Dec 11 2009
The End of Chiropractic
An article written by 3 chiropractors and a PhD in physical education and published on December 2, 2009 in the journal Chiropractic and Osteopathy may have sounded the death knell for chiropractic.
The chiropractic subluxation is the essential basis of chiropractic theory. A true subluxation is a partial dislocation: chiropractors originally believed bones were actually out of place. When x-rays proved this was not true, they were forced to re-define the chiropractic subluxation as “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.” Yet most chiropractors are still telling patients their spine is out of alignment and they are going to fix it. Early chiropractors believed that 100% of disease was caused by subluxation. Today most chiropractors still claim that subluxations cause interference with the nervous system, leading to suboptimal health and causing disease.
What’s the evidence? In the 114 years since chiropractic began, the existence of chiropractic subluxations has never been objectively demonstrated. They have never been shown to cause interference with the nervous system. They have never been shown to cause disease. Critics of chiropractic have been pointing this out for decades, but now chiropractors themselves have come to the same conclusion.
In “An epidemiological examination of the subluxation construct using Hill’s criteria of causation” Timothy A. Mirtz, Lon Morgan, Lawrence H. Wyatt, and Leon Greene analyze the peer-reviewed chiropractic literature in the light of Hill’s criteria, the most commonly used model for evaluating whether a suspected cause is a real cause. They ask whether the evidence shows that chiropractic subluxations cause interference with the nervous system and whether they cause disease. The evidence fails to fulfill even a single one of Hill’s nine criteria of causation. They conclude:
There is a significant lack of evidence in the literature to fulfill Hill’s criteria of causation as regards chiropractic subluxation. No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability. [emphasis added]
While some chiropractors have rejected the subluxation paradigm, it is supported by the major chiropractic organizations and schools and is considered essential by the great majority of practicing chiropractors. In two recent studies cited in the Mirtz et al. article, 98% of chiropractors believed that “most” or “many” diseases were caused by spinal misalignments and over 75% of chiropractors believed that subluxation was a significant contributing factor to 50% or more of visceral disorders (such as asthma and colic), an implausible idea that is not supported by any evidence whatsoever. Simon Singh was sued for saying so when he correctly referred to “wacky ideas” and “bogus treatments.”
When chiropractors use spinal manipulation therapy for symptomatic relief of mechanical low back pain, they are employing an evidence-based method also used by physical therapists, doctors of osteopathy, and others. When they do “chiropractic adjustments” to correct a “subluxation” for other conditions, especially for non-musculoskeletal conditions or “health maintenance,” they are employing a non-scientific belief system that is no longer viable.
As the authors of this paper indicate, the subluxation construct must go. And without the subluxation, the whole rationale for chiropractic collapses, leaving chiropractors no justifiable place in modern medical care except as competitors of physical therapists in providing treatment of certain musculoskeletal conditions.
The absence of publicity is astounding. This study has not even been noticed by the media. Where are the sensationalist journalists who usually exaggerate the news and make up provocative headlines? They could be trumpeting “Chiropractic Is Dead!” “Chiropractors Admit They Were Deluded by False Beliefs” “Simon Singh Vindicated: Chiropractic Really Is Bogus” and so on. Chiropractors demolishing the basis for chiropractic ought to be big news.
When the news finally gets out, I predict contorted efforts at damage control. Chiropractors will claim that it is not appropriate to apply the Hill criteria in this way, and that the criteria are not a valid test of causality. That’s a straw man: not even Hill suggested that the criteria were a definitive test. They are more of a guide to thinking about causality. Edzard Ernst, the world’s first professor of complementary and alternative medicine, finds them useful. He has recently applied Hill’s criteria to neck manipulation as a cause of stroke: he found that it fulfilled all but one of the criteria for causation. (Article pending publication). Chiropractors won’t like that either.
I predict the authors of this paper will be attacked as traitors by their colleagues. And I predict my own comments will be misinterpreted as some kind of personal vendetta and I will be called ugly names. I also predict that no one will dispassionately offer acceptable scientific evidence to contradict the findings of the paper (They can’t, because there isn’t any!). The first comment (and so far the only comment) on the Chiropractic and Osteopathy website offers no counter-evidence but rather calls for not letting evidence-based protocols overshadow clinical experience.(!) The Weekly Waluation of the Weasel Words of Woo could have a lot of fun translating that statement.
