic disease, was not true. When I began my practice in Panama City, Florida, I limited my practice to care of mechanical-type back pain and related problems. Back then, that was not too much of a stretch, since manipulative services were not readily available in medical practices and there were a number of orthopedic and physical medicine texts recommending use of manipulation in the treatment of back pain.
In 1963, I published my book Bonesetting, Chiropractic, and Cultism, renouncing subluxation theory and recommending that chiropractic be developed as physical treatment specialty in the care of back pain. The book was reviewed by the Library Journal (February 1, 1964) and recommended for inclusion in medical and reference libraries. In 1965, I received a letter from the American Chiropractic Association (ACA) informing me that my application for membership in the ACA had been rejected. In the years to follow, I published many articles in an attempt to initiate an effort to change chiropractic from a subluxation-based practice to a legitimate physical treatment method that would fit in with mainstream health care. My suggestions were ignored and I was called a “chiropractic heretic.” Today, I find myself still saying some of the things I said in my 1963 Bonesetting book, still being rejected by most of my colleagues and still voicing opposition to subluxation theory.
There are now some chiropractors who do not subscribe to the theory that some kind of segmental dysfunction in the spine can cause organic disease, but they are overshadowed by subluxation-based chiropractors who publish their own journals, using scientific-sounding jargon to defend implausible theories and dubious treatment methods. Some of these chiropractors do not use the “subluxation” word, instead substituting some other vague description of a spinal lesion, such as “joint dysfunction,” alleged to have the same affect on the nervous system and general health as a “vertebral subluxation.”
The Status of Chiropractic Vertebral Subluxation
In the United States, state laws and chiropractic publications define chiropractic as a method of correcting vertebral subluxations to restore and maintain health. A 2010 publication of the National Board of Chiropractic Examiners (NBCE), Practice Analysis of Chiropractic, states that “The specific focus of chiropractic practice is known as the chiropractic subluxation or joint dysfunction. A subluxation is a health concern that manifests in the skeletal joints, and, through complex anatomical and physiologic relationships, affects the nervous system and may lead to reduced function, disability, or illness.” This definition of chiropractic is in keeping with a paradigm formulated by the Association of Chiropractic Colleges (ACC) in 1996, signed by 16 North American chiropractic college presidents: “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.”
When the Council on Chiropractic Education (CCE) published its proposed 2012 Accreditation Standards for chiropractic colleges, reference to the word “subluxation” was omitted. The American Chiropractic Association (ACA) responded, in part, arguing that “The elimination of any reference to this term in the proposed standards will be viewed by many within the profession as a counter productive action that will, in the long-term, likely weaken the profession’s collaborative strength and historical identity.“ The CCE compromised by using the nebulous phrase “subluxation/neuro-biomechanical dysfunction” in the final 2012 Standards in order to satisfy advocates of the vertebral subluxation theory. (An open letter to the profession from CCE, Nov 22-11) Obviously, the factory of the chiropractic profession has not discarded subluxation theory. Chiropractic associations continue to reflect the views of the majority, even if such views are based on a belief system.
At least one recent study by individual academic chiropractors has concluded that “No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention.” (Mirtz, et al. An epidemiological examination of the subluxation construct using Hill’s criteria of causation. Chiropractic and Manual Therapies. 2009;17:13)
Another independent study by academic chiropractors revealed that “Despite the controversies and paucity of evidence the term subluxation is still found often within the chiropractic curricula of most North American chiropractic programs.” (Mirtz & Perle. The prevalence of the term subluxation in North American English-Language Doctor of Chiropractic programs. Chiropractic and Manual Therapies. 2011;19:14)
It will not be enough for chiropractors and chiropractic colleges to substitute such words and phrases as “joint dysfunction,” “vertebral subluxation complex,” and “subluxation/neuro-biomechanical dysfunction” for the word “subluxation” if they continue to imply that such disturbances can affect the nervous system to cause illness. A chiropractic subluxation by any other name is still a chiropractic subluxation.
Real and Imaginary Benefits of Spinal Manipulation
Recent reviews of the literature indicate that manipulation may not be any more effective than other treatment methods in affecting the ultimate outcome in recovery from back pain. For symptomatic relief of uncomplicated mechanical-type back pain, however, use of hands-on manipulation may provide more immediate and dramatic relief by stretching tight muscles and mobilizing the spine. Apart from the misinformation provided by chiropractors who keep asymptomatic patients coming back for correction of “subluxations” alleged to cause a myriad of health problems, many back-pain patients return for manipulative treatment for the symptomatic relief they experience. A competent chiropractor would release the patient when back-pain symptoms have resolved, as opposed to subluxation-based chiropractors who lock their patients into lifetime “subluxation correction” as a preventive measure. Endorsement of the use of manipulation in the treatment of mechanical-type back pain is not an endorsement of chiropractic adjustments used to correct subluxations or some other “joint disturbance” alleged to cause illness or poor health.
In rare cases involving articular adhesions, actual locking of a vertebral joint, or post-traumatic loss of mobility in spinal joints, there is no substitute for appropriate manipulation. Recognizing this, physical therapists and orthopedic manual therapists are now including use of manipulation in their treatment armamentarium.
In addition to the effect of mobilization and manipulation in relieving uncomplicated mechanical-type back pain and restoring mobility in spinal joints, there are additional effects produced by “popping” the vertebrae.
When vertebrae are manipulated to produce a popping sound, there is a slight separation of joint (facet) surfaces, producing a vacuum that pulls in nitrogen gas from joint or synovial fluids to fill the space. This is called “cavitation,” an effect that temporarily increases mobility and range of motion. Such an effect may produce a sense of well being, which seems compelling for some people. There might also be some slight temporary increase in height as a result of cavitation and decompression of disc cartilage.
Persons who believe that they have subluxations or vertebrae out of place causing a health problem may be subject to a powerful placebo effect when the spine is popped, leading them to believe that their condition is being helped or cured by replacement of a vertebra. Such popping does not mean that a vertebra was out of place. Normal vertebrae can be popped when thrust-type manipulation forces movement of spinal joints into the paraphysiologic space (beyond the normal range of movement).
After vertebrae have been manipulated to produce cavitation, it may take three or four hours for the joint surfaces to settle back together so that the vertebrae can be popped again. This popping sound may produce fear that failure to get regular adjustments to pop or align the vertebrae will result in development of illness─a nocebo effect often exploited by chiropractors who have asymptomatic patients coming back on a regular basis for “preventive maintenance.”
Alternative Medicine: A Refuge for Chiropractic
In view of increasing opposition to subluxation theory, some chiropractic colleges have read the handwriting on the wall and moved into the camp of alternative medicine. The National University of Health Sciences (NUHS), for example, often referred to as the foremost American chiropractic college, offers Doctor of Chiropractic, Doctor of Naturopathic Medicine, Master of Science in Acupuncture, and Master of Science in Oriental Medicine degrees. NUHS recently announced a new cooperative arrangement with the Graduate Program in Complementary and Alternative Medicine at Georgetown University Medical Center in Washington D.C. Faculty at the two schools will work together to help students seeking advanced degrees in health care by advising students of the benefits of each other’s programs and providing preferential seating and advanced standing in each other’s programs when appropriate.
The web site of the Association of Chiropractic Colleges, in its “What Is Chiropractic?” section, states: “Because of the emphasis on holistic health care, chiropractic is associated with the field of complementary and alternative medicine.” (Accessed December, 13, 2011) Most health-care professionals consider “alternative medicine” to be a haven for unproven and implausible treatment methods.
Few consumers are aware of the great diversity in chiropractic, and few know what questions to ask when looking for a science-based chiropractor. Until all chiropractic colleges uniformly renounce the vertebral subluxation theory and are upgraded to training musculoskeletal specialists, treatment methods will vary from one chiropractor to another, incompatible with exchange in mainstream health care. With increasing numbers of physical therapists using high velocity, low amplitude thrust-type manipulation, physicians and other health-care providers can refer a patient to physical therapy for spinal manipulation, thus avoiding the problems associated with finding a chiropractor who uses manipulation appropriately.
In observing the web sites and promotional materials of newly graduated chiropractors, it appears that many of these chiropractors are combining science and pseudoscience to support treatment methods based on the basic tenets of traditional chiropractic, that is, manipulating the spine for some unverifiable neurological effect that will affect general health or organ function. Some, claiming to be primary care providers, combine “spine care” with “health care” and “wellness care” in a holistic approach that entails treatment and prevention over a broad scope of ailments, using a variety of alternative healing methods. Legislation to allow chiropractors with an “advanced practice” certification to prescribe drugs from a limited formulary has been proposed in New Mexico, South Carolina, and Alabama. Chiropractors would be required to have 90 hours of additional training in pharmacology. So far, such legislation, opposed by chiropractors who feel that chiropractic should remain a drugless healing profession defined by the basic principles of chiropractic, has failed.
Chiropractic and Physical Therapy Are Not the Same
The only thing unique about chiropractic is its basic definition as a method of adjusting vertebral subluxations to restore and maintain health. Any other physical treatment method, including generic spinal manipulation, is physical medicine. The subluxation theory has been the chiropractic profession’s only reason for existence since its inception in 1895. Failure of the profession to establish itself as a legitimate physical-treatment specialty with an armamentarium that includes use of generic spinal manipulation continues to leave the profession dependent upon the basic tenets of chiropractic. Many chiropractors feel that if the chiropractic profession discards the subluxation theory and specializes in the care of back pain and related musculoskeletal problems, it will not be able to compete with physical therapists and other musculoskeletal practitioners who use manual therapy.
With a foundation based on an implausible theory that nurtures a hodgepodge of dubious chiropractic techniques, the chiropractic profession is splintered by philosophies that go in many different directions. The approach of chiropractic colleges may range from “straight chiropractic,” which proposes that most ailments can be treated by adjusting vertebral subluxations, to “alternative medicine,” which permits use of unproven treatment methods to treat a broad scope of ailments without resorting to subluxation theory.
It’s important to understand that manipulation used in the context of chiropractic subluxation theory is not done for the same reasons guiding the use of manipulation by physical therapists. With the exception of a few science-based chiropractors who use manipulation appropriately, it appears that most chiropractors manipulate or adjust putative vertebral subluxations in a misguided effort to restore and maintain health. Physical therapists use manipulation-mobilization primarily to restore mobility in the spine. When chiropractors accuse physical therapists of stealing their treatment method, nothing could be further from the truth. Generic spinal manipulation has long been a part of physical medicine and is unrelated to subluxation-based chiropractic. Chiropractors often say that the difference between physical therapists and chiropractors is that chiropractors adjust vertebrae while physical therapists manipulate the spine.
Entrenched Subluxation Theory
There is no reason to believe that the subluxation theory will ever be discarded by all chiropractors. Unable to demonstrate that real orthopedic subluxations can cause organic disease, some chiropractors refer to a “vertebral subluxation complex,” another name for a chiropractic subluxation that is asymptomatic and undetectable. Belief systems cannot be eradicated by scientific presentations, especially subluxation-based chiropractic which finds support in the pseudoscience of alternative medicine. It seems unlikely that chiropractic, tainted by subluxation theory, will ever be absorbed by physical therapy, become a subspecialty of medicine, or be welcomed by academia. It may already be too late for the chiropractic profession to make the changes needed to train chiropractors to do what physical therapists, physiatrists, and orthopedic manual therapists are already doing. It certainly does not seem likely that the chiropractic profession, as it stands today, could take the path chosen by osteopathy in 1929 when the federal government gave the osteopathic practitioner the same privileges granted to medical doctors.
In the final analysis, we see only what we are ready to see, what we have been taught to see. We eliminate everything that is not part of our prejudices.
— Jean-Martin Charcot, 1825-1893
Sam Homola, at the age of 82, is the author of 15 books, including Bonesetting, Chiropractic, and Cultism, published in 1963, and Inside Chiropractic, published in 1999. He resides in Panama City, Florida, with his wife, Martha.
187 Responses to “Subluxation Theory: A Belief System That Continues to Define the Practice of Chiropractic”
Wow! Well said and beautifully explained and summarized. Threatening to the chiropractic mainstream, so it will be vilified and ignored by that set, I predict. Homola, a second generation chiropractor with vast experience, has always been a sober and thoughtful objective observer and explainer.
What Marcus Welby said. An excellent piece that is now the lead link in the chiropractic section at ebm-first:
http://www.ebm-first.com/chiropractic.html
As documented by Jann Bellamy in a previous post, the U.S. Dept. of Education allows private post-high school educational institutions to self-accredit, so chiropractors are vetting their schools and curricula. Of some interest, a number of chiropractor graduates who cannot repay their educational loans have been angry at the DOE and other targets over their feelings they were mislead about the value of their education. Also, there are indications the Chronicle of Higher Education will come out with some articles about chiropractic education and the fact some of the DC professors are raking in salaries in excess of 700K although a recent chiro school in L.A. closed and enrollment is dropping in U. S. chiro schools.
Where all these PTs that do manipulation? After 8 operations on my arm, I’ve seen a lot of them, but only guy, in Taiwan, ever did any kind of manipulation, which always made me feel better, and none of the other PTs had any idea what I was talking about when I described this to them/
My general experience with PTs is they treat everything with weight lifting.
A few points:
1. I wholly believe that chiropractors are simply redundant. The profession is rooted in vitalism and is based on a disproven concept, the subluxation. Shifting it towards something more science based is always going to be met with resistance, just as it would if we tried to shift iridology or reflexology to a science based practice.
Let’s be honest, the only reason some chiropractors want to “shift” to evidence-based practice is because a lot of them “know” that they’re practice is unscientific, but they’ve already invested so much money and time into their education that going to back to school is unfeasible. They want a shortcut to something better.
Physical therapy is already established as a profession. While it has its own share of pseudoscience, it is much more evidence-based, isn’t rooted in vitalism, and doesn’t claim to be able to treat all sorts of diseases that it has no business treating.
It doesn’t seem necessary to transform chiropractic care into physical therapy. Chiropractors who want to be science-based picked the wrong profession. They need to go to physical therapy school, sit through their curriculum, and get the degree. They can’t just start shifting their practice over assuming they know everything that a PT does.
Chiropractic curriculum spends a lot of time on non-existant subluxations (12-22%, in fact – Mirtz TA, Perle SM. “The prevalence of the term subluxation in North American English-Language Doctor of chiropractic programs.” Chiropr Man Therap. 2011 Jun 17;19:14.) I don’t have any evidence of this, but I would assume that if someone went to school and 1/10th to 1/5th of what they learned was based on pseudoscience, then they would definitely have some gaps in their knowledge.
If I’m a family medicine doctor, and want to start doing neurosurgery, I just don’t start slowly operating on people. I have to go to a residency or fellowship training program and start from the beginning. Likewise, if a chiropractor wants to be a physical therapist, then they need to go to school for that.
2. You wrote: “Recent reviews of the literature indicate that manipulation may not be any more effective than other treatment methods in affecting the ultimate outcome in recovery from back pain.”
I can’t help but be bothered by this statement. The recent reviews that I’ve read found that manipulation may not be effective. Period. Not that they may not be MORE effective than other treatments. It’s that they aren’t effective period.
Ernst E, Canter PH. “A systematic review of systematic reviews of spinal manipulation.” J R Soc Med. 2006 Apr;99(4):192-6. – Found spinal manipulation to not be effective for any medical condition. They found spinal manipulation was only superior to sham manipulation for back pain.
But that review was updated:
Ernst E, Canter PH. “A systematic review of systematic reviews of spinal manipulation.” J R Soc Med. April 2006 vol. 99 no. 4 192-196. – Found spinal manipulation to not be effective for any medical condition.
Another review:
Ernst E. “Deaths after chiropractic: a review of published cases.” Int J Clin Pract. 2010 Jul;64(8):1162-5. – The risks of chiropractic manipulation far outweigh any benefit a patient may receive from it. Given that reviews find there is essentially no benefit from spinal manipulation, any risk at all makes it a negative risk-benefit analysis. I equate it to sticking my finger in an electrical socket. There’s just no good reason to do it.
(I can’t begin to imagine how much alternative medicine practitioners hate Dr. Ernst.)
Note: The studies are interesting, because (for anyone who doesn’t know, Sam, I know you know this) there is a distinction between “spinal manipulation” and “chiropractic care.” Spinal manipulation is self described, but “chiropractic care” can encompass spinal manipulation and any other of a number of treatment modalities, including massage, heat, exercise, etc. Just something to keep an eye on when reading these studies.
3. You wrote: “For symptomatic relief of uncomplicated mechanical-type back pain, however, use of hands-on manipulation may provide more immediate and dramatic relief by stretching tight muscles and mobilizing the spine.”
The use of “may” is ambiguous. You’re saying that for some very specific type of back pain, some technique may or may not provide some type of relief. But you also say “may provide more” – more than what? Nothing? More than standard medical care?
The latest Cochrane review would disagree. For spinal manipulation, they found: “There was little or no difference in pain reduction or the ability to perform everyday activities between people with low-back pain who received spinal manipulation and those who received other advocated therapies. This review of 39 trials found that spinal manipulation was more effective in reducing pain and improving the ability to perform everyday activities than sham (fake) therapy and therapies already known to be unhelpful. However, it was no more or less effective than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner.”
For combined chiropractic interventions, they found: “The review shows that while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low-back pain, there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain. Any demonstrated differences were small and were only seen in studies with a high risk of bias.”
When we combine data from reviews like Cochrane and Ernst, we can see that chiropractic care probably has a very small effect on specific types of low-back pain. For anything else, we can see it’s likely to be ineffective. … So what is the point of chiropractors again?
4. Because of #3 (chiropractic care has almost no effect, except a very small possible effect for specific types of low-back pain), it seems that chiropractors are pigeonholed in their profession. They simply can’t sustain a practice if they practice in an evidence-based manner.
Please note: I am not attacking you. I just have different feelings about chiropractic. I have the writing ability and wit of a corpse. I wish I could have WLU construct these posts for me.
[...] Science-Based Medicine » Subluxation Theory: A Belief System That Continues to Define the Practice … [...]
Perhaps this is a false prediction but, if you look at National University of Health Sciences, which was once a chiropractic degree granting institution only, they have now expanded to include naturopathy and TCM.
All, by magic of institution title, instantly
SCIENCE.
Prediction: the DC education machine will further diversify, and science, academically speaking at least,
will continue to be degraded to the point of meaninglessness.
In terms of commerce: the consumer, because this occurs so institutionally nested, will have no rights in terms of fair trade, because in complaining that ‘I wasn’t treated per science’ or ‘I wasn’t educated per science’, a bunch of “fully accredited” eggheads will defend such legal action and win merely by dog-piling.
-r.c.
DrRobert
“It doesn’t seem necessary to transform chiropractic care into physical therapy. Chiropractors who want to be science-based picked the wrong profession. They need to go to physical therapy school, sit through their curriculum, and get the degree. They can’t just start shifting their practice over assuming they know everything that a PT does. ”
That approach is not how osteopathy got to where it is today in the US. Sam is likely correct that it’s too late for chiropracty to go the route that American osteopathy went, but it might be possible to design a specialized course/ set of courses and certification to help transition chiropractors who want to be science-based into PT without requiring them to start over from scratch. To say “Chiropractors who want to be science-based picked the wrong profession” is to give up on a group (however small) that want to be on our side. I’m not sure that’s the best idea or only practical option.
“If I’m a family medicine doctor, and want to start doing neurosurgery, I just don’t start slowly operating on people. I have to go to a residency or fellowship training program and start from the beginning. Likewise, if a chiropractor wants to be a physical therapist, then they need to go to school for that.”
Yes, but you wouldn’t have to go back to medical school and start from square one. Perhaps chiropracty is so far off base that there’s nothing in their education and training that can be of use in the transition to a science based PT practice, but maybe there’s a way to transition them to PT without them completely starting over. Maybe it’s less than ideal, and you’d have a generation of slightly wooey PT practitioners that came over from chiropractic, but it might be a step in the right direction. On the other hand, maybe the reality is that the number of hypothetical chiropractors we’re talking about is so incredibly small that it’s a moot point anyway.
“It doesn’t seem necessary to transform chiropractic care into physical therapy. Chiropractors who want to be science-based picked the wrong profession. They need to go to physical therapy school, sit through their curriculum, and get the degree. They can’t just start shifting their practice over assuming they know everything that a PT does.”
I was thinking this throughout the article. There is simply no justification for anything called chiropractic. It also seems reasonable to offer some kind of “transition training” as mentioned by Karl W., but it must be rigorous and root out the woo. Students who feel cheated by the training they got in chiropractic need to address this through the licensing bodies of their states. We could simply dispense with the whole notion of chiropractic and offer some assistance for these people to retrain–paid for by the lawsuits they are now involved in (assuming some would succeed).
I’m not sure what part of chiropractic training would help in a transition, but presumable they learn some basic anatomy and terminology. There probably isn’t much that would carry over, though.
Mr. Homola (Dr?) seems very well-intentioned and I applaud his long term effort to dignify his profession, but you cannot simply take people’s word that they are now interested in SBM and want to restyle themselves as a PT. I am very grateful to the PT who helped me following rotator cuff surgery and I would hate to think that next time I might get a former chiropractor with no additional training, who would “manipulate” my shoulder!
Great conversation all. My eyes always widen when I see posts on manipulation and PT since I am a manual physical therapist and academic.