If chiropractors reject the conclusions of the Mirtz et al. paper, the burden of proof falls on them to show
- that the subluxation can be objectively demonstrated,
- that it does cause interference with the nervous system, and
- that it does cause disease.
They have failed to do so for 114 years.
Most chiropractic research falls under the category of Tooth Fairy Science. Instead of doing good basic research to examine the subluxation construct as a falsifiable hypothesis, they blindly forged ahead, implemented it for diagnosis and treatment, and studied various aspects of its clinical use.
The chiropractic emperor has no clothes, and now even some chiropractors have realized that. This study should mark the beginning of the end for chiropractic, but it won’t. Superstition never dies, particularly when it is essential to livelihood.
181 Responses to “The End of Chiropractic”
Na-a-a-ah. They’ll do what the naturopathologicals did in Ontario, Canada: they’ll pass legislation that will allow them to prescribe drugs. Who says you need all those years of education, internship and residency?
Besides, we all know that disease is actually caused by deviant phlogiston. 500mg Keflex po bid should whack that phlogiston right back into shape. And if that doesn’t work we have colonic irrigation available in the next room.
One stop shopping for all you healthcare needs.
I imagine the Chiropractic associations won’t be trumpeting this story to the papers – so perhaps it falls to a group like Science Based Medicine to issue its own press release?
Perhaps the Institute for Science in Medicine should take up this news item and make it big. That reminds me… Anyone knows what happened to the Simone Singh lawsuit, finally?
‘Scuse me for being a party pooper but this is a review paper, not a breakthrough. 4 guys sat in front of their computers, typed in a few keywords and attempted to pull up as many relevant research articles as they could find. And guess what. They found less than 10 articles that tried associating sublexation with disease, and they were all crappy or useless. wow. I’m just shocked. Really? That’s news worthy? Frankly, any SBM contributor could have written this article in a weekend.
to be sure, i gave the article a read. to no discredit, I thought perhaps the interpretation was perhaps a bit heavier than the conclusions presented. However, and I scoffed quite loudly, the stated conclusions are painfully clear, in addition to HH’s quoted text. Sorry, I am a skeptic to a “fault”
CONCLUSION: There is a significant lack of evidence to fulfill the basic criteria of causation. This lack of crucial supportive epidemiologic evidence prohibits the accurate promulgation of
the chiropractic subluxation.
I will surely be doing my best to circulate this. Can we expect a scourge of chiros jumping onto the sbm site and ad homineming/strawmanning it to death?
[...] Medicine reviews a research paper in a chiropractic journal showing that a key chiropractic claim—treatment of [...]
draal,
starting the count early.
“this is a review paper, not a breakthrough.”
those terms are mutually exclusive?
“They found less than 10 articles that tried associating sublexation with disease, and they were all crappy or useless.”
I believe that is exactly the point. burden of proof squarely rests on who now?
I am not new to reading research, but fairly new to critiqueing it. Could anyone explain to me what is Hill’s criteria of causation or at least point me to a resource to learn about it?
[...] Hey, guess what, turns out chiropractic is still bullshit. As Harriet Hall points out, the history of the practice is 114 years of failing to demonstrate any [...]
[...] who are functioning without much evidence to support them. Harriet Hall describes that topic in The End of Chiropractic. In “An epidemiological examination of the subluxation construct using Hill’s criteria of [...]
For the Hill’s criteria, the article references the following book: Jenicek, M. Foundations of Evidence-Based Medicine. Partheon Publishing. Boca Raton. 2004.
I’ve seen calls for a skeptical chiropractor to write for SBM. I think we just found four of them.
—————————
“those terms are mutually exclusive?” -What was that about the burden of proof? A nice example is in order.
@Kausik
Simon Singh’s appeal is getting very interesting. Jack of Kent has the details;
http://jackofkent.blogspot.com/2009/12/bca-v-singh-making-legal-history.html
[...] Read the original: Science-Based Medicine » The End of Chiropractic [...]
Couldn’t agree more. I “sublux” my knuckles all the time, and really I’m doing nothing but moving some nitrogen in and out of solution. Makes the same pop as what a chiropractor does in the spine.
Chiropractic as a cure for a wide variety diseases makes no physiologic sense, and not surprisingly, cannot be proven to be effective.
[...] From Around The Blogosphere 12.11.09 1. Chiropractic debunked…again – The vast majority of chiropractors believe that most disease is caused by spinal [...]
[...] be able to fix anything, because everything was related to the nervous system. Well there’s a new post on the Science-Based Medicine blog that adds a measure of sanity to the whole chiropractic [...]
The importance of the paper is not in showing that there is no evidence for the chiropractic subluxation. We knew that a long time ago, and we have written about it rather extensively. For instance, see http://www.sciencebasedmedicine.org/?p=59 The importance is that it was published by chiropractors in a chiropractic journal. When the emperor himself realizes that he has no clothes, that is news.
I have no problem with anyone against chiropractic, but the fact that this article just says how they “think” chiropractic is wrong, without showing anyone scientific articles that have proved it to be wrong.
This article just said….blah blah blah…chiropractic is wrong and doesn’t work just because a few people said so. Ok….so medical doctors don’t work either because a couple people said so. I have no problem with a agrument, but the fact that there is no argument says nothing. Where is the proof? Scientific research articles that say it isn’t so. What about all the pub med articles that have research for it? Please….how about you make a statement with scientific articles against something against science.
There is another very interesting article oat Chiropractic & Osteopathy: http://www.chiroandosteo.com/content/17/1/10
Why do ineffective treatments seem helpful – a brief revue. It states: “I conclude that healthcare will grow to full potential only when judgments of clinical efficacy routinely are based in properly scientific, placebo-controlled, outcome analysis.”
That article could have been on SBM.
Now i can’t wait for a Homeopathic Journal to review the “Science” of their treatment. Unfortunately i doubt that we will see any of this.
“evidence-based method also used by physical therapists, doctors of osteopathy, and others”.
Does this mean that osteopathy is definitely on the side of the angels?
rmgw on 12 Dec 2009 at 5:24 am “Does this mean that osteopathy is definitely on the side of the angels?”
In the USA, osteopaths are equivalent to MDs. Outside the USA, they are as quacky as chiropractors.
Help out a laymen; I am interpreting correctly that chiropratic as a treatment for spine issues is still considered valid and potentially useful but the obvious “woo” stuff is (of course) total BS? I used to go for back problems and found the treatment very helpful, thus my asking.
Ah, sweet schadenfreude.
LabRat:
If you’re lucky, you get a good physical therapist and/or masseur(/se) as a chiropractor. There’s a greater chance of injury, since they think they’re doing imaginary things, but they can massage and stretch muscles and joints to decent effect.
@TheLabRat, Go to http://www.quackwatch.org and subsidiary http://www.chirobase.org Also, gasp, get hold Samuel Homola’s book “Inside Chiropractic.
Rule #1, never let a chiro touch your neck.
There is some evidence that chiro manipulation can be as effective as massage and other, standard treatments for short-term low back pain.
If two or three visits don’t do the job- try something else.
Don’t get regular check-ups or “maintenance” adjustments.
Tigerpython,
I suggest you go back and read the post again. From your comments it sounds like you either didn’t read it all or didn’t understand it.
We are talking about evidence, not opinion. The Mirtz article reviewed all the published literature – all the studies that were both pro and con. They didn’t say they think chiropractic is wrong. They said there is no evidence in the literature to support the subluxation construct as causal for disease. It’s not a matter of “proving” chiropractic wrong. The burden of proof is on chiropractors to show that the chiropractic subluxation causes disease and that manipulation reverses it.
I was wrong when I said the article was written by 4 chiropractors. The lead author wrote to inform me it was actually 3 chiropractors and a PhD in physical education. I have edited the post to reflect the correct information.
“If two or three visits don’t do the job- try something else.
Don’t get regular check-ups or “maintenance” adjustments.”
That’s my thing. I’ve never been but I know lots of (mainstream) people who swear by chiropractor care. My question is… then why do you keep having to go back? They’ve got to be making a boatload of money.
Hey, TheLabRat. Good question. Yes, there is some evidence that spinal manipulation therapy (SMT) can be useful for treating back and neck pain, and I have certainly experienced temporary relief from such adjustments myself from time to time. However, even if SMT were highly effective and completely safe, one of Dr. Hall’s key points in this article would still be quite important: without subluxation theory, chiropractors have “no justifiable place in modern medical care except as competitors of physical therapists in providing treatment of certain musculoskeletal conditions.”
And even if SMT works for spinal pain, and even if it’s safe, consumers are still faced with the challenge of obtaining the service from one of the few chiropractors our there who has clearly renounced subluxation theory. Even if SMT works, do you really want to seek care from an irrational professional clinging to beliefs that have been under siege for decades? Beliefs that many of their own colleagues have harshly criticized?