Karl:
There is no way chiros will be given a fast tract to a PT license. Being a PT is about thinking like a PT. There really is not anything PTs do that is not done by other professionals. Joint manipulation, soft tissue massage, exercise, education, modalities are all done by other professionals. To be a PT you need to learn how to think like a PT, with a focus on movement. This thought process (along with literature and scientific thinking) is what guides a good PT’s decision making. To get that one has to go through the whole course work. Comparing changing medical specialties to moving from chiro to PT is a poor example. One is moving within a profession and the other is changing professions entirely. Orthopedic manual PT is only a small part of what PTs do. PTs work in all types of setting and with patient who have varying diagnosis/movement dysfunctions. Would a chiro be prepared to treat a patient with a stroke, CP, unhealed wound, massive burn, amputation, hip replacement, developmental delays, is in the ICU etc…? Also I can’t see the politics allowing it. We can’t even agree to grandfather PTs with masters to a doctorate.
Dr. Robert:
Much of orthopedic care suffers from a lack of good quality evidence and treatment of low back pain is not an exception (in fact it is the rule). High velocity, low amplitude thrust techniques to the low back (HVLA) has been studied a decent amount and as you pointed out in general the results have been underwhelming. I call it HVLA because the vernacular for any manual therapy technique moving the spine is manipulation. This can include both low velocity (mobilization) or high velocity (often called manipulation but this term is not exclusive). So most if not all of the systematic reviews include studies looking at both high and low velocity techniques. So we need to be careful to acknowledge that these reviews are lumping two very different techniques under the same umbrella. Another potential problem is that most RCTs make very little attempt to sub categorize individuals with low back pain beyond duration of symptoms. The reason for this is that in most cases a clear way to sub categorize them is not evident. In the PT literature we are starting to see attempts at classification beyond duration of symptoms. This has shown some promise in identifying individuals who respond very dramatically and consistently to HVLA spinal thrust. By dramatic I mean more than a 50% improvement in disability and by consistent I mean over 90%. This has been demonstrated in several studies.
But lets face it, when dealing with low back pain, we are dealing with pain. Pain is inherently a complex experience which is influence more by the individuals beliefs, perspective, fear, past experience etc.. then it is by pathology, structure, damage or injury. This makes treating patients with low back pain as clear as mud (really, really dark mud).
@ Janet Camp
“I’m not sure what part of chiropractic training would help in a transition, but presumable they learn some basic anatomy and terminology. There probably isn’t much that would carry over, though.”
Chiro schools require ~24 credit hours of basic/gross anatomy and PT schools require ~5 credit hours. As for the rest of the cirriculum, I think you should compare them before you make these ill informed statements.
I will make it easy for you. Here are two links, one is chiro requirements and is one PT.
http://www.ahs.uic.edu/pt/programs/dpt_requirements.php (PT)
http://www.uws.edu/Academic_Programs/Doctor_of_Chiropractic/DC_Program_Curriculum.pdf (chiro)
previous comment inspires the following:
I believe the manipulation of my shoulder (performed by a PT in Taiwan who’d received his doctorate from NYU) was a form of muscle energy technique, where the practitioner manipulates and the patient resists. It was very useful in getting me to find and fire up the right muscles and not the wrong ones (I’ve noticed that I tend to overuse my scalenes and sternocleidomastoids and the expense of other muscles both in breathing and moving my arms, and have learned on my own to control this). It helped, although unfortunately he could only see me briefly.
I have no idea what the effect of weightlifting was on the rotator cuff tear that was incidentally discovered and repaired in one of my subsequent operations. I do know that after a few months of weightlifting my neck and shoulder were extremely tense, painful and hypersensitive to touch, especially at the nerve running down the neck.
I have no particular interest in manipulation per se, but I do think there are a lot of modalities out there that are too rare among PTs, such as Feldenkrais, muscle energy technique, and the Edgelow protocol, on which there isn’t much research, and which, like so much of physical therapy, doesn’t lend itself to placebo controlled trials.
oops, no longer the “previous” comment; I meant Janet Camp’s
Elmer:
Thanks for sharing your experience! Your post highlights the reason why we need “science-based medicine”.
Although your experience and your beliefs:
“I’ve noticed that I tend to overuse my scalenes and sternocleidomastoids and the expense of other muscles both in breathing and moving my arms, and have learned on my own to control this)”, “I do think there are a lot of modalities out there that are too rare among PTs, such as Feldenkrais, muscle energy technique, and the Edgelow protocol,”
seem very real and accurate to you, they are simply anecdotes and don’t tell us much.
What if I were to tell you that “weightlifting” (I will call it strength and or endurance training) help improve symptoms in 90% of people with rotator cuff problems and METs only help 3% of people. Maybe your experience simply fell outside the norm? Does this mean that PT practice should be changed based on your experience or should it be based on scientific reasoning and probability of success. It is pretty clear that if you can convince patients of the efficacy of a treatment several of them will get improvement regardless of the efficacy of the treatment (especially when dealing with pain). Before I get jumped on, I simply made up those numbers to prove a point.
Bottom line, if we rely on anecdotes and beliefs (which are not critically and skeptically appraised) I think we are likely to be mislead far more than we will come to the correct conclusion.
So I appreciate you sharing your experience with us, however don’t expect the PT profession to move in a direction based on your personal experience or the personal experience of any other person.
@jhawk
In regards to comparisons Chiro to PT schooling and curriculum it may be difficult with the information that you provided. Quarters and Semesters are different time frames. Also there are different accredidating bodies for these different schools (Chiro and PT) so it is difficult to measure if there are similarities or differences of curriculum within those classes and the hours listed based just on the title of the class.
I would agree that the basic anatomy would most likely not be a significant difference between the schoolings though. I think comparing a technique to equate professions is problematic. Many different professions use manipulation techniques (Chiro, PT, Osteopaths, and others) they are all distinct professions in of themselves with separate schooling and body of thought. I often use an analogy of health care providers that use a sphygmomanometer to measure blood pressure. Many of health care providers are trained in its use, but obviously those professions are significantly different. The profession should be defined by its school of thought not the techniques used.
So while Chiro and PT use some similar techniques, the school of thought and range of treatment areas are considerably different and any attempt to equate them is wrong on many levels.
It seems to me that a critical thing that should be required for a chiropractor to transition would be re-education directed at correcting the pseudoscientific beliefs many chiropractors hold, from anti-vaccine fallacies to applied kinesiology.
But if they insist on applied kinesiology, the transition should instead be directed to a career on the carnival midway. That one is inescapably ridiculous. Are there papers supporting its diagnostic abilities in the industry journals?
@Devout:
http://en.wikipedia.org/wiki/Applied_kinesiology#Scientific_research
Double blinded RCTs are negative. Biased trials that were designed by people who believe in things as ridiculous as AK are positive.
Good piece. Now, what about Osteopathy? I have always thought of this as a parallel to Chiropractic, but is it?
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arufa:
As I said, the rotator cuff was just one thing I was dealing with. My story is a long one, and I get tired of telling it. But I know from reading case histories and discussion forums (fora?) that there are a lot of long stories out there.
Earthman, the page about Osteopathy at Quackwatch is pretty interesting. I don’t feel like googling it.
I also understand that the core of PT techniques was developed to get injured soldiers back up and fighting in WWI. When a doctor writes a script for weightlifting do deal with a repetitive-stress injury, what he’s most likely prescribing is more of what caused the injury in the 1st place, depending on the PT’s skill set. If anybody has real (not made-up) data showing that this is effective, I’d like to see it. In the meantime, I’ll say that it doesn’t seem reasonable to me.
Dr Robert,
With respect to your comment on the efficacy of spinal manipulation, research has shown there is a great heterogeneity in patients with low back pain (LBP) which accounts for the results of the systematic reviews you stated. It’s not the same as taking a drug for a particular disease. The drug, ie manipulation, has only been found to be effective in a subgroup of patients. Thus in PT, the ICD-9 diagnoses that apply to LBP do not guide specifics of treatment. Of course, a spondylolisthesis will guide precautions/contraindications, but LBP/lumbago/stenosis does not help. Particularly since the medical profession only knows the exact cause of the pain in 15% of cases due to the complexity of anatomy and false positives with imaging.
For instance, in a validated clinical prediction rule conducted by Fritz et al in 2002, it was found that in a subgroup of patients with LBP “The presence of four of five of these variables (positive likelihood ratio = 24.38) increased the probability of success with manipulation from 45% to 95%.” See the results abstract below.
“Seventy-one patients participated. Thirty-two had success with the manipulation intervention. A clinical prediction rule with five variables (symptom duration, fear-avoidance beliefs, lumbar hypomobility, hip internal rotation range of motion, and no symptoms distal to the knee) was identified. The presence of four of five of these variables (positive likelihood ratio = 24.38) increased the probability of success with manipulation from 45% to 95%.”
ARTICLE: A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. – http://www.ncbi.nlm.nih.gov/pubmed/12486357
Mr Homola,
Regarding the indications for manipulation or “thrust mobilization” used by PTs, it is mainly for pain, or muscle guarding. The mechanism is most likely via a neurophysiological inhibition of pain and muscle guarding at the spinal level. The biomechanical model has been shown to be an unlikely explanation for changes in pain, muscle turgor (reflexive muscle guarding), and mobility.
Here is a nice listing of other Treatment Based Classification rules either in progress, or validated in PT literature:
http://physicaltherapydiagnosis.blogspot.com/2011/12/new-treatment-based-classification.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+physical-therapy-diagnosis+%28Physical+Therapy+Diagnosis%29
Re: research in PT, one reader pointed out the difficulties with having high quality studies. Just a few things: blinding can be difficult, and usually treatments are used in combination. I would NEVER use manipulation in isolation despite short term benefits. Also, the patients we see are again very heterogeneous. Patient management decisions are influenced by a number of variables, including psychological measures. For example, one indicator of poor prognosis in LBP or cervical patients is a high score on the fear avoidance beliefs questionnaire (see Steven George, PhD, PT et al).
Other techniques used such as muscle energy can work via reciprocal/autogenic inhibition of muscle tone and again, neurophysiological inhibition of pain. We know from scientific study that muscles relax after a contraction, and also contraction of a muscle agonist can inhibit the antagonist muscle. All clinical decisions I make have a scientific backing and a PT that does not use an evidence based rationale is behind the times. There is a lot of clinical research that needs to be conducted, but a great deal currently exists published by “PT, PhD” researchers. Systematic reviews or other studies that lump together poorly defined “physical therapy” into non-surgical or conservative management go nowhere near what is required to determine true treatment effects. The TBC article cited above is just one example of that.
As a resident, and possible future fellow, I also using many other scientifically based decision making tools to guide outside referral, including but not limited to CPRs for cancer, vertebral fracture, DVT, PE, stenosis, cervical radiculopathy, and the list goes on. In school I have studied the same interviewing techinques, systems review/review of systems influenced by the medical model, ICF model, and of course PT researchers/clinicians. We are trained at a much higher level than sometimes portrayed so please forgive me for taking the opportunity to comment and plug my profession.
Many here are correct in saying that there are many more differences between the professions of PT and Chiro which include at least philosophical, educational, extent of scientific rationale, clinical reasoning paradigms, etc…
I hope this provided at least some insight into a PTs mind.
I enjoyed the article and comments and have followed this blog for some time!
J
Earthman, as I understand it, the case of osteopathy is confusing. In the US, osteopathic training is similar to that for MDs, and they practice side-by-side. Some may have quack leanings (see John Upledger DO for an example). What Barrett recommends:
I’m not sure about the UK. Perhaps someone more knowlegeable will tell us.
It is an interesting article but I keep re-reading one statement…which I believe needs clarification:
“It may already be too late for the chiropractic profession to make the changes needed to train chiropractors to do what physical therapists, physiatrists, and orthopedic manual therapists are already doing.”
Physiatrists are physicians who specialize in physical medicine…they are not physical therapists or orthopedic manual therapists. And Elmer, you might want to seek a consultation with a physiatrist…by getting a referral from your primary MD or a teaching hospital that has an orthopedic rehabilitation department.
I have a degree in nursing and I never worked with orthopedic patients, but I’ve forgotten more information about the human skeletal/musculature structure and body kinetics than any practicing chiropractor I have ever met. They simply do not have the education background that a physical therapist has. So, no, they are not qualified to transfer their education background and their skill set to “become” physical therapists.
Through circumstances (my very profoundly/multiply disabled son, who had spastic quadriplegia, bilateral dislocated hips, severe scoliosis and kyphosis), I have had a lot of experiences with orthopedists, physiatrists and many physical therapists. All of the physical therapists that provided therapies for my son were very well versed in providing the appropriate passive range of motion therapies, stretching of heel cords and hamstrings and rehabilitating his right leg after 10 weeks in a hip spica cast following a supracondylar femur fracture. I never worried that any of them would inadvertently dislocate a joint or fracture his brittle bones. I would never allow any chiropractor to touch him.
I’ve known nurses who have returned to school to become PTs and one particular wonderful pediatric PT specialist who was firstly a nun, secondly a registered nurse and finally a licensed physical therapist. BSc-Nurses have the education background and the experience in a clinical setting…to switch careers and become PTs or physicians…chiropractors don’t.
On the issue of the unknown number of non-crazy chiropractors, I note that all 6 DCs on the Texas Board of Chiropractic Examiners (the board consists of 6 chiropractors and 3 laypersons) have nuttery on their websites:
CYNTHIA TAYS, D.C. – President
“discount program for our acupuncture services”
“If the nervous system is impaired, it can cause malfunction of the tissues throughout the body.”
KAREN CAMPION, D.C.
“Acupuncture works to reprogram, and restore normal functions by stimulating certain points on the meridians in order to free up the Chi energy.”
“Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health.”
JANETTE KURBAN, D.C.
“Fellow of the Acupuncture Society of America” (no real website, just a Tripod page)
TIM MCCULLOUGH, D.C.
“He is an experienced physician in [...] homeopathy, ”
LARRY MONTGOMERY, D.C.
“Keeping your spine in proper alignment will help everything else in your body function better.”
“People can now be examined by the Insight Subluxation Station,™”
PATRICK THOMAS, D.C.
“Dr. Thomas is committed to providing relief for many conditions through the use of chiropractic and acupuncture ”
“Electro Meridian Imaging”
“With Infertility, only one spinal nerve involvement or acupuncture meridian can be out of balance and it will not allow conception. ”
I don’t know how many reformed we-only-treat-lower-back-pain chiropractors are out there, but they sure as hell are not occupying the TBCE.
Science Based Quackery!
The biggest issue with chiropractors who want to be evidence-based is the stigma associated with the name of their profession. It will be extremely difficult for any evidence-based chiro to convince a practitioner they have given up all woo and are now focused on what the evidence says. And many patients have a bad impression of chiropractors as well. A study I read recently found the “usage” of chiropractors has been pretty stable over the last 10-15 years (study was in 2005-ish), so it’s not like people are utilizing them more and more.
I just don’t see chiropractors ever achieving mainstream acceptance when they advertise things like this:
(Warning, very graphic images of children having their necks manipulated)
http://www.kidchiro.com/children/
@lilady
They’d have to start from square one. They might as well go to college and pursue a degree in trombone. I do know of a massage therapist who threw it all away and went back to school to become a physical therapist. My guess is that this is a pretty rare occurrence. What pains me about alternative medicine is the inadvertent arrogance practitioners pick up along the way, that is, I believe they start out as innocent, well intentioned people, and thereafter it all goes sour. Thus we have the massage therapist here in my town who believes their product is superior to what a PT can offer, when there is no comparison. I wouldn’t let your son near a massage therapist, either, it’s not a predictable profession when it comes to whether or not any given practitioner possesses the simple error correction necessary to prevent delusions of grandeur. No telling how they might decide to “improvise”.
My guess is that the utility of chiropractic is that it gives pleasure to the clients who enjoy that kind of snap crackle pop thing, but I can’t take the profession seriously. Harriet Hall admits that chiropractic can help simple lower back pain, but would she refer anyone to a chiropractor? It’s a can of worms, a can of octopuses. Or…
“Unfortunately , a thorough examination of the individual vertebra is not within the scope of most Western trained pediatricians.”
…indistinguishable from PT Barnum.
(quote is from DrRobert’s link)
Elmer
Thank you for not providing your life story and I think you missed the point of my post. The point I was trying to make had nothing to do with the effectiveness of the interventions you had. My point was that you were making comments on the types of treatment a profession should use, based on your experience and with an ignorance of the evidence. This is exactly the kind of ‘logic’ used by CAM practitioners to justify their treatment decisions. It is dangerous.
To your question on the effectiveness of “weightlifting”, your question is way to vague. What do mean by weightlifting, (type of exercise, dosage etc..) for what condition and compared to what?
Exercise may not always be the best choice, however there is no other treatment around which has been shown to be effective at treating so many different disorders. There is evidence for use in many orthopedic problems, heart disease, high blood pressure, obesity, depression, dementia, etc… o and it is associated with lower cancer risks.
[...] I call it HVLA because the vernacular for any manual therapy technique moving the spine is manipulation. This can include both low velocity (mobilization) or high velocity (often called manipulation but this term is not exclusive). So most if not all of the systematic reviews include studies looking at both high and low velocity techniques. So we need to be careful to acknowledge that these reviews are lumping two very different techniques under the same umbrella. Another potential problem is that most RCTs make very little attempt to sub categorize individuals with low back pain beyond duration of symptoms. The reason for this is that in most cases a clear way to sub categorize them is not evident. In the PT literature we are starting to see attempts at classification beyond duration of symptoms. This has shown some promise in identifying individuals who respond very dramatically and consistently to HVLA spinal thrust. By dramatic I mean more than a 50% improvement in disability and by consistent I mean over 90%. This has been demonstrated in several studies. Read more on Straight Chiropractic [...]
“Harriet Hall admits that chiropractic can help simple lower back pain, but would she refer anyone to a chiropractor?”
No I wouldn’t. I might do so in specific instances if I knew of one like Samuel Homola who could be trusted to only provide expert spinal manipulation and other evidence-based treatments for short-term care of amenable musculoskeletal problems without any nonsense like applied kinesiology, without risky neck manipulations or inappropriate treatments, and without anti-vaccine or anti-mainstream propaganda. Sam is now retired, and anyway I live at the other end of the country, and I have never found anyone even remotely like him in my area. Here they all seem to do crazy things like rejecting the germ theory, using applied kinesiology, assessing brain function by the size of the blind spot, charging patients thousands of dollars for spinal decompression treatments, or treating newborns in the delivery room for subluxations caused by the birth process. One even let his own child die, manipulating him and refusing to allow hospitalization and antibiotics for his meningitis.
@zimney3pt
“In regards to comparisons Chiro to PT schooling and curriculum it may be difficult with the information that you provided. Quarters and Semesters are different time frames.”
My apologies, the 24 to 5 comparison was not fair (not my intention) due to quarters vs. semesters but all that needs to be done is multiply the quarter hours by 2/3. So, 24*2/3= 16 hours of anatomy in chiro compared to 5 hours in PT. Lets take a peek at the rest of the core basic science classes: Physiology is 7 (chiro) and 3 (PT). Histology equal at 4. Neuroanatomy 5 (chiro) and 3 (PT). pathophys is 8 (chiro) and 4 (pt). biomechanics is 11 (chiro) and 10 (pt). Basic science courses taught in chiro but not in pt include biochemistry,cell biology, microbiology, nutrition and genetics.
“Also there are different accredidating bodies for these different schools (Chiro and PT) so it is difficult to measure if there are similarities or differences of curriculum within those classes and the hours listed based just on the title of the class.”
The basic science courses in chiro school are taught by PhD’s in their respective fields ( Is this true for PT?)
so I think a comparison can be made to these basic science courses. I am only comparing because others here are completely misinformed about chiropractic education.
@arufa
“Much of orthopedic care suffers from a lack of good quality evidence and treatment of low back pain is not an exception (in fact it is the rule).”
I agree and have said the exact same thing there here. Interesting when said by you (non-chiro I assume) you get no response but when said by me (chiro) I get bombarded with the tu quoque logical fallacy argument.
I find it interesting that after numerous vociferous calls for a “debate” with Sam Homola, NMS-DC is nowhere to be found here….
I also agree wholeheartedly with Dr. Hall’s reasons for reticence in referring any patient to a DC.
And as for jhawk:
Even if I were to grant that the basic sciences component of DC training is at least on par and perhaps better than that of PT, it is a total wash because the context in which it is taught mitigates most of that.
If you look at the prospectus for a degree in Homeopathy at a popular school in Australia (PDF) you will find that they have courses titled:
Chemistry and Biochemistry
Foundations of Critical Inquiry
Human Biological Science
Pharmacology (which is separate from Foundations of Homeopathy and Materia Medica
Clinical Examination and Biomedical Techniques
Interspersed with:
Miasms and Chronic Disease
Materia Medica Studies
Homeopathic Research Skills
New Developments in Homeopathic Method
So having a listing of courses means rather little when we know that they are coached in the magical thinking of subluxation theory. Especially considering that you have stated it is possible to palpate and manipulate the anterior vertebral bodies through the back – something which a knowledge of anatomy would preclude. And yes, I do remember your claim about palpating the spleen not being direct due to skin and viscera in the way. But even in that sense, palpation of the L spine anterior vertebral body is simply not possible – only perhaps from an anterior approach in a very thin person, but that is clearly not what you meant by it.
Because stating a deficiency in our own practice for improvement is inherently different than stating it as an indictment of a practice different from your own in an attempt to prove the validity of yours. The former is merely stating fact that we all agree on. The latter is what you and NMS-DC have done in order to try and establish the validty of chiropractic and indeed the very definition of tu quoque. In other words, intent of the statement is important.
What I mean by “weightlifting” is the experience I have had with almost every one of the many PTs I’ve seen: essentially, “Here, lift this weight.” Me: “How?” PT: “Just lift the weight.” Me: “Ow!”
And I do exercise now, a lot. But I’ve had to figure out on my own how to do this without screwing myself up worse. I’ve been more focused on trying things on myself than gathering data, but I’ve seen articles about “evidence-based” PT that admit the limitations on experimental evidence for PT by its nature. The protocols I’ve mentioned, especially Feldenkrais and Edgelow, which are general methodologies for teaching a patient to become more sensitive to the sensations associated with various movements, can’t be compared to an injection that’s contrasted with a placebo.