Unfortunately, SMT is not highly effective or entirely safe. At best, it is only moderately effective, and can cause rare but serious complications.
There are serious concerns about the safety of neck treatments, as Joe said. Although no one believes that it’s common, the evidence pretty clearly shows that neck adjustment may cause strokes. I have an article with an interesting perspective on the neck safety issue, and it’s also a good example of why it’s important to seek care only from rational and well-trained health care professionals:
“What Happened To My Barber?”
http://SaveYourself.ca/barber
@Harriet Hall on 12 Dec 2009 at 11:57 am
I made the same mistake, the author’s credentials were not clear. In this case, the distinction is of consequence to your analysis. If just three chiros publish evidence that the subluxation is unsupported, it is news.
Joeon 12 Dec 2009 at 2:11 pm
@Harriet Hall on 12 Dec 2009 at 11:57 am
I made the same mistake, the author’s credentials were not clear. In this case, the distinction is of consequence to your analysis. If just three chiros publish evidence that the subluxation is unsupported, it is news. [italics added]
Dang, that should have read “no consequence.”
As a chiropractor, it is understandable that this article is offensive to me, and I would find it more disturbing if it wasn’t so laughable. The subluxation theory is, just that, a theory. While I personally don’t use the term in my practice because it doesn’t fit with my paradigm (I guess I must be part of the 2%…..c’mon please), the evolution away from this term doesn’t have much of an implication. The onus on investigators is to show that the treatment is effective and outweighs the risks, not necessarily why the treatment is effective. What some chiropractors believe doesn’t necessarily mean they practice using this belief system. A family physician may believe that their physical exam skills can detect the slightest abnormality, but in reality they use a variety of far more objective methods than auscultation or percussion to determine a diagnosis. In the real world, away from your unscientific ‘scientific’ crusade, the vast majority of chiropractors see clients every day for back pain. Spinal manipulative therapy is just as effective or more effective as other therapies (such as NSAIDS) that treat the same problems with much less side effects. This effectiveness and safety is well documented through multiple reviews and ignoring it is committing the same scientific sins as the chiropractors who tell their clients that manipulation will cure every ailment. The evidence supporting SMT is there for all to see, but our profession continues to be attacked by those who ignore the evidence. The subluxation theory originated as a way of trying to explain why SMT works as well as it does. It has since evolved through science and while still incomplete has made great strides. In my practice, I use SMT to help people with back pain, along with the vast majority of chiropractors. Like many of my colleagues, I do my very best to help my clients to improve their overall mobility, posture, ergonomics and core strength. I use therapeutic exercise with most of my clients to rehabilitate from back injuries. This is the modern chiropractic that uses the best science available to do whatever we can to help our clients. While this practice model is very common in the real world, it often gets ignored by those with an agenda who have very limited understanding of this profession and who use far more questionable science than those they are attacking.
chiro1,
Perhaps you missed the part of my post where I said “When chiropractors use spinal manipulation therapy for symptomatic relief of mechanical low back pain, they are employing an evidence-based method also used by physical therapists, doctors of osteopathy, and others. When they do “chiropractic adjustments” to correct a “subluxation” for other conditions, especially for non-musculoskeletal conditions or “health maintenance,” they are employing a non-scientific belief system that is no longer viable.
Since the licensing laws define chiropractic as the diagnosis and treatment of subluxations, it is not accurate to say what you are doing constitutes “chiropractic.” You have rejected the underlying basis of “chiropractic” and are simply doing many of the same things physical therapists do.
According to the studies by chiropractors cited in the Mirtz study, it appears that at least 98% of chiropractors believe the subluxation causes most or many diseases. Can you provide evidence to contradict that? What is the actual percentage of practicing chiropractors who reject the subluxation construct?
The Mirtz et al. article was of rather poor quality, to say the least. Surely if an article of this quality supporting chiropractic subluxation were to be published it would be strongly criticized by “SBM”. Having your cake and eating it too?
Having been a chiropractor I can say that subluxation as the chiropractor’s reason for being is real. At least that seemed to be the mainstream in 2005 when I got out. With all the professional infighting, lack of a rigorous evidence indicating the need for chiropractic care beyond low back pain, and the need to be a marketing/sales whiz just to make it, I said bye-bye to the “profession”. I think Dr. Hall’s post accurately shows the chiropractic dilemma.