Here’s a quote I like by physical therapist Jan Dommerholt that I typed out elsewhere (I’m leaving my original typos intact, out of laziness):
“Although there appears to be consensus that pysical therapy is an integral component of pain management centers, few physical therapists have received adequate training in clinical pain mechanisms and pain management strategies, which is somewhat remarkable considering that the chronic pain prevalence is estimated to range from 10% to 55%. The International Associaton for the Study of Pain (IASP) has developed a specific pain curriculum for occupational and physical therapy education (http://www.iasp-pain.org/ot-pt_toc.html), yet there is no evidence that htis or similar curricula are commonly taught in physical therapy academic programs. It should then come as no surprise that many phsyical therapists lack knowledge on pain managment and may not be all that interested in working with persons with chronic pain.
According to Wolff and colleages, 96% of orthopedic physical therapists prefer to work with patients who are not likely to have chronic pain. A search of the membership directory of the Orthopedic Section of the American Physical Therapy Association (APTA) suggests that its Pain Management Special Interest Group has less than 400 physical therapy members out of a total APTA membership of about 64,000, which equates to approximately 0.6 percent (from “members only” section of http://www.orthopt.org, accessed October 30, 2004). A similar search of the membership directory of the American Academy of Pain management suggests that there are less than 100 identifiable physical therapy members out of a total of approximately 6,000 members (less than 1.7 percent)(http://www.aapainmanage.org/search/MemberSearch.php, accessed October 30, 2004). The apparent lack of professional interest and insufficient education and knowledge in pain mechanisms and pain management strategies can create multiple challenges for physical therapiests to become effective pain management clinicians.”
@nybgrus
“So having a listing of courses means rather little when we know that they are coached in the magical thinking of subluxation theory”
How do you know this? My school had only a 1 credit hour course on chiropractic history and philosophy. This is how it was taught, as history. Actually, in Sam’s article where he talks about cavitation being a nitrogen gas influx due to facet joint gapping is exactly what was taught at my school.
“Especially considering that you have stated it is possible to palpate and manipulate the anterior vertebral bodies through the back – something which a knowledge of anatomy would preclude.”
Actually, I was talking about the cervical spine palpation of the longus colli which can easily be done if trained correctly.
“But even in that sense, palpation of the L spine anterior vertebral body is simply not possible – only perhaps from an anterior approach in a very thin person, but that is clearly not what you meant by it”
If I had been talking about the L spine this is exactly what I would have meant and should not have to explain that to a medical student. Anyone with any knowledge of anatomy would know you can’t palpate the L ant v body from the back.
“The latter is what you and NMS-DC have done in order to try and establish the validty of chiropractic and indeed the very definition of tu quoque. In other words, intent of the statement is important.”
Your assumptions could not be more wrong. I was never establishing validity of chiropractic when stating lacking evidence in orthopedics. I think it is unfair of you and SBM to ask for evidence of chiro when the rest of manual medicine is lacking as well. I fully understand that both fields need to up their respective evidence base.
@jhawk
I think your ideas have been adequately rebuked by other commenters, so I’ll not belabor any points. I kind of think calling me “ill-informed” was a bit much, however, and not in the spirit of a civil discussion. My comment was practically in the form of a question and I don’t mind you responding with your info on the actual hours, but I think my point stands in light of further info offered in subsequent comments.
My comment was actually meant to be supportive of moving those chiropractors who want to do real medicine into other fields, and I cannot see why you took it to be pejorative.
@ Janet Camp
I am sorry if I offended you as it was not my intention.
“I’m not sure what part of chiropractic training would help in a transition, but presumable they learn some basic anatomy and terminology. There probably isn’t much that would carry over, though.”
How can I not take this to be pejorative. You are saying I may have some basic anatomy knowledge at best and that this knowledge of anatomy is inferior to “medical anatomy” and would not carry over to anything.
How does this point stand? Not much that would carry over? When chiro school has more basic science education than pt school.
jhawk,
“@arufa
“Much of orthopedic care suffers from a lack of good quality evidence and treatment of low back pain is not an exception (in fact it is the rule).”
I agree and have said the exact same thing there here. Interesting when said by you (non-chiro I assume) you get no response but when said by me (chiro) I get bombarded with the tu quoque logical fallacy argument.”
It was not my intent, and I don’t think it came across that way, to imply that we should give HVLA thrust a pass because other interventions don’t have supporting evidence. I was simply trying to point out the difficulty and frustration one can go through when trying to pick a treatment technique which has evidence behind it and/or makes logical scientific sense. The problem with spinal manipulation is that we really don’t know what the mechanism is, so it is difficult to come up with a logical reason to use it.
How do I know? Because your licensing exam tests you on a working knowledge of magical thinking. No matter how small it may be (and by my previous calculations it was roughly 5-10%, which is hardly that small) the fact stands that to be licensed in your profession it is expected that you know of the application of verterbral subluxation theory beyond just “history.” That, and acupuncture is another license administered by the same accrediting body. And as ConspicuousCarl pointed out, 6 out of 6 DCs on the Texas accrediting board themselves practice magical thinking.
But the point is, once again, not specifically your education and how you act. As Dr. Hall pointed out, we have only your word on that – nothing about the actual accreditation, licensing, and stated teaching points of the vast majority of DC programs can assure us of this a priori.
Your argument is like a homeopath coming to us and saying they only listened to the courses that made sense and eschewed the rest.
Fair enough. I stand corrected.
Where is the eviednce that doing any C-spine manipulation is of any benefit?
And that is not only the definition of tu quoque but also being self unaware. It is inherently and definitively very fair for us to ask for eviednce for chiro since you (both in the singular and plural) are claiming its efficacy, using it daily, and training and licensing people as “doctors” of it. The point of tu quoque is that your claim that it is unfair for us to ask you for evidence because of any supposed or real lack of evidence on our part is a fallacy.
I will actually voice my opinion as being more in line with yours than the remainder of the commentariat here. I do think that, in general, the basic anatomical knowledge of a chiropractor is very likely to be at least on par with a PT. If something like a transition from PT to DC were to happen, I don’t know that I would press very hard for remediation of anatomy.
The issue however, as was pointed out above, is that the pathology and treatment of said anatomy is coached in magical thinking and this is what would need to be significantly remediated and (as you consistently point out) standardized so that a (soon-to-be) physician like myself could be confident that a referall to a DC would not be likely to entail magical thinking, pseudoscientific CAM, or anti-vaccine propaganda.
@jhawk, you’ll have to excuse us if we aren’t impressed by the chiropractic curriculum. All that education and anatomy and chiropractics still think that vertebrae can magically become subluxated via some mystical way that isn’t perceptible, yet is diagnosable. And all of that pathophysiology and yet most chiropractors still think that disease is caused by these non-existant subluxations of the vertebrae.
Not to mention, four years of school to learn a trade that is essentially useless. Let’s be honest. The root of chiropractic is manipulation, and manipulation is by and large useless. It may or may not be useful for a couple of types of low back pain, but it certainly isn’t superior to any medical treatment, except for perhaps sham chiropractic.
Sure, chiropractors can adopt and implement other treatment modalities, but, they still carry the stigma of being a chiropractor, and will therefore never earn a referral from me. I just cannot imagine a scenario that results in both me acting in my patient’s best interest and referring to a chiropractor. As Dr. Hall said, the mere stigma of chiropractors, with all of their quackery and anti-vaccination nuttery, simply means to me that I can never trust them to act in a patient’s best interest.
P.S. the other thing that drives me nuts about chiropractors is they always refer to themselves as Dr. X, D.C. Do they not understand that D.C. stands for Doctor of Chiropractic? It’s rather redundant.
——
OH, and by the way.
I’m looking at this chiropractic college curriculum:
http://www.nycc.edu/webdocs/registrar/DC_Curriculum.pdf
It was the first that came up on Google.
Some thoughts:
2 hours only dedicated to the science behind chiropractic. I imagine this could be covered in about 5 minutes.
I notice only 1 hour dedicated to the ethics of chiropractic, but ten hours dedicated to running the business behind a chiropractic office. That’s pretty damn funny. Do you know how many hours of medical school (for real doctors) is dedicated to running a business? Zero.
I simply can’t imagine that they teach autonomy, beneficence, non-maleficence, and informed consent in chiropractic school. If they did, the practice wouldn’t exist. Most studies have shown that chiropractors ignore informed consent.
A lot of talk about anatomy education. Basic anatomy education is first grade stuff at best. It is purely memorizing a structure which helps very, very little when trying to make decisions about proper care. There is a lot of anatomy that I have forgotten and you know what, it takes me about 30 sec to look it up if I need to know it. Having the critical thinking and decision making skills to properly treat a patient is the real skill and challenge of educating medical professionals. This skill is a seed that we try to plant in PT students and it hopefully never stops growing. Who cares how much anatomy training someone has (unless maybe they are a surgeon). Teach them lots of anatomy and then train them to look for subluxations on x-rays and you have just wasted a lot of time in the anatomy lab.
[...] For a much better author on this topic please visit: http://www.sciencebasedmedicine.org/index.php/subluxation-theory-a-belief-system-that-continues-to-d… [...]
And by contrast I had a very extensive ethics component to my first 2 years, including (but not even remotely limited to) a 10ish page paper each year on a topic of ethical concern in medical practice. Also, the USMLE Step 1 tests you on ethical scenarios.
Contrasted with the DC licensing exam which tests you on vertebral subluxation theory, it is a pretty wide gulf.
I completely agree, hence my comment above where I found the conversation of whether a DC would need to remediate anatomy to be off the mark. The issue is the application of that and how to critically think your way to a correct diagnosis and management – a skill that is difficult and, IMO, lacking amongst many MDs despite the fact that medical education at least attempts to drill that in your head. Being taught subluxations instead completely short-circuits that. And it seems that our best case scenario is that the short-circuit isn’t there, but neither is the active training and teaching of said critical thinking.
Also worth noting, NYCC doesn’t just teach chiropractic. They also offer degrees in acupuncture and oriental medicine. Not just classes which study it academically, but actual degree programs. They just can’t help themselves.
But more on topic, their actual curriculum is not the only place where they expose their inadequacies. You can just search for “subluxation” in their search box at the top of their website to find more shady stuff than what is merely in their curriculum. They are quite interested in subluxations, both in practice and in various extra-curricular lectures. They even have a document which talks about treating asymptomatic subluxations, as though it is a curiosity in exception to the normal subluxation which is causing diseases.
Pour me another beer, Carl.
“Teach them lots of anatomy and then train them to look for subluxations on x-rays and you have just wasted a lot of time in the anatomy lab.
Couldn’t have said this any better. Kudos.
@ arufa
“It was not my intent, and I don’t think it came across that way, to imply that we should give HVLA thrust a pass because other interventions don’t have supporting evidence.”
I was not implying a pass on HVLA either as there is a good number of studies on HVLA already. I was talking about how it is difficult to study manual medicine via RCT and hence lacking evidence in all areas of manual medicine. This does not mean any treatment should get a pass, just that it may have to be studied differently. A Possibility could be pragmatic trials to compare treatment approaches.
“The problem with spinal manipulation is that we really don’t know what the mechanism is, so it is difficult to come up with a logical reason to use it.”
Spinal manipulation imparts motion so it would make biomechanical and logical sense to use it on a patient with decreased ROM, pain/tenderness, and/or tissue texture change. The mechanism is not fully elucidated yet but there are theories that make biomechanical sense (periarticular facet capsule adhesion and meniscoid extrapment to name two).
“A lot of talk about anatomy education. Basic anatomy education is first grade stuff at best. It is purely memorizing a structure which helps very, very little when trying to make decisions about proper care. There is a lot of anatomy that I have forgotten and you know what, it takes me about 30 sec to look it up if I need to know it.”
Anatomy is mostly memorizing structures but if you don’t have a solid foundation in anatomy it would be difficult to understand how this anatomy moves and works. For example, a patient comes into my office with ankle pain and I note he/she has limited dorsiflexion. If I don’t know every structure by heart that crosses the ankle joint posterior to the instantaneous axis of rotation then how can I even begin to Dx what is limiting this ROM. Also, if you don’t know a structure is there how could you possibly arrive at this structure being the problem?
“Who cares how much anatomy training someone has (unless maybe they are a surgeon).”
This is sad to hear a pt say. Anatomy and biomechanics are the core of manual medicine and if you don’t know it cold, then you might not be able to arrive at an accurate and specific diagnosis.
“Teach them lots of anatomy and then train them to look for subluxations on x-rays and you have just wasted a lot of time in the anatomy lab.”
Chiro school does not train you to look for subluxations on x-rays.
@nybgrus
“How do I know? Because your licensing exam tests you on a working knowledge of magical thinking. No matter how small it may be (and by my previous calculations it was roughly 5-10%, which is hardly that small) the fact stands that to be licensed in your profession it is expected that you know of the application of verterbral subluxation theory beyond just “history.” ”
The licensing exam on on chiropractic history and philosophy is ~3%. Testing on historical concepts does not equate to application.
“Where is the eviednce that doing any C-spine manipulation is of any benefit?”
Bone and joint decade task force on neck pain. Also, there is evidence for moderate effectiveness for neck pain relief by adjusting the thoracic spine (effectiveness of manual therapy: UK evidence report)
“And that is not only the definition of tu quoque but also being self unaware. It is inherently and definitively very fair for us to ask for eviednce for chiro since you (both in the singular and plural) are claiming its efficacy, using it daily, and training and licensing people as “doctors” of it. The point of tu quoque is that your claim that it is unfair for us to ask you for evidence because of any supposed or real lack of evidence on our part is a fallacy.”
I did not mean you should not ask chiro for evidence. I was trying to say that you should not expect evidence for chiro that is above and beyond other manual medicine treatments. Manual medicine is inherently difficult to study via RCT due to many factors that have been discussed here before.
“The issue however, as was pointed out above, is that the pathology and treatment of said anatomy is coached in magical thinking and this is what would need to be significantly remediated and (as you consistently point out) standardized so that a (soon-to-be) physician like myself could be confident that a referall to a DC would not be likely to entail magical thinking, pseudoscientific CAM, or anti-vaccine propaganda.”
I think when you get into practice you will be able to spot the non magical thinking chiro’s pretty easy as they will be writing letters and referring patients to you. Obvioulsy this depends on the specialty you choose.
Name your poison, my Catalytic friend. If you can’t decide, I happen to have a nice tall glass of “my patient has no symptoms, but I am imagining that I see subluxations”…
So someone with no symptoms is apparently to receive “adjustments” for 7 weeks or more, even if those adjustments are causing inflammation?
I am not sure in what context this document is meant to be presented, though it has the college’s seal on the first page and appears to be a straightforward list of things to do. Maybe there is a preceding document which ends with “…but be sure not to do the following:”
Can you specify which school you want to talk about? Maybe we are just looking at the wrong schools.
If that’s true, it would be kind of lame for a chiropractic school not to train its students on how to find subluxations in x-rays.
@ConspicuousCarl
“Can you specify which school you want to talk about? Maybe we are just looking at the wrong schools.”
The course cirriculum I posted earlier was for University of Western States.
The key part of the sentence is or physical exam. Since subluxations (hypomobile joint) can’t be found on x-ray then you must use the phyiscal exam via findings of decreased ROM, tenderness/pain, and tissue texture change.
OK, just one last slam on NYCC before I await jhawk’s choice of schools. I couldn’t help it, because the subject of this course is a sure sign that a person has lost their mind…
No, definitely not just an FYI course so you will know what kind of nutty junk your patient may have been using. That’s the bonus. “The emphasis” is on recommending that people use homeopathy… for FIRST AID.
@jhawk, did you really just say that RCTs “just don’t work” for chiropractic?
Someone else worded it better, but after 100 years, the best quality evidence says chiropractic doesn’t work. It may or may not have a very slight and short-term benefit for a couple of types of back pain. Give it up. Chiropractic is worthless. Quit trying to validate it by molesting science and inventing new things that don’t work.
Also, having homeopathy in the chiropractic curriculum imparts as much respect into your “doctorate” as naturopathy does. ND = doctor of quackery.
I just completed a complete deconstruction of chiropractic, the indefensible profession:
http://www.skepticalhealth.com/2012/01/02/chiropractic-an-indefensible-profession/
@DrRobert
“@jhawk, did you really just say that RCTs “just don’t work” for chiropractic?’
Nope, but nice try putting words into my mouth. If you don’t understand the drawbacks of RCT’s then you should take a methods course.
“Someone else worded it better, but after 100 years, the best quality evidence says chiropractic doesn’t work.”
This statement is false.
“It may or may not have a very slight and short-term benefit for a couple of types of back pain. Give it up. Chiropractic is worthless. Quit trying to validate it by molesting science and inventing new things that don’t work.”
Your extreme bias is showing here.
“Also, having homeopathy in the chiropractic curriculum imparts as much respect into your “doctorate” as naturopathy does. ND = doctor of quackery.”
Homeopathy is not a required part of chiropractic cirriculum. If an institution has a department that offers homeopathy it does not vilify other departments (chiro) of the institution. And if you say it does then any undergrad college that has a theology department is null and void as well as any hospital that offers these “CAM” treatments.
I have shown this to be false in the comments of Jann Bellamy’s post. The textbook cited as the best reference to study for this section is unequivocally one that espouses the traditional Palmer-esque vertebral subluxation.
I suppose that was somewhat rhetorical. There is no good evidence of its utility as has been discussed her numerous times.
When you are basing an entire doctoral profession on it, then yes, it is reasonable to demand more evidence. It is not even remotely the same to compare a stand-alone profession that started out (and as we have demonstrated continues by and large) with purely magical thinking with a subset of an actual science based profession. A large part of that is the tack of approach between the two schools of manual therapy. While certainly lacking in any camp, the onus is distinctly more upon chiropractic than subsets of science based medical practice.
I won’t hold my breath. And even then, I wouldn’t consider that good enough to refer to chiros. Note that NDs are trying to “work alongside” actual medical doctors in cancer institutes while still retaining and practicing their nuttery.
Except that is not the actual application of SM in the majority of cases. As we have said here before, if that is truly all the SM was limited to, then you would be a very bored and broke chiro. Though the “tissue texture change” is a new one that makes little sense to me, but I’ll give it a by.
I agree. But the issue was that the application of said knowledge is questionable, not the possesion of it. I think the point arufa was trying to make was that my Galaxy smartphone has more anatomical knowledge than I ever will, but I wouldn’t trust it to diagnose or treat my patient.
@ConspiciousCarl:
To be fair (and since I damned near wrote a treatise on it before), the language was obfuscated to allow medicare reimbursement for such things. However, the definition that medicare uses is an orthopedic subluxation (actual and independently verifiable dislocation of articular surfaces) whereas the chiro usage slips seemlessly between that and the magical version, as necessary to justify whatever argument they may be making.
but to flip it back a bit, jhawk then says:
Which, taken with CC’s note of the medicare rules, demonstrates quite nicely said seemless transition of definitions.
I’ll have to side with jhawk on this one (sorry DrRobert). However, that said, there is research methodology much more robust than “pragmatic studies” which demonstrate chiro to have little, if any, value.
That which is asserted without evidence can be refuted without evidence. Your statement is false.
Once again I agree. However, it is justified bias, though I personally do my best to eschew it from such discourse.
The theology department is null and void. Quite frankly, so was the majority of my undergrad anthro department. The difference is that a theology department at a university makes up a very small portion of the teaching done there (except for some colleges, like Liberty University and Asuza Pacific in which case, yes the whole institution can be written off). It also depends on how they are teaching theology. But I digress. The real point is that nearly the entirety of the offerings at places like NYCC or Bastyr are nuttery.
@jhawk
Guilty as charged. But, rightfully so.
“This is sad to hear a pt say. Anatomy and biomechanics are the core of manual medicine and if you don’t know it cold, then you might not be able to arrive at an accurate and specific diagnosis.”
This is true that anatomy and biomechanics have been the cores of manual medicine, which have lead us down the wrong path over and over. Lets just look at LBP. If you think that in most cases you can come to an accurate and specific diagnosis then you are fooling yourself. If you know the literature and are honest with yourself you will realize that in the majority of the cases a pathoanatomical diagnosis can not be made with any degree of certainty. Hence the widely used, non-specific low back pain diagnosis. That is not to say that anatomy and biomechanics are never useful.
The evidence suggests that it does not matter the direction you manipulate/mobilize in, it does not matter if you are at the “correct level”, heck a thoracic HVLA thrust can help with neck pain, there is no convincing evidence that spinal manipulation increases segmental mobility and it does not seem to matter if you get a cavitation or not. If the mechanism of manual therapy was biomechanical these issues would be much more clear.
And I am not saying anatomy and biomechanics are not needed. nybgrus said it well
“I agree. But the issue was that the application of said knowledge is questionable, not the possesion of it. I think the point arufa was trying to make was that my Galaxy smartphone has more anatomical knowledge than I ever will, but I wouldn’t trust it to diagnose or treat my patient. ”
If you are learning calculus yes you need to know about addition, but be prepared to get laughed at when you brag about the number of hours you have spent learning addition. No one cares, if you can’t add pick up a calculator. But if you don’t know how to think, no calculator, book or smart is going to help you.
jhawk isn’t throwing out a lot of logical fallacies in his posts here (there may be some, but s/he’s downright reasonable compared to Thing or Dana Ullman’s burning stupid) and I wonder at the details that might be glossed over here. Jhawk, would you mind telling me, based on your education in chiropractic, what you would recommend for the following conditions, including basic follow-up questions?
1) Low back pain
2) Breast cancer
3) Measles
4) Restricted flexion/extension of the neck
5) AIDS due to HIV infection
6) Restricted shoulder mobility post-dislocation
7) Nonspecific fatigue
From the somewhat reasonable debate, it looks like there may be a disconnect between the most-, more- and somewhat-egregiously bad America schools and wherever jhawk may have studied. I know in Canada, American chiropractors trained in certain schools are not permitted to practice; further, I have had chiropractic care that varied from “applied kinesiology + iridology” to simple “do these exercises and your shoulder tear will heal in 10-12 weeks” (and it did!)
I think there is a substantial diversity in the schooling and approach of chiropractors, and it’s possible Jhawk hails from the tailing end of a binomial distribution with “nutjob” on one and and “physiotherapist with a twist” on the other. Some more questions which might help, jhawk:
1) Do you believe subluxations exist?
2) Do you support vaccinations in some or all cases?
3) Do you oppose vaccinations in some or all cases?
4) Do you believe in the germ theory of disease?
5) Do you believe acupuncture “works”, and if yes, do you believe it works through manipulation of chi, placebo effect or another (possibly undiscovered) mechanism?
6) Did you get your schooling in the United States, or elsewhere? If elsewhere, are you willing to tell us where?
This may have been covered previously. Trying to tar, or vindicate, an entire profession is always going to have exceptions – as Sam Homola himself is evidence of.
@WLU
1)LBP- my recommendation depends on the pain generator. LBP is only a sx and not a specific enough Dx to recommend any tx. IMO, this is exactly why the majority of LBP studies in all area’s of medicine have failed to show anything over modest results. The researchers are taking a crappy non-specific Dx and throwing a single tx at a multifaceted condition.
2) Breast CA- I would first make sure they are following up with their oncologist and PCP. I would also be careful to ask more constitutional sx for these pt’s if they are experiencing some new pain as the Hx of CA is considered a red flag. For conservative Tx if they have had lymph node removal and subsequent lymphedema I would reccommend they see an manual lymphatic drainage practicioner and get compression stockings.
3) measles- this is an odd question. I can’t imagine anyone going to a chiropractor for measles but the majority will probably just need rest. I would send them to check up with their PCP. I would also ask about continual fever and cough and watch for rash.
4) restricted F/E of neck- this depends on why they have this restriciton. Do they have fever, nuchal rigidity, HA and confusion then refer out. Were they just in a severe MVA? If no other red flags then I would look to parse out cx F into upper cx F, cx F and CT F first and look for what structure(s) is restricting this ROM and then use myofascial release to increase this ROM.
5) AIDS due to HIV infection- again being more cautious and looking for new pains and constitutional sx. Make sure they are following up with their PCP.
6) resticted sh mobility post dislocation- Have they had it reduced yet? If not, send them for reduction.I would be a little more careful here in checking and making sure the neurovasculature has not been comprimised once they returned to my office post reduction. If already reduced, take them through sh ROM and see what structure is limiting this range.
7) non-specific fatigue- I would ask if they are sleeping well, any extra stress, fever, weight loss/gain, loss of appetite, malaise, Hx of CA, pt over 50, new onset of pain they have never had before, have you discussed this with your pcp, naseau, vomiting, shortness of breath, meds, last lab work, how much does this interfere with your day, Hx of depression, sor throat, cough, etc. I am trained to order and read labs but my personal preference is to refer to their pcp for this as it is most likely not a NMS issue.
second set of questions
1) Do you believe subluxations exist? ACA definiton of subluxation: A motion segment, in which alignment, movement integrity, and/or physiological function are altered although contact between joint surfaces remains intact. Basically a hypomobile joint so yes. If you are talking about the historical veterbral subluxation complex with the vitalistic properties then no.
2) Do you support vaccinations in some or all cases? I guess I would have to say some as I do not personally get a yearly flu shot but my own personal opinion is not always what is discussed with patients.
3) Do you oppose vaccinations in some or all cases? I would not say oppose but if I had a child I might want to spread out his/her inoculations rather then an all at once thing. Furthermore, I have never had a discussion about vaccines with any patient and never plan to as I will fully admit I have not waded through the evidence. Obviously, vaccines have done some wonderful things but I can’t just say all vaccines are good without looking at the evidence and this is out of my area of expertise (NMS). Also, at my school we had a micro/immunology/public health course and not one anti-vax peice of info.
4) Do you believe in the germ theory of disease? yes, this is a rather demeaning question.
5) Do you believe acupuncture “works”, and if yes, do you believe it works through manipulation of chi, placebo effect or another (possibly undiscovered) mechanism? no chi, yes placebo and possibly another mechanism.
6) Did you get your schooling in the United States, or elsewhere? If elsewhere, are you willing to tell us where? US, I went to University of Western States. I posted this earlier for conspiciouscarl and he seemed rather excited to slam my school but I have not heard from him.
Hopefully this helps.
“LBP- my recommendation depends on the pain generator. LBP is only a sx and not a specific enough Dx to recommend any tx. IMO, this is exactly why the majority of LBP studies in all area’s of medicine have failed to show anything over modest results. The researchers are taking a crappy non-specific Dx and throwing a single tx at a multifaceted condition.”
I agree with this to a point. Researchers often use this “crappy” diagnosis of non-specific low back pain because in most cases there is no other option. And that is a big limitation of the LB literature.
Based on my experience and my reading of the literature there seems to be no reliable and valid method to determine a patho-anatomical diagnosis for the majority of people with low back pain. Until we come up with a valid way to classify these people the non-specific low back pain diagnosis will not go away.
I would like to know how you determine the cause of a person’s low back pain. I know that is a complicated question but a general idea of how you go about the process and what validated/unvalidated tools you use.
It seems that many of the tools we have (history, palpation, segmental and global movement testing and imaging) are not very useful at identifying the pain triggers in most cases. One big problem is that we have no gold standard to identify a pain trigger (I use the term trigger because only the brain can generate pain, everything else can only be a factor in triggering pain generation).
How do you confirm that you have actually found the “reason” for the pain?
We know that just about every kind of patho-anatomical disorder of the spine can be present without any symptom, so how do we tell if it is the pain trigger or not?
I don’t know of any direct way of doing that. If you do let me know because it would be a great topic for my PhD.
Jhawk, the vehement opposition you are finding on SBM might have to do with the company you don’t exactly keep, but move in the same circles as. There are chiropractors that deny the germ theory of disease, believe acupuncture manipulates chi, think spinal adjustment can treat and cure infections, and that subluxations are the root of all disease. Not all do, but certainly there are vocal proponents of chiropractic who would consider you a deluded tool of Big Pharma for not embracing the One True Cure for all of life’s ills. Judging by your responses, you appear to be closer to the “chiropractors are a flavour of physiotherapists” school of thought than the “chiropractors are the only true healers in the world” school. Do you recommend nutritional supplements in some or all cases? If so, do you recommend dosages beyond the RDI established by the IOM (I think it’s the IOM anyway)?
Again, there is diversity within chiropractics the world over. Canada doesn’t allow at least some America-trained chiros to practice here, and my experience with them has usually been reasonable. I wonder what you would think of Sam Homola’s books, and chiropractors trained in other schools…
@ arufa
Yes this is a complicated question. I doubt this is to far off of how other manual medicine practicioners think but here we go! First lets say everything but uncomplicated LBP has been ruled out already and the LBP has at least a 3 wk duration of insidiuos onset. Next, I think what are the possible pain generators (pg) of which there are a lot in the LB (top 3 are disc, facet and SI). I think Hx can actually be a good tool here for placing pg at the top or bottom of the DDX list. Some examples: no neuro signs-HNP causing n compression goes way down on the list, no neuro sx-any n irritation goes way down on the list, no am pain along with no antalgia and no pain with ROM-IDD way down on the list, after these three the disc as pg goes way down on the list. Also having pt map out locaiton of pain can be helpful in narrowing down structures but we must be careful here (“those who treat the site of pain are lost”-somebody smarter than me said this but I can’t remember who!). No catching in LB, no excessive motion via palp and neg prone instability test- instability way down on list. Next is facet joint, no pain with laoded E and palpation-facet joint way down on the list. Third is SI- no pain with provocation and not hypomobile-SI way down on the list. A positive to any of these would obviuosly put them at the top of the list. Now we are left with the muscles, tendons and ligamnets of the LB. Here I use gross and segmental ROM eval. Gross Lx F- if limited what structures can limit this range (pretty small list actually). This does not necessarily mean that the structure limiting the range is a pg only that it is likely casuing a faulty movement pattern which leads to tissues being excessively loaded which could lead to degeneration and pain. Next I look at Segmental Lx F- visualizing if every sp is flexing properly. Then I will palpate to feel if a certain structure is pulling tight during Lx F. My goal is to find the structure limiting the ROM and to increase this ROM to decrease tissue compensation and change faulty loading patterns. I will also check hip, knee, and ankle ROM to see if these could be contributing factors to the LBP as well as performing functional evals such as squat, lunge and active hip E. When we add everything up form the Hx, exam and functional eval I think a reasonably specific diagnosis can be made. At least hopefully more specific than LBP!
How do you confirm that you have actually found the “reason” for the pain? I use some sort of provocative test. Example: Lx F increases P to a 7/10 at 30 degrees and active hip E is postive for R Lx deviation upon first visit pre-tx . First visit post treatment of R Lx multifidi from L3 to L5 the pt’s Lx F increases P to only 3/10 at 60 degrees. At next visit pre-tx the Lx F has sustained at 3/10 at 60. I can reasonably assume the R Lx multifidi was a contributing factor to the Pt’s LBP. Then I re-test acitve hip E pre-tx and find R Lx deviation so I treat R psoas. post tx test shows active hip E is neg for R Lx deviation and Lx F now only increases P to 1/10 at 80. This 1/10 at 80 is has sustained at next visit pre-tx as well as the neg active hip E. Now I can reasonably assume the R psoas and R multifidi were contributing to the pt’s LBP.
Now obviously this system has its flaws and you can’t be 100% sure of the Dx but I think this does a good job of increasing the specificity of your Dx.
As an aside and in regards to your PhD topic, have you seen the CPR’s for LBP that delineate who should get SMT, mckenzie or stabilization? I think it’s a good start at subgrouping LBP patients.
@WLU
“Jhawk, the vehement opposition you are finding on SBM might have to do with the company you don’t exactly keep, but move in the same circles as. There are chiropractors that deny the germ theory of disease, believe acupuncture manipulates chi, think spinal adjustment can treat and cure infections, and that subluxations are the root of all disease. Not all do, but certainly there are vocal proponents of chiropractic who would consider you a deluded tool of Big Pharma for not embracing the One True Cure for all of life’s ills.”
There definitely are some, I am just not sure they are in the numbers proposed here at SBM. IMO, I think to a point it is the squeaky wheel gets the grease. The ones with the most extreme viewpoints are the ones that express them and are therefore the ones that are heard. Since they don’t get referrals from other providers they need to market, market, market.
“Judging by your responses, you appear to be closer to the “chiropractors are a flavour of physiotherapists” school of thought than the “chiropractors are the only true healers in the world” school.”
I would agree with this comment but I think both professions have seperate things to offer in some regards as I treat pt’s in my office and receive and give many referrals to pt’s as well as MD’s for that matter.
Do you recommend nutritional supplements in some or all cases? If so, do you recommend dosages beyond the RDI established by the IOM (I think it’s the IOM anyway)?
Almost never. Sometimes I talk about vit D due to my more northern latitude. I do talk about diet more than supplements but not horribly often. Honestly, many of the people I see are in general good health outside of MSK issues and have been referred from another healthcare provider (who usually have discussed these issues already) or have been injured during sporting activities.
“Canada doesn’t allow at least some America-trained chiros to practice here, and my experience with them has usually been reasonable.”
Interesting. I did not know this. The school I went to had a good chunk of Canadians that came down for their education and then returned to their respective provinces post graduation.
” I wonder what you would think of Sam Homola’s books,” I have never read them.
Wonderful piece, thank you. For your interest, there is a debate going on in Australia on the validity of chiropractic degrees and the delivery of pseudoscience in our Universities, which can be followed here https://theconversation.edu.au/theres-no-place-for-pseudo-scientific-chiropractic-in-australian-universities-4576
A rebuttal from a chiropractor stated that there was a whole of of research to provide them an evidence base. To my knowledge the chiropractic schools in Australia have very few PhD students, very few post-docs and very few researchers, which translates to a (disappearingly) small research output. I assume that is also the case in the US?
Wonderful piece, thank you. For your interest, there is a debate going on in Australia on the validity of chiropractic degrees and the delivery of pseudoscience in our Universities, which can be followed here https://theconversation.edu.au/theres-no-place-for-pseudo-scientific-chiropractic-in-australian-universities-4576
A rebuttal from a chiropractor stated that there was a whole lot of research to provide them an evidence base. To my knowledge the chiropractic schools in Australia have very few PhD students, very few post-docs and very few researchers, which translates to a (disappearingly) small research output. I assume that is also the case in the US?
Despite the extensive amount of evidence documented here at SBM, along with the licensing exams you guys take. And even if it is just the squeeky wheel effect, that doesn’t negate the fact that the leading chiro journals and the ACA itself don’t jibe with the non-vitalistic viewpoint.
But even then, I still fail to see how a purely NMS practice, without any utilization of pharmaceuticals or non-manual therapeutic modalities warrants a 4 year post graduate doctoral degree. Nor do I see how that justifies the DC desire to act as PCPs, or really anything else except for referall for a very specific subset of patients much like PT would. It seems like a really extensive pigeon hole at best – trained to figure out who to refer (which is tough!) but to basically do so very little as a stand-alone practice.
Jhawk,
Great answer to my complicated question. You did a wonderful job of explaining how you come to a conclusion regarding the cause of a person’s low back symptoms (better and more concise then I could). I agree with you that what you explained is pretty close to what most PTs would do. I don’t want to spend too much time on this because it may be a bit off topic but I do think it speaks to scientific thinking.
Your process makes sense however in my experience lots of things that have made sense to me (and others) end up being bogus. The method you use while logical is not backed by science. I understand why we need to use a method like yours in the clinic however we need to be honest with ourselves and understand that systematic methods like this are probably not that accurate. Researchers don’t like using the heterogeneous term non-specific low back but they cannot classify subjects with a patho-anatomical diagnosis based on a system that simply makes sense. They need a system that has been shown to be reliable and valid. There have been many attempts at trying to find methods to reliably and accurately diagnose a specific patho-anatomical diagnosis and they have all failed. Even in the few cases where a clear patho-anatomical diagnosis can be made, the research has shown that the diagnosis often does not predict which interventions will be most effective.
In the clinic, the success of treatment is often used to confirm that the specific cause of the LBP has been found. This is very flawed as I am sure you are aware.
I am very familiar with the treatment based classification system and the CPR for manipulation and stabilization. That system came about because we are unable to find the cause of LBP. John Childs, Julie Fritz and Tim Flynn decided that instead of trying to find a patho-anatomical cause, they would try to come up with a tool to help clinicians predict the effectiveness of an intervention. The fact that the treatment based classification system ignores the “cause” of the back pain is exactly what makes it unique.
Bottom line it looks like you make decisions in a similar fashion as much of the PT world. However, without any evidence for the effectiveness of a system like yours, it is very possible that flipping a coin would be just as effective.
Jhawk:
Nonscientific practitioners have a disproportionate impact over their scientific competitors. They use rhetorical (and at times political) strategies to compensate for the dearth of scientific evidence supporting their chosen interventions. This is a greater poison than their day-to-day treatment of the worried well; I would be that most people at SBM would be perfectly happy to let people waste their money on chiropractic, acupuncture and homeopathy were it not for the corrosive effect on the overall reputation of medicine and efforts to get public support. As a Canadian with medical insurance, I really don’t want either covering (most) chiropractic care, homeopathy, acupuncture, Gerson therapy for cancer and the Liberation procedure for MS until they’re proven to work (assuming they ever are).
My main objections to nonscientific practitioners are not about people wasting their time and money. I object to:
* Misuse of public funds (only a concern in countries with national health care systems)
* Higher premiums for insurance companies
* Criticisms of mainstream medicine, particularly if a patient is too young to understand or they quackery for substitute conventional care
* General erosion of public respect for science and scientific medicine
* “Big Pharma” accusations that divert time and attention from scientific investigation as well as meaningful efforts to regulate the pharmaceutical industry
If you really want to do something to help your profession and reduce criticism from this blog, I would suggest advocating for a separate regulatory body and professional identity that separates you from the lunatics who think spinal manipulation cures cancer. It would help pretty much everyone if we could point to chiropractors and say “they’re nuts” while pointing to your profession, calling it something different and saying “they’re not”.
Again, you’re being tarred by brushes with your less respectable colleagues. If you wish to avoid being blackened, the solution is distance.
@Harriet Hall,Jann Bellamy,Nybgrus,Sam Homola and especially Dr Robert
Who’ll be the first of you to dismiss this:
http://www.pulsetoday.co.uk/newsarticle-content/-/article_display_list/13254843/spinal-manipulation-and-exercise-best-for-neck-pain
Edzard Ernst was the first to comment. He said “This study has numerous rather obvious flaws. For several reasons, the comparisons between the SMT or HEA and the medication group are of questionable validity: the latter group was treated in a different setting with medications that are only loosely described, at unspecified doses and durations; amazingly we are even told in the small print (legend of appendix Table 5) that “6 participants in this group… received no treatment”.
This leaves us with the comparison between the SMT and the HEA groups which, I fear, is equally problematic. Not only was there no attempt to control for placebo effects, but the patient- therapist contact time differed considerably between both groups. While the SMT group enjoyed an average of 15 “hands on” treatment sessions of 15-20 minutes each, the HEA group merely had two 1-hour sessions of instructions. It seems reasonable to assume that the non-specific effects of patient-therapist interactions involving touch, verbal and non-verbal communications etc, determined the outcome.
In my view, a rational conclusion from the reported data would be that 1) different therapeutic setting can lead to different outcomes, 2) despite strong non-specific effects, SMT is not better than HEA, 3) this study continues the long list of NCCAM-funded RCTs of chiropractic which are ill-conceived and poorly reported (2).”
My interpretation is similar. The abstract even says “No important differences in pain were found between SMT and HEA at any time point.” So it means home exercise works just about as well as manipulation; and home exercise has the added advantages of greater safety, fewer trips, and less expense.
@ arufa
I agree with much of what you are saying but I do have a few thoughts and questions. I think the “cause” of LBP has not been “found” because it is different for each individual. Each individual most likely has many compensation patterns and degenerated (not necessarilly cartilage degeneration more dis-use atrophy) tissues over mutliple years leading to a multicausal origin, which in some is going to include casues outside of a patho-anatomical Dx such as psychosocial factors. This is why I am not sure researchers will find a way to reliably classify LBP subjests. Is it possible to amount an evidence base through this systematic process that is used in the clinic? Has this been studied? I know the seperate parts have been studied but what about the system as a whole as many data points need to be added up from each part to arrive at a Dx. It seems to me that it could be done in at least a single blind manner. The only other flaw that I could see (at this point) would be that the sham Tx would have to be made up on fly by the practicioner and therefore would be different for every pt. Is this to much of a confounding variable? Example: take a group of ULBP patients and then randomly allocate them to 3 or more cohorts. Cohort 1- clinical systematic process (CSP), cohort 2- sham (CSP), cohort 3- watch and wait, cohort 4,5,6- Rx, SMT, back school, etc. I know this leaves us with interaction bias but wouldn’t this at least show us which Tx approach is most effective for LBP and that this CSP that many manual medicine practicioners use is either more or less effective than the controls (watch and wait and sham) and therefore better than a coin flip?
@rwk:
That was easy.
Oh yeah, and lets see. What else.
A 6 year long study that had a whopping 272 patients.
Pain scores in all all groups dropped to: 1.5, 2.08, and 1.74. Can anyone say “statistical significance but no clinical significance?”
Study leader was vice president at an chiro and acupuncture school.
And like Dr. Hall (and Ernst) said, many, many more chiro adjustments and “No important differences in pain were found between SMT and HEA at any time point”
Oh yeah, and they didn’t even define their groups “No specific criteria for defining clinically important group differences were prespecified or available from the literature”
Looks like a great study to show how chiros can pump more money out of people.
Did you honestly think that was a good study that showed any sort of vindication for cervical spine manipulation??
@nybgrus
“But even then, I still fail to see how a purely NMS practice, without any utilization of pharmaceuticals or non-manual therapeutic modalities warrants a 4 year post graduate doctoral degree.”
I don’t think NMS Dx and Tx is as simple as you think. Chiro’s see NMS issues without referral so chiro’s must have training to take a full Hx, do a full exam and arrive at a Dx and be able to spot non-NMS issues (not that easy sometimes as I am sure you are aware) and refer. I think 4 years is sufficient just as optemetry and dentistry are sufficient.
@ WLU
“Nonscientific practitioners have a disproportionate impact over their scientific competitors. They use rhetorical (and at times political) strategies to compensate for the dearth of scientific evidence supporting their chosen interventions.”
This is exactly what I meant by the squeeky wheel analogy and is why I have heard the names Mercola, Weil, Oz, etc. but have never heard the name of any MD on SBM. In anticipation of your response to this comment: is there a disproportionate amount of these nonscientific practicioners in chiro as opposed to medicine? I would say yes but I do think there is change in the chiro profession (U. of Western States I believe is an example as well as the closing of Cleveland school and the addition of the research department at Palmer which is considered to be one of the least scientific schools.
http://www.palmer.edu/FundedResearchProjects/)
I will try and answer more later but I have to go exercise this damn holiday weight off yet again!