[...] Hall kommenterer hos Science-Based Medicine at det etterlater kiropraktikk som bare nok en form for fysioterapi. Hvilket vel er hva det [...]
Harriet,
I did not miss that part in your post, but it followed “death knell” for chiropractic which is ridiculous based on the citations you provided and assertions made. Furthermore, you do not provide any evidence that even any chiropractors perform manipulation or adjustments to treat non-musculoskeletal conditions directly.
My response was simply to bring some reality into the argument. In reality, if you walk into most chiropractic offices, one of the first questions will likely be “where is the pain?”. A focused exam will follow to attempt to determine the likely source of the pain. Range of motion is determined, orthopedic and neurological testing is performed, and we palpate the spine. In order to determine where to manipulate we attempt to locate joint dysfunctions (others may call it subluxations), which is basically where the spinal pain is located and may be tender to palpate, the joint may feel fixated, and there may local swelling, muscle tightness etc. If the low back hurts, and there are no contraindications to SMT, we will very likely seek consent to try SMT, at least for a trial of care anyway. Determining the joint dysfunctions or other spinal conditions, simply allow the practitioner to specify their treatment. For example for low back pain, is it L1/L2 or L5/S1 that is creating the most problems? This is tough to objectify and is tough to study, although we and others have been trying to do better. But, if the patient has low back pain we will be treating their low back.
If a chiropractor attempts to educate their patient that joint dysfunctions or ‘subluxations’ are the cause of other diseases and especially if they treat specifically for this, then they are probably not acting appropriately. But your citations do not address how many chiropractors do this. While I question, the Mirtz 98% figure, it doesn’t really matter what chiropractors believe, it matters what we do. And what we do, is help millions of people with back pain and help them to achieve better spinal health with other methods beyond manipulation. Again, please do not ignore the evidence that SMT is as or more effective and safe than comparable therapies for back pain. I am a science-based practitioner but I believe that having severe back conditions can cause enough stress that can lead to plenty of other non-musculoskeletal conditions, but I don’t treat these conditions, it is simply a belief. Your evidence to support your “Death of Chiropractic” beliefs are being used inappropriately.
Furthermore (to Paul as well), please see the Bone and Joint Decade Task Force reviews for clarity on neck manipulation effectiveness and risks. The risks for VBI stroke with manipulation has always been extremely low, but the current literature supports that the risk for VBI stroke with neck manipulation is the same as a patient seeing their family physician. The common link is that neck pain is one of the earliest signs of VBI stroke and these patients often seek the services of chiropractors or their family physicians for neck pain. The science has now evolved away from causation in regards to SMT and VBI stroke towards prevention by ensuring we can properly recognize these patients that present to our office with subtle signs of a VBI stroke in progress.
@chiro1 http://www.chirocolleges.org/paradigm_scope_practice.html
“Chiropractic is Concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.”
It doesn’t get simpler than that. If you are not focused on subluxations you are not a chiro. Instead, you are playing PT- without the proper education.
Joe,
Your citation is really meaningless based on the assertions made by the original author. You know that this is not evidence to support the original position. Additionally, manipulation and therapeutic exercise etc. is within my legal scope of practice with the proper education.
On the same page:
3.0 Defining Chiropractic Practice
A. DIAGNOSTIC
Doctors of Chiropractic, as primary contact health care providers, employ the education, knowledge, diagnostic skill, and clinical judgment necessary to determine appropriate chiropractic care and management.
Doctors of Chiropractic have access to diagnostic procedures and /or referral resources as required.
B. CASE MANAGEMENT
Doctors of Chiropractic establish a doctor/patient relationship and utilize adjustive and other clinical procedures unique to the chiropractic discipline. Doctors of Chiropractic may also use other conservative patient care procedures, and, when appropriate, collaborate with and/or refer to other health care providers.
C. HEALTH PROMOTION
Doctors of Chiropractic advise and educate patients and communities in structural and spinal hygiene and healthful living practices.
chiro1 on 13 Dec 2009 at 10:06 am “Joe, Your citation is really meaningless …”
It was a direct quote from the Association of Chiropractic Colleges. As is your meaningless quotation about the imaginary role of chiropractors. At least what I quoted, about chiro focusing on subluxation, is concrete. You prefer not to use that word because it is becoming as embarrassing as Innate Intelligence; which doesn’t exist, either. I bet you have an alternative term for II, I’ll further bet that I know what it is.