There’s an extremely well written critique of that chiro neck pain study here:
http://updates.pain-topics.org/2012/01/chiropractic-or-exercise-tops-meds-for.html
My comments, which are in that thread:
- I think it’s rather important to note that medical doctors do not simply treat pain disorders with only pain medication. No medical doctor believes that pain medication cures the body. Not one. Pain medication is a “crutch” to help while the patient receives treatment that will cure the body.
- In the example of neck pain: the patient’s medical doctor may or may not prescribe pain medication, but will also prescribe a slew of other treatment modalities for the patient. For example, depending on the actual severity and cause of neck pain, the doctor may prescribe home exercises (we have sheets pre-printed to give patients.) Or, we may prescribe for the patient to attend physical therapy X number of days per week. Or, if indicated, we may ask the patient to consider undergoing surgery. Obviously, it depends on the actual pathology.
- I think it’s a major point about the gigantic discrepancy in the number of follow-up visits each set of subjects had. Chiropractic care subjects received the most number of follow ups, and I’m sure they were given enthusiastic statements such as “We are really going to tackle that neck pain! We really want that neck pain to go away!” HEA subjects had fewer follow-ups, and medicine subjects had fewer follow-ups too.
- I also think it’s a major point that “chiropractic care” in this circumstance included essentially everything possible (SMT, massage, hot/cold compresses, etc) which, if anything, validates physical therapy and not chiropractic manipulation.
—
So what did that study tell us? It told us that having a patient miss work and come in to a chiropractors office 5 days a week and receive expensive and possibly lethal manipulation of the neck is just as poor of a treatment for neck pain as having a patient meet a couple of times over a period of many months and showing them a few exercises and encouraging them to do them. Fantastic. Chiropractic = completely obviated by a xerox machine and exercise handouts.
I think, if anything, this study just damns chiropractic. It shows that chiropractic is no better than minimal contact while showing patients a few exercises, and not any better than pain medication, which isn’t even a treatment for neck pain (as I stated above.) If anything, the specific neck pain in this study heals over time.
I also think the “significant statistical difference” of a subjective pain score between 1.5 and 2.08 is hilarious.
Off topic and pet peeve of mine,
Dr. Robert, please do not “prescribe” physical therapy. Physical therapy is not a thing like a medication. Physical therapy is a profession. You would not prescribe neurology for a patient, you would refer them to a neurologist.
Please refer someone to a physical therapist so that the therapist can evaluate the patient and treat them appropriately.
It seems like a small point but this attitude leads to paper titles like “physical therapy vs. education for treatment of X”. Often these studies make no sense because what they call PT is way off and the education they give is exactly the education a patient would get from a good PT.
@arufa,
Perhaps you can clarify something for me. When I practiced in the Air Force, I could put in a consult to physical therapy but I was required to specify what I wanted. I was not allowed to simply ask them to evaluate and treat. It seems like you’re saying that is exactly what doctors should do. Has the situation changed?
@ Hall
I am saying that all you should put is evaluate and treat. Sometimes other info may be helpful like MRI findings or precautions after surgery if they are not standard. Often it may be required by insurance that you put down a diagnosis, but I am going to evaluate them and treat them based on my diagnosis.
I cannot speak about the Air Force and its policy. I will say that in the Army, PTs are primary care for musculo-skeletal disorders. Most times soldiers will see a PT first who then decides if the patient is appropriate for PT or needs to be seen by another specialist. This system works amazingly well and saves a boat load of money. There are many other examples of PT being put first and patients get better faster with less expense.
In just about every state in the US, PTs see patients direct access (without a referral). Some insurances may require that the MD sign off on the plan of care but that is simply and outdated, wasteful and unnecessary step. The vision of the APTA (American physical therapy association) is that PTs will be recognized as the first line provider of choice for musculoskeletal management (non-operative) by 2020.
It makes no sense to tell a therapist what to do. If you have such little confidence in the PT you are sending your patients too then you should find a new one. I guarantee that I know a lot more about physical therapy then any practitioner who sends a patient to me. I am always open to suggestions but I am going to treat the patient based on my judgment not based on what I am told to do.
@arufa,
I apologize if I offended you. I do think you’re overreacting though. I never stated I would tell the physical therapist how to do their job. On the form I fill out I put the recommended number of treatments per week and what my diagnosis is. Of course if the PT wants to change the number of sessions per week, or anything else, that is completely fine and I wouldn’t argue. I certainly hope the PT knows more about PT than I do. Otherwise your profession would be redundant. But yes, I do prescribe physical therapy.
Sorry, but I don’t like your idea of letting the physical therapist come up with their own diagnosis and going from there. Also, I think the idea of a physical therapist acting as a “primary care provider” for musculoskeletal pain is an absolutely horrible idea. A few years back my mother had skeletal pain in her ribs. Turns out it was multiple myeloma, and we were able to put her into remission because we caught it so early. How many months would that have gone untreated if she first presented to a person who is musculoskeletal oriented?
Honestly, from your comment above it seems that PTs are making the same mistakes chiropractors made. You want to be seen as a “primary care doctor” but that’s just an absolutely horrible idea. You say it’s an “outdated, wasteful and unnecessary step” to have a MD refer to a PT. I think it’s a dangerous and unwise proposition to have a PT be a “primary care provider.” Honestly, that’s the type of PT that I would never refer a patient to.
@DrRobert
Your above example is political correctness at it’s worst. What if Arufa was a chiropractor? You may not like the headlines or the study behind it :
http://well.blogs.nytimes.com/2012/01/03/for-neck-pain-chiropractic-and-exercise-are-better-than-drugs/
but do know you’re along way off from your goal of eliminating the chiropractic profession.
jhawk,
If every patient’s low back pain is caused by something different, then how would we ever be able to chose the appropriate treatment. Wouldn’t every patient need a different intervention if the cause was unique to that patient?
Dr. Robert,
No offense taken just pointing out that you prescribe a treatment or a medication and you refer patients to professionals. PT is not a treatment.
I would put a PT up against an MD any day in determining if a musculoskeletal complaint was mechanical or non-mechanical. I would not expect a PT to diagnose a myeloma but I would expect them to catch that the condition was not simply musculoskeletal and get the patient to an MD. There are always cases where more serious conditions mimic msk sx very closely. I would say that most people would miss this unless they are doing advanced imaging on everyone. The great advantage we have is that I am seeing the patient weekly. After a few weeks if they are not progressing as expected off they go to the MD.
The PT profession is nothing like Chiro. We do not want to be primary care physicians. If someone has back pain it is wasteful to have them wait 3 weeks to see their MD, then get meds, then get unneeded images and then after 5-6weeks get sent to a PT. If they have symptoms and risk factors which make them likely to have a more serious problem then the PT will “prescribe”(j/k) doctoring and send them to their MD.
I mean think about it. Someone has back pain they can go see a massage therapist, a chiro, an acupuncturist, yoga therapist etc… and you have a problem with them seeing a PT? A PT who has been trained very well to identify individuals who need further workup. It has worked for the military, several other countries and it is working in the US in many states.
Don’t get me wrong. I love being part of a team and I love getting referrals from MDs, DOs, PAs, NPs etc… However, if a patient wants to see me there should not be an extra hurtle.
Bottom line there is no evidence that seeing a PT direct access is a danger to patients. There has been no increase in malpractice suites and other litigation against PTs in states with direct access. Check out this study from the military.
http://www.jospt.org/issues/articleID.814,type.2/article_detail.asp
Dr. Robert
I am curious as to what your specialty is and what state (or country) you live in.
There are very few states (less than 5 I think) that don’t allow direct access to PT. So if a patient walked off the street into a PTs office and that PT did not turn them away, you would not send any of your patients to them? If you are in a direct access state I am sure that the PTs you send patients to accept patients direct access.
Its not that. It is that what we are getting to is that the only scope of practice that seems to be of any remote utility in chiro is so limited, that the extra training seems completely extraneous. If all you can do is a couple of maneuvers for low back pain (as we’ve seen, cervical manipulation is, well, pointless) then why need to have any other skills? And as I’ve said before – pare it down to that alone, and you areone bored and broke chiro. Start adding stuff that is more in line with science based thinking, and you are merging lanes over to PT.
Weil and Oz are MDs. MDs we think are a crock and whom we call out regularly. If you are going to try and play the persecution card, don’t dismiss your argument in the same sentence.
@arufa:
When I had my shoulder surgery a couple years ago, my ortho “prescribed” PT. He came in with me (it was an adjunct to his office) and told the PT what my surgery was about and why, my particular time frame, and a few suggestions as to exercises he thought would be most beneficial. From there, the PT tailored everything based on my ability and his experience.
From my understanding the insurance wouldn’t cover it if it wasn’t “prescribed.” I get where you are coming from but it seems purely semantic in this case.
As for PTs acting as PCPs…. well, I’m not 100% sold. I fully agree with your arguments, and I definitely see the utility there. However, catching red flags and not missing sinister diagnoses is actually a very difficult thing. I’m not even 100% sold that NPs or PAs could do it entirely stand alone. The difference is they work in the same office as a physician, so if a question arises they can just excuse themselves for 5 minutes and get a quick “consultation.” I reckon with the proper education, a PT could do something similar, but how would you propose to handle the “consulation” issue? Or do you even think it is an issue? I think it is, but my knowledge and experience is limited compared to some of the commentariat here.
As my step-father quips, “85% of medicine is what the girls in the beauty shop can diagnose. The reason we train for 14 years after high school is to catch that last 15%” And I have seen many real world examples of nurses we were really good – very knowledgeable – think that they were just as knowledgeable as a physician. Because they saw the same thing over and over again enough, combined with a decent base of knowledge, to think that had it nailed down. And then make a mistake.
So I’m not saying PTs couldn’t do it in principle, but that the education necessary to make them truly stand-alone as PCPs is not too far off from just getting an MD. Unless there is a system wherein the MD can be readily accesible at all times to act as a “consultant” for any cases that get slightly trickier.
Anyways, just my thoughts on it.
@ JHawk: I don’t want to be picky here. Your reply on January 3rd regarding “measles” is IMO, (coming from a public health background), totally unsatisfactory:
“3) measles- this is an odd question. I can’t imagine anyone going to a chiropractor for measles but the majority will probably just need rest. I would send them to check up with their PCP. I would also ask about continual fever and cough and watch for rash.”
No, no, no, You should immediately call their PCP, not send them to their PCP’s office…thus increasing the risk of exposing additional people to a measles case.
You should also immediately call your local department of health. If you have seen this patient in the evening or on a weekend…there is always a public health physician or public health nurse “on call” that you will speak with. If there is a possibility that the patient does in fact, have measles, the doctor/nurse will come to your office prepared to draw blood from the “suspect” case and to begin an extensive case investigation. The “typical” telephone conversation with that doctor or nurse would be:
1. To hold the patient in your office and close off the examination/treatment room where the patient is.
2. To explain to other patients in your waiting room and to your staff that a health department doctor/nurse is in transit because there is a possible measles exposure and to please wait until the doctor/nurse arrives.
3. To telephone patients who are “expected” and cancel their appointments…with no discussion about a possible measles case presently in your office.
4. To have the names, addresses, telephone numbers of patients who were exposed to the possible measles case within the previous two hours, available for the public health doctor/nurse.
Measles is a high priority “reportable communicable disease” in all of the United States and suspect or confirmed cases require immediate notification to the local health department. Exposures in waiting rooms of doctor’s offices or in other health care facilities, have been implicated in large outbreaks of measles.
BTW…I reside in New York State…always have, and have had a number of medical insurance plans. Each of those plans do not permit a policyholder to “refer” themselves directly to a PT, yet do permit the policyholder to go to an orthopedist without referral from a primary care doctor. As much as I love my PCP, if my pain is so bad that I need to see a doctor, I go directly to the “specialist”…the orthopedist. Whenever I or a member of my family has required PT, the orthopedist writes the orders describing the location of the pain, the results of their physical examination and the results of any X-rays taken in the orthopedist’s office.
@ arufa
“If every patient’s low back pain is caused by something different, then how would we ever be able to chose the appropriate treatment. Wouldn’t every patient need a different intervention if the cause was unique to that patient?”
Not necessarily a different intervention but an intervention (same or different) to different areas of the MSK system. This is the purpose of the systematic process, to determine not only what intervention to use but where to use it.
@nybgrus
“Its not that. It is that what we are getting to is that the only scope of practice that seems to be of any remote utility in chiro is so limited, that the extra training seems completely extraneous. If all you can do is a couple of maneuvers for low back pain (as we’ve seen, cervical manipulation is, well, pointless) then why need to have any other skills?”
Chiro scope of practice includes all MSK issues (plantar fasciitis, achilles tendonopathy, carpal tunnel syndrome, med/lat epicondylitis, shoulder impingement, rotator cuff strain, meniscal injuries, ITB syndorme, and hamstring strain to name a few) with a focus on spinal MSK issues.
“Weil and Oz are MDs. MDs we think are a crock and whom we call out regularly. If you are going to try and play the persecution card, don’t dismiss your argument in the same sentence.”
No persecution, I was just pointing out that the most extreme viewpoints are the ones that get all the press.
nybgrus,
You are right that the prescribe vs referral thing is a bit about semantics however the language we use is often more important than we think.
You are also correct that some insurances will not cover PT without a referral, similar to how they won’t cover a specialist without a referral. Every state and every insurance company has different rules/regs.
I am not one for putting a lot of credence on years of schooling but PTs get 7 vs 8 for MDs. We are not required to do a residency but that is why many states require a certain number of years of experience before a PT can see patients without a referral. In schooling there is a good deal of emphasis put on differential diagnosis and clearing for red flags. I do not agree that “the education necessary to make them truly stand-alone as PCPs is not too far off from just getting an MD”. I think it is very far off from an MDs education. I don’t need to know how to diagnosis and treat anything but neruro/msk problems. I simply need to be aware of, patient and symptom characteristics which raise the probability of a non nmsk condition enough that further workup is needed. We see so many patients with nmsk conditions that we get very good at picking out those which don’t fit the normal patterns and who are at higher risk for mets, infections and other such bad things.
All a PT has to do is determine if something is neuro/msk related and is appropriate for PT care. If not, or if in question we simply send the patient on (either to the er or physician). I sure that PTs will miss things on occasion but not at a higher rate than other professional. PT without a referral is not new and the fears that conditions will be missed have not come true.
Your example of the shoulder surgery is interesting. I have a few thoughts on that. First, post surgery is a little different than walking off the street with back or neck pain. Do you think the conversation your surgeon had really made any major difference in your PT outcomes? My guess is that it did not. But, if a surgeon or any practitioner has information about a patient’s condition they should communicate the info to the PT.
lilady,
I also live in NY state and you are correct that few insurances will pay for services without a referral. But there are some that do and the momentum is moving towards more allowing it.
Think about this case, which is a very common situation I deal with. A patient has low back pain and gets an appointment with their PCP. This takes 3 days and the PCP takes an x-ray (which is not needed) and prescribes medication. The PCP also sets up a referral to an orthopod. 3 weeks later the patient gets in to the orthopod who orders an MRI (which is not needed). The ortho then sends the patient to me and in 2 visits they are 80% better and independent with a home exercise program. 6 months later that patient has a re-occurrence of low back pain. That patient now wants to see me as soon as possible and not jump through all those hoops. So they call my office I get them in and they get treated in 1-2 days not in 4 weeks. Plus the expense of medication, office visits and unneeded imaging are gone. There is a growing number of examples where PTs are being put first and the results have been great as far as outcomes and expense. This article was just published.
http://www.usatoday.com/money/industries/health/story/2012-01-05/health-care-collaboratives/52394918/1
rwk,
Thanks for bring up that wonderful study that shows a 1 hour visit to a PT is better than medication and just as good as weeks of chiro. Talk about a low cost, low risk intervention!
@ Arufa
“Thanks for bring up that wonderful study that shows a 1 hour visit to a PT is better than medication and just as good as weeks of chiro. Talk about a low cost, low risk intervention”
The only thing is no one is going to spend an hour showing anybody these exercises:
http://www.annals.org/content/suppl/2011/12/29/156.1_Part_1.I-30.DC1/156-1-I-30-supplement.pdf
You wouldn’t get paid.
@rwk exactly. Arufa proposes a rather ridiculous and expensive scenario supposedly showing the incompetence of medical doctors in managing simple LBP. I have a scenario for Arufa: pt presents to GP with c/o mild LBP. GP spends $0.05 to photocopy exercise handouts, spends a few minutes or has nurse go over exercises, and offers mild pain meds as a crutch while patient does home exercises. No referral to PT or chiro necessary.
After all, the neck pain study showed us that pain meds, home exercise, and the deluxe, all-inclusive care package are essentially equivocal. Again, I point out that no medical doctor says that pain medication will heal the patient. This study showed that simple pain medication and time allowed the patient to heal just about as well as more expensive therapies (well 6 patients didn’t even get medication…) I obviously support home exercise because anything getting the patient moving around and, well, exercising is fantastic. (Note: I don’t believe that 0.58 difference on an extremely subjective 10-point pain scale is significant, considering most patients when I ask them to rate pain on a scale of 1 to 10, give me answers such as “I don’t know, maybe 5-7.”)
Don’t get me wrong. I have faith in PTs to handle nmsk pain, despite being treated with ultrasound by multiple PTs over the years. But I do wonder if some of this drive to be a “primary care nmsk provider” is reactionary in light of some studies showing perhaps home exercise is equivalent to the care they provide. I don’t doubt the PT does a better job, but we can’t deny that it’s incredibly easier on the patient, and cheaper, to do things at home as opposed to spending hours with a PT.
No arguments from me Dr. Robert however there is some major risk with some of the medications used.
I am a little bias that a few visits with a PT to educate and problem solve to make sure the “right” exercises (those that don’t make the patient worse) are used. I would guess that a less cookie cutter set of exercises would have shown better results but I could be wrong.
There has been a good study on low back pain that showed a lot of cost reduction if patients saw a PT soon and got good PT. Not the magic wand (ultrasound) which is a waste of time and money. I have not done an ultrasound in, I can’t even remember.
@ arufa: I guess with the scenario and the linked article that your provided about patients who have intermittent episodes of pain, certain insurance companies could permit patients to “refer” themselves to a PT. Just to clarify arufa, according to the scenario and article, these patients have already been seen by an orthopedist to determine that their pain is chronic, correct?
Also, I don’t set up an appointment with my primary care physician, when the nature of my problem is orthopedic. I’m just full of anecdotes…here comes another one. I dealt with a painful right knee for about ten days, before I made an appointment with the orthopedist for the following day. I could palpate the crepitus and yet I had no signs of inflammation. The doctor examined me and diagnosed a probable spontaneous torn meniscus. We agreed that no MRI was indicated unless the pain was constant and I did not respond to meloxicam and a few PT treatments. Well I responded within 24 hours to meloxicam and “recovered” completely after 3 PT therapies. I also have a stash of meloxicam on hand, for episodic pain and the exercises taught to me by the PT. The MRI would only be necessary to confirm the diagnosis and prior to surgical repair. Other “patient characteristics”…I’m 68 years old and I intend to leave this life without ever having had any surgery.
lilady,
I wish you luck on making it though life without surgery. That is a great goal but I question your choice to then use a surgeon as your primary care provider for msk problems. They are really good at surgery but if your goal is to avoid surgery at all costs then I can’t see why you would go right to ortho. It would seem more cost effective to see your primary physician first (I won’t dare say your PT first) and not spend the big bucks on a specialist whos specialty service you don’t want.
And what if the knee pain had been from inflammatory arthritis, and a rheumatologist might have been a better choice?
@Arufa, I would accept an orthopedic surgeon’s diagnosis and treatment of msk problems above any other profession’s on the entire planet.
Another anecdote…I have had right sided (what I believed to be sciatica) episodes since my first pregnancy 42 years ago, then throughout a second pregnancy. I have used this same orthopedist for ~ 30 years. Examination and x-rays never showed any deterioration or misalignment of the spine. I tried to remember to bend properly and to avoid torsion disc injuries. One Saturday evening I just arose from a chair and experienced shooting pain from my right buttock to my knee. I crawled upstairs to bed with a heating pad and some ASA. Early in the AM when I awakened I couldn’t get out of bed…the pain was excruciating.
I was “rescued” by volunteer EMTs who transferred me on an elongated back board to the hospital, then an MRI. Once the MRI was read and my orthopedist examined me, I was diagnosed with sacroiliitis with possible mild spinal stenosis. I was out of of the hospital in 4 days still in some pain, dulled by some tylenol/codeine. The doctor gave me a corticosteroid shot, but I think the pain would have resolved in the same time frame. I still am very active, a little more careful now whenever I use a ladder to do plastering and painting. (My husbands brags that he buys me the best tools and supplies for my house maintenance.) The only sign of osteoarthritis that I have, are limited to my hands.
We have found a great PT who also has a plan for $65/month, for unlimited use of the equipment at his rehab center. Great for an older guy like my husband to keep in shape, especially during inclement weather, under the direction of any of the therapists who are at the center. Also great for my husband for returning to a fitness program S/P cardiac stent placements last winter.
Where it hurts taking into account referred pain? I learned that in a week during med school.
How about a list of what you do and what evidence you have for interventions for a few of those? I realize not all of them would have particularly robust evidence, so how about a couple that do and a couple that don’t with a justification that makes scientific sense and also how that is inherently and necessarily different from what a PT would/could do?
Let me re-quote you:
This is exactly what I meant by the squeeky wheel analogy and is why I have heard the names Mercola, Weil, Oz, etc. but have never heard the name of any MD on SBM
Let me rephrashe the statement:
Chiros get a bad rap because some of them are crazy magic believers, but SBM picks on everyone except for their own, because they never call out any MDs
But, as I said, Weil and Oz are MDs and we are happy to call out anyone who isn’t science based.
@arufa:
I absolutely agree. I just wanted to head off what I thought might go down a flame-y tangent is all.
I really didn’t know that. I’ll admit that I thought PT was akin to a bachelors in nursing. Is that the only track for becoming a PT? An undergrad degree (is there any restriction in what major it must be or pre-reqs?) and then a 3 year graduate program? What is the official title at that point?
My apologies for my ignorance.
How to treat, definitely not. How to diagnose…. I am still not sold. I’m also thinking from a practical standpoint. How many sinister diagnoses can present with MSK type issues?
Multiple myeloma, various sarcomas, prostate mets, rhabdomyolysis secondary to medication (statins or tendon rupture from levaquin for example), septic joints, osteomyelitis, or the (albeit rare) dangerous fracture that is just stable enough to be very dangerous (an occult hangman’s fracture for instance).
So I would say a PT would need to know how to at least differentiate those diagnoses, and I would argue it is actually harder to try and restrict the education of differentiation than to just teach the diagnosis as a whole.
And then the practical side become this – is it really more efficient to have patients go directly to PTs and essentially force all PTs to refer to a PCP unless they can absolutely diagnose an MSK issue? (And that’s a genuine question). And how about the people with sinister underlying causes that are lost to follow up (I won’t get into the ones that are misdiagnosed – physicians are able to make mistakes too)?
If the PT is on site with the physician, then I think a lot of that can be mitigated. But being completely standalone with a referral to a different office as the only option, I am concerned about the practical issues therein.
I can’t say. I’ve never had PT for anything before or since. However, the relationship between the ortho and PT seemed quite good and the surgeon’s words were essentially “I want him to focus on X and Y but beyond that you should do what you think is best.”
Anecdote time. My girlfriend has knee issues and I had her see an ortho friend of mine. He recommended PT trial first and if that didn’t work out surgery later (in brief she has her inferior patellar ligament fused to her MCL after an injury, so the patella tracks over the medial femoral condyle and leading to pain and chronic inflammation as well as dystrophic calcification). She said that she would just “do it at home” and not bother with the PT. I told her that she should go for at least a few sessions so she could get a good head start and learn all the right exercise to do. She did and, sadly, has not followed up with her exercises as well as she should.
So perhaps to moderate DrRobert’s statement a bit (which I am certain he is well aware of anyways) there is something to be said for going to PT since it provides the motivation to do it and do it right (just like a personal trainer). However, it became too expensive for her to go so it was a moot point.
Just food for thought.
In Australia they have a pretty rigorous “go to PCP (GP) first for referral” system for precisely such reasons. They pay their GPs a LOT more than their US counterparts and the hours are very reasonable, plus teaching opportunities abound, so it is actually an attractive option for medical graduates. This creates a system that is much more efficient for proper referral because they GPs are extensively trained post-grad for exactly this, and since there is no (well, very little) pressure to pay back loans, it becomes a very feasible career option.
In my limited experience and knowledge that seems like a much better solution than trying to get NPs, PAs, and PTs to act as their own primary-yet-still-specialist-care-providers. Of course I speak in principle, not necessarily in practical application to the US.
A lot of great comments and nybgrus you have some good points. My thoughts on this debate is that it could go on forever with lots of anecdotes and what ifs. The bottom line is all the evidence (I realize there is not a lot of peer reviewed evidence) points to the fact that getting patients to PT soon (and even first) is safe, effective and cost saving. Many of the valid concerns about safety have not come true. The Army (I posted a study about the military’s use of PTs first) several other countries (including Australia), large organizations like Kaiser Permanente and Virgina Mason have put PT first and have found it to be safe, effective and cost efficient We can debate if PTs are qualified but the evidence suggests that they are. I agree that we need more studies about this and they are coming.
We all want what is best for the patient and that is great. I am confident that the data will continue to show that PT first or at least very early in the process is safe, effective and cost savings. I will be very willing to change my position/bias if the literature swings the other way. I am not so sure that others in this conversation would do the same, but I could be wrong.
http://fearonphysicaltherapy.com/_media/media/file/342138/LBCareDelivery-VMason.pdf
http://content.healthaffairs.org/content/30/9/1680.short
nybgrus,
I think every PT school is at the doctorate level at this point. There may 1 or 2 which are still masters but if they they won’t be for long. A student, like with medical school, can have whatever undergrad major they want but there are some specific pre-reqs needed. They graduate with a DPT, doctor of physical therapy degree.
I didn’t go to my G.P. first because the pain in my knee was obviously an orthopedic problem…I palpated the crepitus myself and there were no “typical signs” of rheumatoid arthritis such as multiple joint swelling and redness.
My family (husband, daughter and I) have a long-standing professional relationship with the orthopedist…he operated on my daughter’s knee after a skiing accident and the resulting ACL tear and fx. of the tibial plateau.
I was correct in my diagnosis, but if the orthopedist thought it might be Rheumatoid Arthritis, he would have ordered a rheumatoid arthritis panel blood test. I believe I saved myself an extra trip and the expense of going to my G.P. prior to being seen by my orthopedist. I am very “sensitive” and concerned about the burgeoning costs of health care, and quite politically vocal about a national health care plan so that everyone in our society has the benefit of good health care.
As Nybgrus has correctly pointed out BSc. nurses cannot make a medical diagnosis, but we can and do “play doctor” for ourselves and our family members…before we go to a doctor…not in lieu of a doctor’s consultation. And, I usually nail down the “medical diagnosis” correctly.
@nybgrus
“Where it hurts taking into account referred pain? I learned that in a week during med school.”
Apparently you have not heard of MSK compensation leading to pain at a region away from the dysfunction which is extemely common and much different than referred pain but why would I expect you to as most MD’s have no education in biomechanics. Once again, those who treat the site of pain are lost.
“Chiros get a bad rap because some of them are crazy magic believers, but SBM picks on everyone except for their own, because they never call out any MDs”
So now you get to re-phrase my sentences and then come to a conclusion of what I was saying? MD’s and DC’s with extreme viewpoints get all the press. You are arguing the exact point I was making, end of story.
“How about a list of what you do and what evidence you have for interventions for a few of those? I realize not all of them would have particularly robust evidence, so how about a couple that do and a couple that don’t with a justification that makes scientific sense and also how that is inherently and necessarily different from what a PT would/could do?”
plantar fasciitis- myofascial release (sometimes instrument assisted) to plantar foot stuctures that are “tight” (possibly different than many physical therapists) , at home stretching and icing before walking in am (probably same as PT’s), Check ankle dorsiflexion and use selective tension and palpation to find out if a soft tissue structure is limiting this range leading to increase load on the plantar foot structures and use myofasical release to increase range (different from majority of PT’s), check LE functional eval including lunge, squat, hip E etc. and fix any problems I find (similar to a few PT’s but not others), possibly mobilization (same) of foot bones and HVLA (different) of ankle mortise joint.
CTS- myofascial release to soft tissue wrist, hand and forearm structures. Some PT’s do this and some do not. At home stretches, night splints and ergonomics eval (PT’s do this). palpation exam to search for double/triple crush with nerve entrapment release (not many PT’s to my knowledge). If unresponsive surgical referral.
As to evidence for interventions, a few of these have high quality, many moderate quality and some no evidence either way in which case I use my clinical judgement. This is the case for all NMS medicine. The treatments are inherently difficult to study even on top of the difficulties of sham and blinding. Lets use plantar fascitis as an example. You can not take a group of people with plantar fascitis and lump them in a group and apply a single Tx and expect great results. Why? MSK compensation. Is this patients plantar fascia being overloaded and causing pain due to a decreased/increased arch, overpronation during gait, decreased dorsiflexion, narrow toe box, hallux valgus, hypertonic tib post, etc. If these are not treated along with the plantar fascia then the plantar fasica will not heal properly.
As to different to a PT, some is and some is not. I know many chiro’s including myself that work along side PT’s. We are similar but can bring different approaches to the table. Also, chiro’s are trained in reading and ordering imaging and as far as I know PT’s are not and can not.
Warning, very unfriendly and unpolitically correct post coming:
@jhawk, chiropractors may have training in ORDERING X-rays, but they certainly do not have any training in READING them. I would have more faith in a homeless person off the street reading an X-ray than a chiropractor.
Just today, I had a patient who was told by their chiropractor that they had multiple herniated discs in their cervical spine, and the chiropractor pointed them out to her on X-ray. If anyone knows imaging, they don’t need to be told how stupid, careless, idiotic, and quacky it was for a chiropractor to say that. X-ray of her neck was indicated and besides some loss of lordosis (likely due to muscular strain), her neck was fine. You can’t diagnose a herniated disc on X-ray alone. That’s a quack for you. And for this absolute quack to tell her that she had herniated discs at specific levels, it’s just revolting.
I’ve seen many hundreds of patients come in with ridiculous and impossible findings on X-rays from chiropractors. One patient was told by the chiropractor that he “healed” her scoliosis, and showed her an X-ray (I doubt it was HER X-ray). On physical exam I could see she still had a curvature in her spine. X-ray revealed a > 10 degree scoliosis. Or the chiropractor who X-rayed my wife’s spine (before I met her), and told her she had scoliosis and spinal spurs. Later on, she needed a chest X-ray and her spine was perfectly straight, no spurs, etc. Or the chiropractor that had a overdeveloped X-ray and said he noticed lots of “inflammation.”
The fact that chiropractors take X-rays is PURE QUACKERY. Physical therapy is superior to chiropractic treatment for every indication, and PT’s don’t need imaging studies. There is not a SINGLE CONDITION that chiropractors can treat (prove it with legitimate systematic reviews that aren’t published in “Journal Of Manipulative Therapy”, ok?) that is diagnosed by X-ray. Nothing. They simply have no reason to be taking them.
There’s a story about a chiropractor in our town whose X-ray machine was broke, and when the repair guy came to fix it, he said “I don’t care if it takes pictures, as long as it makes the beeping sound. I have all the X-rays I need already.”
Here’s an excerpt from something I wrote about chiropractic X-ray abuse:
—
The decision by medical professionals to utilize X-rays is a risk-benefit analysis, which means the practitioner must have a clear reason for taking an X-ray, and the X-ray should yield information that will influence the treatment the patient receives.
Chiropractors are often criticized for their excessive and unnecessary use of X-rays. Chiropractors routinely take full spine X-rays without a clear indication for them, and as with NUCCA therapy they take multiple X-rays of the upper neck.
Indeed, multiple studies have found that chiropractors use X-rays unnecessarily. Studies have shown that up to 71% of patients being treated for low-back pain by chiropractors have been X-rayed by them.147 Other studies have found that up to 96% of new patients are X-rayed, and 80% of patients on follow-up visits are X-rayed by chiropractors. (Ernst 1998)
Currently, there is no good reason for chiropractors to X-ray the spine. Many utilize X-rays to diagnose subluxations of the spine, despite the fact that the concept of subluxations is disproven and even evidence-based chiropractors no longer claim they exist.
Experts on low-back pain uniformly agree that X-rays are usually not useful for diagnosis. In fact, chiropractic textbooks point out that “routine radiographic investigation of the lumbar spine should be avoided because of the radiation hazard but also because inappropriate X-ray examination contributes little to the solution of a particular problem and may even obscure it.”
Chiropractic guidelines recommend that X-rays are unnecessary for the management of uncomplicated acute low-back pain. Studies show that chiropractors do not adhere to these guidelines and continue to use X-rays excessively.
Chiropractors routinely employ the use of full spine X-rays, which have been calculated to be more likely to cause cancer than detect bone cancer in the average patient.
In fact, high-quality systematic reviews (see “Investigations” in this post) have shown that chiropractors are unable to treat any condition that would diagnosed by X-ray. Therefore, it is suggested by the author that if a chiropractor suspects a condition that necessitates X-ray, the appropriate course of action should be to refer the patient to a medical doctor.
In 1994, a survey of chiropractors in America found that 96% of new chiropractic patients are X-rayed, and 80% of patients are X-rayed on follow-up visits. (Plamindon 1994)
In 2002, a study assessed the views of chiropractors on the use of radiography (X-rays) for evaluating patients with acute low back pain. The study found that 63% of chiropractors stated they would use radiography on patients with uncomplicated acute low back pain lasting 1 week. 68% stated that radiographs were useful in the diagnostic evaluation of patients with acute low-back pain lasting less than 1 month. The study noted that the reasons given for use of radiography in this study are not supported by existing evidence. The study concluded that there appears to be a high rate of radiographic use by chiropractors which is consistent with findings in previous studies. (Ammendolia 2002)
In 2008, a study examined the instructions provided at chiropractic schools worldwide on the use of spine radiography (X-rays) compared with evidence-based guidelines for low-back pain. The study found that 56% of chiropractors believed, against evidence-based guidelines, that they should Xray the lower back in the absence of “red flags” for serious disease. The study concluded that this may be responsible for chiropractic over-utilization of radiography for low back pain. (Ammendolia 2008)
In 2011, a study aimed to determine how well chiropractors manage low-back pain in accordance with recommendations from an evidence-based acute low-back pain guideline. The recommendations were directed at minimizing the use of plain x-ray and encouraging the patient to stay active. The study found that 68% of chiropractors would take an X-ray even when it was not indicated, and 51% would give advice to stay active when it was indicated. The study showed a low adherence to recommendations from an evidence-based guideline for acute low-back pain. (Walker 2011)
@ DrRobert
Somethings just don’t sound right about your first ” anecdote”. So the patient happened to have their xrays with them and were intelligent enough to show you exactly what and where the chiropractor had shown them. Did they have symptoms or signs of IVD herniation? Was IVD herniation the sole reason for the films?Why didn’t you call the chiropractor or vice versa. If you really cared for the patient ( and the public as is your “mission”)that’s the first thing you should’ve straightened out.
“Physical therapy is superior to chiropractic treatment for every indication, and PT’s don’t need imaging studies”
That’s because you, Nybgrus,WUL and Hall have examined,diagnosed and ordered imaging already,right?
“There is not a SINGLE CONDITION that chiropractors can treat (prove it with legitimate systematic reviews that aren’t published in “Journal Of Manipulative Therapy”, ok?) that is diagnosed by X-ray. Nothing. They simply have no reason to be taking them.”
Unless they were about to manipulate a spine with a tumor or saw some other pathology.
“I’ve seen many hundreds of patients come in with ridiculous and impossible findings on X-rays from chiropractors.”
Hundreds ?,now that’s an exaggeration. Can you prove that? How come the other MDs like Hall don’t ever criticize you?
Considering the wonderful relationship between MDs and DCs I find it unlikely that that many people would be carting around their Xray films after just leaving a chiropractor to see you.
“Chiropractic guidelines recommend that X-rays are unnecessary for the management of uncomplicated acute low-back pain. Studies show that chiropractors do not adhere to these guidelines and continue to use X-rays excessively”.
You repeat that in the last paragraph.( Walker 2011). In that robust study, it was 68% of 273 chiropractors.
( maybe 0.3% of all chiropractors).
I won’t suggest there aren’t a lot of needless imaging studies done on both sides.
Hundreds? Quite possibly, yes. As far as I know, there is no reason to call him a liar. Patients carting around x-rays? No, but I don’t think that’s what he meant. I interpreted it to mean that the patients had reported ridiculous and impossible findings by chiropractors, not that he had seen the x-rays themselves.
@ rwk,
68% of 273 chiropractors. ( maybe 0.3% of all chiropractors).
Are you mathematically challenged? Studies like that are based on representative samples. The fact that the other 99.7% of chiropractors were not subjects in the study is irrelevant to their conclusions.
@rwk:
>>”Somethings just don’t sound right about your first ” anecdote”. So the patient happened to have their xrays with them and were intelligent enough to show you exactly what and where the chiropractor had shown them. Did they have symptoms or signs of IVD herniation? Was IVD herniation the sole reason for the films?Why didn’t you call the chiropractor or vice versa. If you really cared for the patient ( and the public as is your “mission”)that’s the first thing you should’ve straightened out.”
I never wrote nor implied that the patient had their X-rays with them. If it seemed that way I apologize. The patient told me, verbatim, the exact three cervical levels the chiropractor told them were herniated. They said the chiropractor showed them the c-spine X-ray and pointed out the herniations to them.
Sure, it’s possible the patient misunderstood the chiropractor in some cases. We’ve all had our patients that have “ostopopoloris” and “avanicular nicolorosis”. But when a patient is told they have specific findings that are absolutely untrue… There’s no weaseling out of that.
Why didn’t I call the chiropractor?When the patient comes to me, they are under my care. I recommend discontinuing chiropractic treatment and recommend PT. The chiropractor is no longer part of the equation.
>>“There is not a SINGLE CONDITION that chiropractors can treat (prove it with legitimate systematic reviews that aren’t published in “Journal Of Manipulative Therapy”, ok?) that is diagnosed by X-ray. Nothing. They simply have no reason to be taking them”. Unless they were about to manipulate a spine with a tumor or saw some other pathology.
So your only justification for chiropractor use of X-ray is that they may have a chance finding? Wow. (Personally, I doubt they would be able to diagnose a chance finding anyway, given my experience with their inability to read an X-ray)
>>“I’ve seen many hundreds of patients come in with ridiculous and impossible findings on X-rays from chiropractors.”
Hundreds ?,now that’s an exaggeration.” Can you prove that? How come the other MDs like Hall don’t ever criticize you?
Can I prove what? That I have patients? I swear on my life that my “anecdotes” involving chiropractors’ incompetence with X-rays are absolutely true. And they are only scratching the surface. You can’t criticize fact. Sure, the authors of this blog may criticize me for being unfair and just plain rude towards chiropractors, or for being slanted or biased. I admit that. But after reading hundreds of chiropractic studies, I find that it’s an essentially worthless profession that is more likely to do harm than good. I will not write nice things about it. There may be “legit” chiropractors out there, but I think they are extremely rare and few and far in-between.
>>”Considering the wonderful relationship between MDs and DCs I find it unlikely that that many people would be carting around their Xray films after just leaving a chiropractor to see you.”
I’m not sure if you’re being facetious or not. No one ever said patients are walking around with their X-rays. If patients want copies of their X-rays, they pay for them.
>>“Chiropractic guidelines recommend that X-rays are unnecessary for the management of uncomplicated acute low-back pain. Studies show that chiropractors do not adhere to these guidelines and continue to use X-rays excessively”.
You repeat that in the last paragraph.( Walker 2011). In that robust study, it was 68% of 273 chiropractors.
( maybe 0.3% of all chiropractors).
See Dr. Hall’s comment. I guess they don’t teach statistics in chiropractor school?
@rwk, regarding this:
>>”In that robust study, it was 68% of 273 chiropractors. ( maybe 0.3% of all chiropractors).”
Refer to this:
In 2007, a study evaluated the perceptions of research, frequency of use of research findings in practice, and the level of research skills of chiropractors. Surveyed chiropractors acknowledged the importance of research to validate their practice, but had little confidence in their research skills and the overall application of research in practice was limited. The study concluded that chiropractors do not consistently apply research in practice, which may result from a lack of research education and research skills. ( Suter 2007 – http://www.ncbi.nlm.nih.gov/pubmed/17320731 )
@rwk, I apologize if these replies are rather rude. I don’t want to create online enemies. I know not every chiropractor is a quack, and I do feel bad for those that aren’t quacks but somehow ended up in chiropractic school.
[...] Blockages of mental impulses, called vertebral subluxations, occur when a vertebra misaligns, occludes an opening, impinges on a nerve or otherwise interferes [...]
@DrRobert
“@jhawk, chiropractors may have training in ORDERING X-rays, but they certainly do not have any training in READING them. I would have more faith in a homeless person off the street reading an X-ray than a chiropractor.”
Not so says this study: Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists.
“Just today, I had a patient who was told by their chiropractor that they had multiple herniated discs in their cervical spine, and the chiropractor pointed them out to her on X-ray. If anyone knows imaging, they don’t need to be told how stupid, careless, idiotic, and quacky it was for a chiropractor to say that. X-ray of her neck was indicated and besides some loss of lordosis (likely due to muscular strain), her neck was fine. You can’t diagnose a herniated disc on X-ray alone. That’s a quack for you. And for this absolute quack to tell her that she had herniated discs at specific levels, it’s just revolting.”
Nice anecdote. Are you sure the patient didn’t mean degenerated and not herniated?
“Physical therapy is superior to chiropractic treatment for every indication, and PT’s don’t need imaging studies.”
Nice opinion. Evidence please. Here are 2 studies that say otherwise; (Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up.) and (Health maintenance care in work-related low back pain and its association with disability recurrence.)
“There is not a SINGLE CONDITION that chiropractors can treat (prove it with legitimate systematic reviews that aren’t published in “Journal Of Manipulative Therapy”, ok?) that is diagnosed by X-ray. Nothing”
This is easy, rib fracture.
“They simply have no reason to be taking them.”
How about to rule contraindications to HVLA, acute sports injury, MVA, non-response to Tx.
“There’s a story about a chiropractor in our town whose X-ray machine was broke, and when the repair guy came to fix it, he said “I don’t care if it takes pictures, as long as it makes the beeping sound. I have all the X-rays I need already.”
Wow, another anecdote.
—
“Studies have shown that up to 71% of patients being treated for low-back pain by chiropractors have been X-rayed by them.”
Yep a study from 1977 with patients that had LBP for over 3 months. Need I say more.
“In 1994, a survey of chiropractors in America found that 96% of new chiropractic patients are X-rayed, and 80% of patients are X-rayed on follow-up visits. (Plamindon 1994)”
You really do like this Ernst article don’t you. I can not get to this article (the one ernst is citing) and can not take his citing seriously due to the 1977 study he cited.
“In 2002, a study assessed the views of chiropractors on the use of radiography (X-rays) for evaluating patients with acute low back pain. The study found that 63% of chiropractors stated they would use radiography on patients with uncomplicated acute low back pain lasting 1 week. 68% stated that radiographs were useful in the diagnostic evaluation of patients with acute low-back pain lasting less than 1 month. The study noted that the reasons given for use of radiography in this study are not supported by existing evidence. The study concluded that there appears to be a high rate of radiographic use by chiropractors which is consistent with findings in previous studies. (Ammendolia 2002)”
N=26 with a 76% response rate which means total N=20. Is this generalizable? Hell no. Talk about homeopathy level evidence.
“In 2008, a study examined the instructions provided at chiropractic schools worldwide on the use of spine radiography (X-rays) compared with evidence-based guidelines for low-back pain. The study found that 56% of chiropractors believed, against evidence-based guidelines, that they should Xray the lower back in the absence of “red flags” for serious disease. The study concluded that this may be responsible for chiropractic over-utilization of radiography for low back pain. (Ammendolia 2008)”
Interesting how you cherry picked the conclusion. It also said, This survey suggests that many aspects of radiology instruction provided by accredited chiropractic schools appear to be evidence based. And from the results: Of the 33 chiropractic schools identified worldwide, 32 (97%) participated in the survey. Consistent with the guidelines, 25 (78%) respondents disagreed that “routine radiography should be used prior to spinal manipulative therapy,” 29 (91%) disagreed that there “was a role for full spine radiography for assessing patients with low back pain,” and 29 (91%) disagreed that “oblique views should be part of a standard radiographic series for low back pain.”
“In 2011, a study aimed to determine how well chiropractors manage low-back pain in accordance with recommendations from an evidence-based acute low-back pain guideline. The recommendations were directed at minimizing the use of plain x-ray and encouraging the patient to stay active. The study found that 68% of chiropractors would take an X-ray even when it was not indicated, and 51% would give advice to stay active when it was indicated. The study showed a low adherence to recommendations from an evidence-based guideline for acute low-back pain. (Walker 2011)”
A survey with a response rate of 37%. Nice evidence.
Your extreme bias, cherry picking, and citing of worthless studies leads you to your unscientific conclusions.
@DrRobert and Hall
Statistics or Biostatistics was not a requirement to chiropractic school admission in 1987. I can find no US medical
school that requires it at entrance. Yes, it is taught in medical schools and also my Alma Mater. I believe it is only in the last
twenty years with the advent of EBM that it began to be slowly included in medical curriculum. So there are a lot of
older practitioners of all disciplines that are deficient.
By the way,here’s the full study done in Australia:
http://chiromt.com/content/pdf/2045-709X-19-29.pdf
Notice the Study Limitations section. As I said this is not a robust study.
@rwk, every medical school teaches biostatistics. I don’t believe it is a pre-requisite for medical school, although it is a required class for science majors, etc.
@jhawk, link to high quality systematic review showing chiropractic care is effective for broken rib?
It’s so strange, because when I look for evidence, I keep finding this
Posadzki P, Ernst E. “Spinal manipulation: an update of a systematic review of systematic reviews.” N Z Med J. 2011 Aug 12;124(1340):55-71.
“Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition.”
It just seems that if a reasonable person looked at the big picture, where there are a ridiculous number of studies that together show spinal manipulation is essentially worthless for every single condition (either in the form of studies, systematic reviews, or systematic reviews of systematic reviews), that they would just push chiropractic to the side and start investing time in something else.
But instead, these quacks design and construct ridiculous studies (such as the recent chiro neck study) in a vain and futile attempt to show that the care is somewhat effective for at least one condition. They are so proud to have at least one study that says “hey we might almost be effective as a xerox’ed piece of paper showing some exercises, only we cost over 25,000 times as much and have a risk of death.”
@rwk, excuse me, statistics, not biostatistics, is a req class for most science majors.
@ DrRobert
So you have given up providing weak “evidence” (I hate to even call it evidence) to support your unscientific opinion of radiology and chiropractic and moved on to SMT.
Ernst study: 4 of the negative studies are done by the authors….. selection bias. 16 (studies included in the review)-4=12. Of these 12 another 4 were for non MSK. 12-4=8. Of the last 8, 3 are for LBP and all conclude that SMT is as effective as any other medical Tx. 2 are for neck pain of which one concludes it is a viable option and the other concludes it is effective with exercise (normal practice). The last 3 are for HA: one concludes better than massage and as effective as meds, second one does not support effectiveness, and third one not enough evidence either way. So LBP: SMT is effective. neck pain; SMT is effective. HA: not enough evidence to say, more needed. All this from an Ernst paper none the less. I must ask did you actually critique this study or just take your buddy Ernst’s word for it?
This coupled with the American College of Physicians, American Pain Society, AHCPR guidelines and the NICE guidelines and the inherent difficulties in studying manual medicine I am led to a more evidence based conclusion than your bias opinion.
@jhwak, thats’s just sad.
@ jhawk
Please note that NICE didn’t take into account the chiropractic ‘bait and switch’ when it made its recommendation:
http://www.dcscience.net/?p=1516
Nor did NICE take into consideration the fact that chiropractic back pain patients are often given potentially dangerous neck manipulations. Perhaps the reason for these serious omissions lie in the following quote lifted from the above link:
“Proponents of spinal manipulation/mobilisation were [therefore] over-represented in the generation of these guidelines, which, in turn could have generated the over-optimistic conclusion regarding this intervention.”
@ jhawk
Interestingly, despite the NICE recommendations, many GPs in the UK aren’t referring to chiropractors:
Quote
“GPs are being prevented from putting controversial NICE guidance on low back pain into action because primary care organisations [PCOs] are refusing to fund its recommendations of acupuncture and spinal manipulation. Of 127 PCOs responding to requests under the Freedom of Information Act, half said they were currently providing no funding for spinal manipulation…The institute’s guidance on low back pain advises that patients should be offered exercise, a course of manual therapy or acupuncture as first-line treatments. The recommendation was fiercely attacked by musculoskeletal specialists, who questioned whether there was evidence the treatments were effective on top of standard care. Pulse’s investigation suggests PCOs have felt able to ignore NICE’s recommendation because of the controversy surrounding it.”
http://tinyurl.com/5wjwes7
@ jhawk
Re your accusation of selection bias in the Ernst study, you might be interested to read Ernst and Canter’s response to that criticism following the publication of the original study:
http://jrsm.rsmjournals.com/content/99/6/279.full
@ Blue Wode
C’mon! I’m sure you’ve done at least a little study on your own and verified some of the things that Ernst says
here:
http://jrsm.rsmjournals.com/content/99/6/279.full
First he says
“Spinal manipulation was first described in 1895 by the `magnetic healer’ D D Palmer as a treatment of `subluxations’ of the spine and other joints”
Wrong Wrong not even close. Osteopathy was discovered ~ 1874 by AT Still. His first school was started in 1892.
DD Palmer not only was aware of what was going on there but took some classes ! So, chiropractic and spinal manipulation are not original ideas. They’re borrowed. All of you SBM people who think crazy chiropractors started this for spurious reasons need to hone your “research” skills.
So first of all,Herr Ernst the chiropractic inquisitor immediately looses credibility. If he can’t get that right, and he wrote a book about it, how can you trust him to be unbiased when decided if a study is valid or not? And it can go both ways, that what this site is all about: arguing who’s evidence is better.
So you, Hall, Dr Robert, Nygmus, WUL,Scott ,Chris,Quill blah blah blah ought to read this and then tell us that there is no value to spinal manipulation whatsoever:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565620/
Herr Ernst should be forced to read this .
@ rwk
Ernst doesn’t use the word ‘discovered’. He uses the word ‘described’ in the context of chiropractic, presumably because he is addressing chiropractors due to most of the criticisms being made by them, and because spinal manipulations (adjustments) are their hallmark intervention.
@rwk,
Your reference doesn’t support your claim. It says manipulations date back to 400 BC. Still is considered the father of osteopathy, Palmer of chiropractic. It says on his tombstone that he founded chiropractic on September 18, 1895. Manipulation existed long before either of them. Still and Palmer adopted it for different rationales: one involving blood circulation and the other, nerves.
You are attempting to create a diversion. Even if you think Ernst is not “credible” on a historical issue (which you haven’t proven), you have not refuted the findings of his many studies.
I have never said that spinal manipulation has no value. It is a reasonable alternative for early relief of low back pain for patients who want to avoid medication and don’t mind many visits to a provider’s office.
If all you can do is lash out like this with insults and put words in people’s mouths, you are the one who will lose credibility.
How about a little respect? “Herr” Ernst is Doctor Doctor Ernst, both MD and PhD, and you may be surprised to know that he learned to do manipulation as part of his training. Rather than being an “inquisitor” he was favorably inclined towards manipulation and other types of alternative medicine at first, and became disenchanted when he studied the evidence.
DrHall
Do you not read the vile comments about chiropractic on this site?
You chide me but DrRobert( and others) says things like
“The fact that chiropractors take X-rays is PURE QUACKERY”
and
“But instead, these quacks design and construct ridiculous studies (such as the recent chiro neck study) in a vain and futile attempt to show that the care is somewhat effective for at least one condition. They are so proud to have at least one study that says “hey we might almost be effective as a xerox’ed piece of paper showing some exercises, only we cost over 25,000 times as much and have a risk of death.”
I can dig up some others if you’d like.
I’ve never seen you criticize any of the insulting comments against by SBM members,did I miss something?
And of Ernst
In 2002 Ernst said of homeopathy:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1874503/
“Until more compelling results are available, homeopathy cannot be viewed as an evidence-based form of therapy”.
Ernst, in a 2003 interview:
http://www.guardian.co.uk/science/2003/sep/25/scienceinterviews.health
He treats his French wife with homeopathy, he says. “We were both brought up with it.”
In 2010, he calls it unethical to use homeopathy as a placebo
http://www.guardian.co.uk/commentisfree/2010/feb/22/science-homeopathy-clinical-trials
I wonder if he still dabbles in a little homeopathy with his wife.
DrHall
Do you not read the vile petty comments about chiropractic on this site as well as participate?
You chide me but DrRobert( and others) says things like
“The fact that chiropractors take X-rays is PURE QUACKERY”
and
“But instead, these quacks design and construct ridiculous studies (such as the recent chiro neck study) in a vain and futile attempt to show that the care is somewhat effective for at least one condition. They are so proud to have at least one study that says “hey we might almost be effective as a xerox’ed piece of paper showing some exercises, only we cost over 25,000 times as much and have a risk of death.”
I can dig up many many others if you’d like.
I’ve never seen you criticize any of the insulting comments against chiropractic by SBM members,did I miss something?
And of Ernst
In 2002 Ernst said of homeopathy:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1874503/
“Until more compelling results are available, homeopathy cannot be viewed as an evidence-based form of therapy”.
Ernst, in a 2003 interview:
http://www.guardian.co.uk/science/2003/sep/25/scienceinterviews.health
He treats his French wife with homeopathy, he says. “We were both brought up with it.”
In 2010, he calls it unethical to use homeopathy as a placebo
http://www.guardian.co.uk/commentisfree/2010/feb/22/science-homeopathy-clinical-trials
I wonder if he still dabbles in a little homeopathy with his wife.
Finally:
http://www.guardian.co.uk/lifeandstyle/2011/jul/30/edzard-ernst-homeopathy-complementary-medicine
Ernst says the evidence – though not his own clinical research – supports some uses of acupuncture, herbal medicine, massage, hypnotherapy and relaxation techniques
And we know what you think of Acupuncture
@ Blue Wode
you said: “Re your accusation of selection bias in the Ernst study, you might be interested to read Ernst and Canter’s response to that criticism following the publication of the original study:”
I assume you were mostly pointing me to this quote from the article; “The fact that four of the 16 included articles were our own simply shows that we are research-active in this area. To exclude one’s own work in systematic reviews would be woefully unscientific.”
Just for shits and giggles lets say Ernst is not biased in his reporting and add back in the 4 studies he cited of himself in his review. There is 1 (SMT not effective) for LBP so 3 positive and 1 negative. There is 1 for neck pain which concludes SMT is not more effective than exercise- so it is as effective as exercise and the study does not compare to other Tx’s. The other 2 are for non-NMS issues.
When you look at the results from this review and even allow Ernst’s reviews of himself it still shows SMT is as effective as any other Tx for LBP and neck pain. And Ernst’s conclusion says this:”Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.” This conclusion is rather disengenous as it comlpetely contradicts the results of the study. This along with his citing of the 1977 study (mentioned earlier in this thread) of LBP patients of 3 month duration to demonstrate that chiro’s x-ray excessively leads his work to be extremely suspect and bias.
@ Blue Wode
you said: “Re your accusation of selection bias in the Ernst study, you might be interested to read Ernst and Canter’s response to that criticism following the publication of the original study:”
I assume you were mostly pointing me to this quote from the article; “The fact that four of the 16 included articles were our own simply shows that we are research-active in this area. To exclude one’s own work in systematic reviews would be woefully unscientific.”
Just for shits and giggles lets say Ernst is not biased in his reporting and add back in the 4 studies he cited of himself in his review. There is 1 (SMT not effective) for LBP so 3 positive and 1 negative. There is 1 for neck pain which concludes SMT is not more effective than exercise- so it is as effective as exercise and the study does not compare to other Tx’s. The other 2 are for non-NMS issues.
When you look at the results from this review and even allow Ernst’s reviews of himself it still shows SMT is as effective as any other Tx for LBP and neck pain. And Ernst’s conclusion says this:”Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.” This conclusion is rather disengenous as it comlpetely contradicts the results of the study. This along with his citing of the 1977 study (mentioned earlier in this thread) of LBP patients of 3 month duration to demonstrate that chiro’s x-ray excessively leads his work to be extremely suspect and bias.
Maybe a third time is a charm. Sorry if all three of these get posted. I am not sure why this comment is awaiting moderation as there are no links posted.
@ Blue Wode
you said: “Re your accusation of selection bias in the Ernst study, you might be interested to read Ernst and Canter’s response to that criticism following the publication of the original study:”
I assume you were mostly pointing me to this quote from the article; “The fact that four of the 16 included articles were our own simply shows that we are research-active in this area. To exclude one’s own work in systematic reviews would be woefully unscientific.”
Just for shits and giggles lets say Ernst is not biased in his reporting and add back in the 4 studies he cited of himself in his review. There is 1 (SMT not effective) for LBP so 3 positive and 1 negative. There is 1 for neck pain which concludes SMT is not more effective than exercise- so it is as effective as exercise and the study does not compare to other Tx’s. The other 2 are for non-NMS issues.
When you look at the results from this review and even allow Ernst’s reviews of himself it still shows SMT is as effective as any other Tx for LBP and neck pain. And Ernst’s conclusion says this:”Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.” This conclusion is rather disengenous as it comlpetely contradicts the results of the study. This along with his citing of the 1977 study (mentioned earlier in this thread) of LBP patients of 3 month duration to demonstrate that chiro’s x-ray excessively leads his work to be extremely suspect and bias.
@rwk,
You didn’t respond to what I said. You continue to attack Ernst and to provide links that don’t support your points. The Guardian article shows that he is anything but biased against CAM, that he started out with a very favorable impression but was forced to change his mind by the evidence. You continue to attack the writer rather than the content of the writing. You continue to create diversions. You have offered us nothing of substance. I don’t think there is anything to be gained by continuing this discussion.
@drHall
And you didn’t answer the first part of last response.
How about it?
@ moderators,
any particular reason my comment is still awaiting moderation? There are no links.
@rwk
Assuming that Ernst got the date wrong (which is itself questionable vis. Blue Wode), that puts his credibility as a historian into question. However, he’s primarily writing as a scientists and medical doctor.
You trust reviewers to be unbiased by laying out their selection criteria in advance and sticking to it.
Citing a historical overview to demonstrate that spinal manipulation is a valid medical intervention is curious.
As for Ernst’s use of homeopathy on his wife – first that interview is from 2003 and it’s quite possible that he’s changed his mind since then. Second, the rest of the interview pretty clearly demonstrates that he believes homeopathy “works”, but it’s his definition of “works” and the “how” that is questionable. He’s pretty obviously stating (and again, in 2003) that he’s open to, if not actively believing, that it works through placebo.
Part of the problem with the chiro threads is the diversity of the field. Some are essentially indistinguishable from physiotherapists (jhawk seems to be in this group). Others are distinguishable from quacks like homeopaths and acupuncturists only because of their favoured form of intervention and woo. Everyone seems to be getting tarred with the same brush, which doesn’t mixes valid criticisms of nutjobs with invalid criticisms of people who seem to be simple flavours of manipulative therapists (again, I would suggest jhawk fits into this category). A proposed way forward would be for jhawk to admit some of his peers are loons and lunatics, and Sam Homola, Dr. Hall and much of the SBM primary contributors to admit that not all of them are loons and lunatics. I think jhawk would happily admit that vaccinations are good and chiropractic can’t cure cancer, and Drs. Homola and Hall would happily admit spinal manipulation may have some benefit in the treatment of back pain.
@WLU,
I’ve already said it, repeatedly, but I’ll say it again. I support chiropractors like Sam Homola who limit their practice to short-term treatment of musculoskeletal conditions and avoid the nonsense (like applied kinesiology, the subluxation concept, and discouraging vaccination). And SMT is a reasonable alternative for patients with garden variety low back pain who prefer not to take pills and who don’t mind multiple trips to a provider’s office.
My apologies Dr. Hall, I believe you have said that exact thing in the past. I’m wondering if jhawk agrees with you, which was more the thrust of my comment.
Cue dramatic reconciliation music?!?!?!
SBM needs dramatic music HTML tags.
jhawk,
“any particular reason my comment is still awaiting moderation? There are no links.”
There is also some randomness in which posts go to moderation.
It should be disabled. The reason I say this is that moderated posts probably never get read because everyone has moved on by the time they get posted.
I suggest reposting it.
@WLU
“A proposed way forward would be for jhawk to admit some of his peers are loons and lunatics”
“I think jhawk would happily admit that vaccinations are good and chiropractic can’t cure cancer”
Yep, I agree with both of these comments and believe I have said this before at some point as well. I also agree with Dr. Hall’s comments.
@BillyJoe
Thanks for your input. I posted it three times already and don’t want to add multiple posts of the same comment but I will try once more.
WordPress stopped me for duplicate comment. I will change it a bit. Not sure my comment is really worthy of this hassle!!
@ Blue Wode
you said: “Re your accusation of selection bias in the Ernst study, you might be interested to read Ernst and Canter’s response to that criticism following the publication of the original study:”
I assume you were mostly pointing me to this quote from the article; “The fact that four of the 16 included articles were our own simply shows that we are research-active in this area. To exclude one’s own work in systematic reviews would be woefully unscientific.”
Just for fun, lets say Ernst is not biased in his reporting and add back in the 4 studies he cited of himself in his review. There is 1 (SMT not effective) for LBP so 3 positive and 1 negative. There is 1 for neck pain which concludes SMT is not more effective than exercise- so it is as effective as exercise and the study does not compare to other Tx’s. The other 2 are for non-NMS issues.
When you look at the results from this review and even allow Ernst’s reviews of himself it still shows SMT is as effective as any other Tx for LBP and neck pain. And Ernst’s conclusion says this:”Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.” This conclusion is rather disengenous as it comlpetely contradicts the results of the study. This along with his citing of the 1977 study (mentioned earlier in this thread) of LBP patients of 3 month duration to demonstrate that chiro’s x-ray excessively leads his work to be extremely suspect and bias IMO.
“When you look at the results from this review and even allow Ernst’s reviews of himself it still shows SMT is as effective as any other Tx for LBP and neck pain”. So a 3-year post-graduate degree’s primary (and some may argue, rightfully, only treatment modality) is roughly equivalent to a couple of Tylenol for LBP. Hardly impressive and certainly not worth wasting my time looking for the few EBM practitioners when I can just tell the patient that the LBP will go away without treatment in a couple of weeks without going to the local back-cracker (or PT or MD, for that matter) 5 or 10 times.
“And SMT is a reasonable alternative for patients with garden variety low back pain who prefer not to take pills and who don’t mind multiple trips to a provider’s office.”
Sure but, Dr Hall, if each of these visits costs 40 bucks and the average chiromancer gets 5 visits (an obnoxiously low estimate) before the insurance stops covering the essentially useless treatment (at least compared to placebo or no treatment) this is going to be an awfully expensive therapy for everyone that experiences LBP.
Simply, if everyone in the US starts collecting on this “benefit” then add at least a couple billion to the annual HC budget. Hardly chump change and certainly something we could drop with affecting mortality or morbidity to any great extent.
Conwy1 could not possibly be a medical doctor or have anything to with money other than collecting his check
More stupid comments Dr Hall.
Ps Cowy1
If you are a medical doctor or soon to be you’ll make alot more than $40 a visit and do a lot less.
@ Dr. Robert:
“After all, the neck pain study showed us that pain meds, home exercise, and the deluxe, all-inclusive care package are essentially equivocal…..”
HUH? “equivocal”? Seriously?
Perhaps you read a different study? Per this study, the pain medication group had clear and profoundly poorer results.
@ jhawk
Re Ernst and bias.
Harriet Hall wrote: “…you may be surprised to know that he [Professor Ernst] learned to do manipulation as part of his training. Rather than being an “inquisitor” he was favorably inclined towards manipulation and other types of alternative medicine at first, and became disenchanted when he studied the evidence.”
That seems to me to be fair comment. For example, in The Desktop Guide to Complementary and Alternative Medicine: An Evidence-Based Approach (2006), 2nd Ed. Ernst E, Pittler MH and Wider B, in the concluding part of the chiropractic section which focuses on giving a risk-benefit assessment, it says:
Quote
“Chiropractic treatment might be helpful for low back pain, but the evidence is not convincing. In view of the lack of truly effective conventional treatment for this indication, chiropractic might therefore be worth considering for such patients. For all other indications the evidence is even less compelling. Severe adverse events may be infrequent but mild transient complaints are common.”
So, in 2006, Ernst concedes that chiropractic *might* be worth considering for *low back pain* sufferers.
However, in his 2009 paper in the International Journal of Clinical Practice, ‘Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines’, he has become far more cautious:
Quote
“It is true that serious complications occur mostly (not exclusively) after upper spinal manipulation. So the guideline authors felt that they could be excluded. This assumes that a patient with lower back pain will not receive manipulations of the upper spine. This is clearly not always the case.
Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them. And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.
The guidelines have a number of serious flaws. I contend that they over-estimated the effectiveness of spinal manipulation and under-estimated the risks of this treatment. If evaluated on the basis of the best current evidence by applying the cautionary principle, one will arrive at the following conclusion: it is uncertain whether spinal manipulation generates more benefit than harm for patients suffering from back pain.”
http://tinyurl.com/6b6nkzg
Then last year, in his co-authored update of A Systematic Review of Systematic Reviews of Spinal Manipulation in the New Zealand Medical Journal, he doesn’t condemn outright the use of chiropractic in the conclusion:
Quote
“The aim of this update is to critically evaluate the evidence for or against the effectiveness of spinal manipulation in patients with any type of clinical condition…Conclusion: Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition.”
Note the use of the words “collectively” and “convincingly”.
I’m struggling to understand how you can accuse him of bias.
@ Hall:
“The guidelines have a number of serious flaws. I contend that they over-estimated the effectiveness of spinal manipulation and under-estimated the risks of this treatment. If evaluated on the basis of the best current evidence by applying the cautionary principle, one will arrive at the following conclusion: it is uncertain whether spinal manipulation generates more benefit than harm for patients suffering from back pain.”
http://tinyurl.com/6b6nkzg”
Seriously?
UMMMM……Your link is to a blog……..
Can you please provide an objective, preferrably indexed, cite?
This is, after all, supposed to be a “science based” site…..?
rwk, I wasn’t aware that chiropractors were free, thus entitled to criticize MDs for charging for their services. Fantastic, I’ll start going immediately since all it will cost me is time.
Also, criticizing a doctor for charging for their services doesn’t magically make chiropractic care more effective. You’ve combined two logical fallacies, ad hominem (attacking the person rather than the argument) and false dilemma (assuming that doctors can either give an honest opinion or make money). You’ve mixed in a bit of tu quoque as well I think (doctors and chiropractors both charge money, therefore both have equally valid treatment options). I wonder if your skepticism also applies to chiropractors themselves, since they charge money for their services (but have a significantly less extensive science- and evidence-base to their practice despite many stating they can treat just as many conditions as a doctor).
Nobs – how about this link, is this indexed enough for you?
http://www.ncbi.nlm.nih.gov/pubmed?term=19689486
By the way, there is a trick somewhere in my post. A shiny dollar to whoever finds it!
@ nobs
I supplied that link because I couldn’t find a link to the full text online. Hopefully, though, you’ll be able to access the full text via WilliamLawrenceUtridge’s link above.
BTW, I have a copy of the full text and I quoted the above passage because it is the most relevant to the current discussion. Let me know if you think differently once you’ve read it in full.
Aw, BlueWode gave away the trick – that was indeed a pubmed-indexed article he linked to (no full text however, google scholar doesn’t show any). I’m keeping my shiny dollar, mostly out of pique.
@nobs,
It was a typo. He meant “equivalent.” And the study showed that home exercise was as effective as manipulation.
@Cowy1,
I was talking about what works. Cost effectiveness is a different subject altogether. Chiropractors have claimed that their treatments are more cost-effective; but I question that, especially considering that patients are often persuaded to return for maintenance adjustments and for conditions where manipulation is not effective. The most effective treatments are usually cost-effective in the long term.
@WilliamLawrenceUrtidge
A commenter who talks about “chiromancers” ripping off the health care budget for charging $ 40 a visit ?
Why are you making my comment out to be so complex ?
Please re-read the tone of the post I commented on.
@ Blue Wode
Re: Ernst and bias
I have already pointed out 2 instances of bias. His 2006 review of reviews conclusion completely contradicts the actual results of the paper. This is either a monumental mistake, bias, or seriously flawed research-take your pick. Here is a more formal review of his 2006 article. http://chiromt.com/content/14/1/14
“Then last year, in his co-authored update of A Systematic Review of Systematic Reviews of Spinal Manipulation in the New Zealand Medical Journal, he doesn’t condemn outright the use of chiropractic in the conclusion:”
I can not get to this article and will not take his conclusion at face-value for reasons I have mentioned previously.
“Quote
“The aim of this update is to critically evaluate the evidence for or against the effectiveness of spinal manipulation in patients with any type of clinical condition…Conclusion: Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition.”
Note the use of the words “collectively” and “convincingly”.”
This conclusion is the same conclusion he wrote in the 2006 article with the added word convincingly. I can only take this to mean that he actually found more evidence for SMT in this review than the 2006 review, which I have shown that the results actually favor SMT and are in direct contradiciton to his conclusion.
@Cowy1
“primary (and some may argue, rightfully, only treatment modality)”
This comment is ridiculously misinformed to put it nicely. What about chiro’s training in exercise prescription, Mckenzie, myofascial release, any number of pt modalities, postural retraining, stability training, mobilization, stretching techniques, PIR, PNF, etc.
“when I can just tell the patient that the LBP will go away without treatment in a couple of weeks without going to the local back-cracker (or PT or MD, for that matter) 5 or 10 times.”
I wish I could be in the treatment room when you tell this to your first LBP with a 10/10 ops, severely guarded ROM, unable to work, and barely able to get out of bed. This is the exact moment when the pt leaves your office, crosses the street and goes to the chiro. By the way, a majority of patient’s have already taken Tylenol and have had sx lasting longer than 2 wks by the time the come see us.
@ Dr Hall,
“I was talking about what works. Cost effectiveness is a different subject altogether. Chiropractors have claimed that their treatments are more cost-effective; but I question that, especially considering that patients are often persuaded to return for maintenance adjustments and for conditions where manipulation is not effective. The most effective treatments are usually cost-effective in the long term”.
We’re in agreement here; the cost-effectiveness part is just kind of interesting.
For example, the best-case scenario here is that, if you spin the data just right and ignore crappy study design, a “trial” of SMT is roughly equivalent to a $4 bottle of Tylenol for uncomplicated LBP. Not superior, probably not any safer and it can’t possibly be any cheaper. Certainly, if I had a 3-year post-undergrad degree I’d want a little more bang for my buck, at least for my own self-respect.
Considering the majority of chiropractors still believe in the subluxation (or whatever new name they thought up for it) so they will treat pretty much anyone with anything while ignoring the quasi-legitimate uses for SMT why should we refer to them at all? Gives most of the legitimacy they don’t deserve, at least based on their practices.
Predictably, the chiros here will probably start screaming about how deadly Tylenol is after this post.
@ jhawk
You are failing to address the real problem. Even if you were correct about Ernst’s alleged bias, you’d still have to get past the lack of evidence-based standardisation in chiropractic (the topic of Dr Homola’s blog post above):
Quote
“Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them. And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.”
http://tinyurl.com/6b6nkzg
What’s being done to ensure that chiropractic patients aren’t ensnared by chiropractic quackery?
I think something has been missed in the criticism of Ernst’s studies, and it speaks to the purpose of this blog. Evidence can be found to support any CAM treatment, but most of that evidence is compatible with what you would expect to find when an ineffective treatment is tested. Ernst is looking for strong, credible, convincing evidence, and he’s not finding much.
Personally, I don’t take a chiropractor’s criticism of a MD PhD’s reaearch with over 600 (or is it 700?) publications very seriously. Especially when said research shows that chiropractic care is …. underwhelming.
Anyone who has LBP that would respond to a $ 4 bottle of tylenol like Cowy1 states is unlikely to be in any of our offices anyway.
This is the only systematic review I could find for “myofascial release”:
http://biblio.physiotek.com/sites/biblio.physiotek.com/files/myofascial.pdf
@rwk, @jhawk:
This is M.D.s are so critical of chiropractors:
http://www.youtube.com/watch?v=0zRhUmgnIQM
Looks like this conversation has taken a turn towards the unproductive. My better judgement is telling me to stay out of it, but I have never been a very good listener.
First I just want to point out that many on this site seem to be so bias against chiro that they loose their ability to argue convincingly and effectively. The arguments seem to degrade into “I am going to disagree with anything a chiro supporter says because I don’t like them.” This leads to an unproductive conversation and the valid, well supported, concerns of those who question the tenants of chiro get lost in these non-scientific arguments.
There are some chiros who attempt to be science and evidence based and they treat very similar to PTs (this includes SMT). If we are going to have a productive conversation about a specific topic like SMT, then we need to drop our biases against a profession and talk scientifically and objectively about SMT.
My reading of the literature is that using SMT for long term chronic management of low back pain is poor practice. However, one can make a convincing argument that SMT is effective for short term treatment of acute and subacute low back pain. No other intervention that I have as a PT can give me such drastic results in such a short period of time. By drastic I mean at least a 50% reduction is disability after 1-3 sessions. And yes, there is evidence to back that up.
Now it is justified to ask about cost effectiveness and comparison to other treatments. But bottom line we don’t know what the best treatment is and SMT used wisely seems to be a logical choice.
We spend billions of dollars on low back pain a year and a very small percentage of it is from SMT. In fact, there is good data to suggest that high quality PT treatment (which includes SMT) can save a lot of money. If I provide SMT and get a patient better 3 days faster, that is 3 days less out of work and they are less likely to see there MD and get an xray/MRI or get sent to a surgeon. The large cost of low back pain treatment comes from imaging, long term use of medication (which makes as much sense as long term use of SMT) and surgery. The kicker is many of these medical interventions (especially complex spinal fusions) are unneeded and don’t lead to better outcomes.
@arufa: I’m ignoring most of what you wrote because I don’t have time to be involved in another argument on the internet, but: would you say that you can treat back pain just as well, if not better, than chiropractors, without ever having to utilize X-ray?
Yup!
@arufa, I 100% agree with you.
Dr Robert says
@arufa: I’m ignoring most of what you wrote because I don’t have time to be involved in another argument on the internet, but: would you say that you can treat back pain just as well, if not better, than chiropractors, without ever having to utilize X-ray?
arufa says
Yup!
Dr Robert says
@arufa, I 100% agree with you.
Well I guess that settles it,you both win.
And for some more childishness- I’ll bet my dad can beat up both your dads.
This is scientific based medicine.
@rwk, http://drvittoriarepetto.wordpress.com/2009/05/23/what-is-an-ileo-cecal-valve-and-how-is-it-related-to-your-digestive-health/
DrRobert
What is your point with the URL?
rwk?
Not sure what part of DrRobert’s and my exchange was childish. I made a statement (a lot of which was expressing my opinion, anyone is welcome to agree or disagree) and then he asked me a simple question and I answered it.
He maybe could have asked the question in more neutral language like “can patients with low back pain be treated with SMT or by a PT effectively without x-rays”. I think it is pretty well established that best practice is to only perform imaging on those patients (with LBP) who are at an elevated risk for nasty things (or maybe to help guide surgery). In no way do findings on an x-ray or MRI help guide the interventions we can provide as PTs and Chiros. They may help with referral decisions but beyond that imaging does not improve outcomes and it does not predict which conservative interventions are most likely to help a patient. This statement is not simply my opinion it is support by the evidence.
And for the record, is the bet that your dad can beat up both our dads at the same time or in separate altercations? j/k
@arufa
The childishness bit was mainly directed at DrRobert,the anti-chiropractic militant. You said exactly what he was looking for. He’s trying to pit PTs against DCs whom can be rivals. You’ve likely given him fodder for his next blog article.
I’m starting to suspect if he actually is a MD, he’s not a very busy one( or is retired ) to devote his life to the extinction of chiropractic. When does he see patients, make hospital rounds,etc? Most MDs I know don’t have time to do such things.
X-rays and other imaging have their place,there are guidelines. I’d rather be able to take or order them on my own
when I think they are clinically necessary than to have to convince DrRobert to do it for me.
If I said my interventions were better than PTs,that would be just as silly to you,right?
Don’t forget to look at DrRobert’s latest blog on Myofascial Release and Rolfing. A grade school student couldn’t have done much worse at investigative journalism.
Myofascial Release is not Rolfing and vice-versa. Not even close. I’d bet there are way more OTs and PTs than DCs doing Barnes’ ( who as you know is a PT ) Myofascial Release. Yet he only mentions DCs and NDs.
@ Blue Wode
” Thus many, if not most back pain patients receive upper spinal manipulations.”
Is there any evidence behind this comment?
“It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.”
This would only be the case if there is solid evidence for the above comment.
“What’s being done to ensure that chiropractic patients aren’t ensnared by chiropractic quackery?”
Many of the schools have added research departments, evidence based practice courses and are teaching the quackery from a historical perspective. UWS being a prime example. Hopefully this will continue and seep into every chiro school.
@DrRobert
“Personally, I don’t take a chiropractor’s criticism of a MD PhD’s reaearch with over 600 (or is it 700?) publications very seriously. ”
Ahhh, the old argument from authority game. It is not just my criticism of the Ernst review, did you read the critique of his review I posted earlier? It includes an MD, PhD (I matched your authority) and will trump it with multiple other PhD’s. Their conclusion: The conclusions by Ernst and Canter were definitely not based on an acceptable quality review of systematic reviews and should be interpreted very critically by the scientific community, clinicians, patients, and health policy makers. Their conclusions are certainly not valid enough to discredit the large body of professionals utilizing spinal manipulation.
@HH
“Ernst is looking for strong, credible, convincing evidence, and he’s not finding much.”
Does any treatment for LBP and neck pain have “convincing” evidence? I think we both understand why there is not any robust evidence so I will not belabor these points again.
@jhawk,
“Does any treatment for LBP and neck pain have “convincing” evidence?”
When I said Ernst was looking for convincing evidence and not finding much, I was referring to all of his CAM investigations, not specifically to manipulation, but…
Yes. There is convincing evidence for analgesics, exercise, avoidance of bedrest, etc. There is convincing evidence that manipulation is equivalent to other treatments for certain limited circumstances, but some people are less convinced than others because of the difficulties in separating the specific from non-specific effects of treatment and because of other factors affecting the quality of the evidence.
There is no convincing evidence that manipulation is superior, and there are legitimate concerns about safety, time commitment, and pseudoscientific adjuncts frequently found in chiropractic offices. There is no convincing evidence that “subluxations” exist.
@ jhawk
Re the evidence behind this Ernst comment:
Quote
“Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment.”
Reference (11) is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62.
http://tinyurl.com/7gknxhy
Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and references Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.
@ jhawk
I don’t have access to the Coulter et al paper, but here’s what Dr Homola said about it in a previous blog post:
Quote
“When the RAND (Research and Development) organization published its review of the literature on cervical spine manipulation and mobilization in 1996, it concluded that only about 11.1% of reported indications for cervical spine manipulation were appropriate…Since about 90% of manipulation in the United States is done by chiropractors (1) who use spinal manipulation as a primary treatment for a variety of health problems, neck manipulation is more problematic among chiropractors than among physical therapists and other practitioners who use manipulation only occasionally in the treatment of selected musculoskeletal problems…A physical therapist trained in the use of both manipulation and mobilization for musculoskeletal problems would be less likely to use manipulation inappropriately than a chiropractor who routinely manipulates the spine for “the preservation and restoration of health.”(15)…According to the Association of Chiropractic Colleges (ACC), “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.” (15) Chiropractors who are guided by this vague paradigm (more of a belief than a theory) often manipulate *the full spine of every patient* for “subluxation correction”. Few chiropractors specialize in the care of back pain and other musculoskeletal problems, and only a few have renounced the chiropractic vertebral subluxation theory…Whatever the incidence of stroke per number of neck manipulations might be, this risk is greater per patient among chiropractic patients who may be manipulated many times for “health reasons” and who may be manipulated regularly for ‘maintenance care’.”
http://www.sciencebasedmedicine.org/?p=1037
@ jhawk
Also, it’s worth noting what Dr Homola has to say here:
Quote
“There is good reason to believe that most chiropractors are adjusting the spine to correct vertebral “subluxations.” According to Job Analysis of Chiropractic (National Board of Chiropractic Examiners,2005), 96.2% of chiropractors in the United States use a diversified technique that includes an average of six different techniques for full-spine adjusting. About 26% of chiropractors include the Palmer upper cervical/HIO technique among their adjustive procedures. A small percent–1.2%–specialize exclusively in upper cervical techniques, adjusting the atlas as a primary method of treatment. A survey published by Ohio Northern University, How Chiropractors Think and Practice (2003), 88.1% of North American chiropractors believe that the term “vertebral subluxation complex” should be retained in defining the practice of chiropractic; 89.9% believe that a chiropractic spinal adjustment should not be limited to musculoskeletal conditions. The “Chiropractic Paradigm” formulated by the Association of Chiropractic Colleges in North America states that “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.” Most state laws, in keeping with the consensus of chiropractic colleges, define chiropractic as a method of correcting vertebral subluxations to restore and maintain health. Since surveys indicate that most chiropractors are using a diversified or specialized technique to adjust subluxations in the spine, and since most chiropractors believe that vertebral subluxations can affect general health, it’s logical to assume that most chiropractors routinely adjust the spine to “restore and maintain health.”… Many chiropractors dance around the [subluxation] theory, saying one thing and doing another, that is, they do not treat disease; they simply make spinal corrections to relieve interference with the body’s healing powers. The patient might be led to believe that a chiropractic adjustment for neck or back pain might also provide an inadvertent or indirect cure for an organic ailment, thus baiting the patient for spinal care that might help whatever ails them.”
See http://tinyurl.com/6wjq9f9
By the way, in the UK around 60-70% of chiropractors admit to chiropractic philosophy (subluxation theory) being important to their practices, and I understand that the figure is higher in Australia and New Zealand.
@ jhawk
Re my asking what’s being done to ensure that chiropractic patients aren’t ensnared by chiropractic quackery, you wrote: “Many of the schools have added research departments, evidence based practice courses and are teaching the quackery from a historical perspective. UWS being a prime example. Hopefully this will continue and seep into every chiro school.”
Teaching the quackery from a historical perspective despite the Association of Chiropractic Colleges claiming “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation”?
I’m not convinced. Besides, my question was in the present tense and addressed an enormous, problem with current chiropractic practices – i.e. how are the patients of licensed chiropractors in the 30-60 age group, of whom 60-90% (as noted above) operate practices rooted in pseudoscience, being protected from risking their time, money and lives on chiropractic quackery?
Re: chiropractors abandoning the subluxation.
Got the hard-sales push from one of Chicagoland’s larger chiropractic practice-management firms, ChiroOne, while picking up some Goose Island after clinic at the local grocer.
DC – “Want to get your spine checked for nerve interference?”.
Me – “Not really”.
DC – “We’ve got a great deal right now to keep your spine healthy”.
Me – “Not interested”.
DC – “When did you last get your spine checked?”.
Me – “A long time ago”.
DC – “More than a year?”.
Me – “Yes”.
DC – “You should really get it checked to make sure you don’t have any subluxations that could cause all kinds of bad things to happen to you”.
Me – “I’ll be fine, thanks”.
He then proceeded to start bugging the next guy in line. I was polite but these things are irritatingly frequent in my neck of the woods.
These people have 50+ “clinics” in the greater Chicago area alone, many of them filled with young grads. The chiropractor hassling me couldn’t have been 30. Sort of blows a hole in the “us new science-based grads don’t believe in the subluxation” theory.
@cowy1
1.Why didn’t you tell him off and embarrass him? It’s your duty to SBM
2.What does Goose Island have to do with it ?
3.after Clinic as in “Student Clinic”?
BTW It’s embarrassing to me. The owners of Health Source make all the money not the grunt doing the canvassing.
The medical counterpart happens at corporate health screenings, hospitals and “clinics” that are basically doing the same thing: Looking for more patients. Your future salary will depend on it.
http://www.comhs.org/community/screenings.asp
I meant ChiroOne not Health Source
@rwk
#1
Not my place, not in the middle of the grocery store. Besides, as you admit, standing there in front of the discount pastries and harassing people to get your spine checked is probably embarrassing enough for someone with a “doctoral” degree.
#2
It had been a long, crappy day and I needed a drink. It was on sale so I bought that instead of Guinness.
#3
Sort-of; I’m an M3 on a core rotation of which the clinic blows terribly, at least from my perspective.
There is no medical counterpart to “subluxation” screening at a grocery store.
Besides, and this should be obvious to you, checking for hypertension or hyperlipidemia has a proven mortality benefit; checking for invisible spinal lesions does not. In case you missed it, they were offering a “deal” (reduced rate) where you pre-pay for some number of visits to get your back whacked back into line.
Re HealthSource,
Looks like the exact same scam as ChiroOne except the cancer has spread across the entire country. The fact that the state chiropractic boards aren’t investigating these con-artists for out-and-out fraud is unbelievable.
@rwk
“your future salary will depend on (health screenings)”.
LOL, I have yet to see any MD hurting for patients so badly that they feel the need to stand next to the deli counter at a grocery store trolling for business.
Perhaps we need to consider legislation like has evidently been passed in Mexico:
http://hosted.ap.org/dynamic/stories/L/LT_MEXICO_FAKE_MEDICINES?SITE=FLPET&SECTION=HOME
Anyone know how much a Chiropractor’s malpractice insurance is?
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[...] attempt to overcome charges of promoting quackery by substituting the word ‘subluxation’ with other terminology. The SCA, however, seems content to make reference to ‘subluxations’ on its website, although [...]