What chiros will never understand is that, despite the terminology, you make testable claims. But, the claims are seldom tested, and they fail when properly tested. So, your legal scope of practice is irrelevant; it was conferred by ignorant politicians.
chiro1 said, “you do not provide any evidence that even any chiropractors perform manipulation or adjustments to treat non-musculoskeletal conditions directly.”
The key word here is “directly.” According to chiropractic theory, as you well know, correcting the subluxations is never intended to treat any condition directly. It is intended to remove the interference with the nervous system and allow “Innate” (the body’s vitalistic life force) to restore normal function.
As for evidence that chiropractors use manipulation for non-musculoskeletal conditions, that is common knowledge. In fact, Simon Singh was sued by chiropractors for saying that practice is bogus.
And your wording “manipulation or adjustments” is interesting. What are these “adjustments” that are not manipulation, and where are the studies showing they are effective?
chiro1 said “we will very likely seek consent to try SMT”
I don’t think most chiropractors “seek consent.” If you have any figures on how many chiropractors seek any kind of consent, much less informed consent, please share. It is my understanding that most chiropractors adjust their patients without specific consent, and there are documented cases where the patient’s neck was adjusted without consent and the patient suffered a stroke on the table.
chiro1 said, “it matters what we do. And what we do, is help millions of people with back pain”
I don’t doubt that chiropractors “help” their patients. Even outright quacks have satisfied customers (no, I did not say chiropractors are quacks). The point of science-based medicine is to tease out the truly effective treatments from the placebo response, the natural course of disease, and the many other factors that can make a treatment seem effective when it really isn’t.
chiro1 said “SMT is as or more effective and safe than comparable therapies for back pain.”
The evidence shows that for certain types of low back pain, SMT is effective in the short term but the long-term outcomes are not superior to other treatments. I don’t think there is published evidence clearly showing it is safer, but I wouldn’t dispute that. But none of this is an argument for subluxation or chiropractic. It is simply an argument for SMT, a treatment that is also used by non-chiropractors.
chiro1 said, “the current literature supports that the risk for VBI stroke with neck manipulation is the same as a patient seeing their family physician. The common link is that neck pain is one of the earliest signs of VBI stroke and these patients often seek the services of chiropractors or their family physicians for neck pain.”
That is a complete misrepresentation. The “current literature” boils down to one study, the Cassidy study. It was analyzed on this blog by Mark Crislip at http://www.sciencebasedmedicine.org/?p=170 It did not even attempt to determine whether patients who saw chiropractors got neck manipulation. It did not even attempt to determine why patients went to a doctor or chiropractor, so it couldn’t show that they went for neck pain. And the idea that patients are already having a stroke is contradicted by the numerous documented “smoking gun” cases of patients with no symptoms suggestive of stroke in progress who had a stroke on the chiropractor’s table immediately after neck manipulation.
chiro1 said, “… The common link is that neck pain is one of the earliest signs of VBI stroke and these patients often seek the services of chiropractors or their family physicians for neck pain.”
I missed that. So, if you think neck pain indicates an oncoming stroke- why do you snap necks of people with neck pain?
@chiro1
I suggest you familiarize yourself with the views of your fellow chiropractors, in which case I imagine you will become as alarmed regarding chiropractic practice as the rest of us.
A good place to start would be McDonald WP, et al., How Chiropractors Think and Practice: The Survey of North American Chiropractors (Institute for Social Research, Ohio Northern University, 2003). It is full of interesting statistics, such as this quotation from the “Conclusions and Implications:”
“Rank and file chiropractors of North America line up in super-majorities (75% or more) to endorse the following key concepts:
. . . The term vertebral subluxation complex. . . . The subluxation as a significant contributing factor in many visceral ailments. . . . The adjustment as a treatment procedure for both musculoskeletal and selected visceral conditions. . . . The concept of maintenance/wellness care. . . . The teaching of a relationship between spinal subluxations and visceral health.”
(Id. at 89.) In answer to the question “Do adjustments Usually Elicit Improvements in the Following Cases?” 84.2% said yes to dysmenorrhea, 77% to otitis media, and 75.5% to asthma. From such data, the authors perceive “an endorsement of the traditional chiropractic principle: adjustment of the vertebral subluxation restores normal nerve activity to somatic and visceral tissues.” So there is your “evidence that even [sic] any chiropractors perform manipulation or adjustments to treat non-musculoskeletal conditions directly.”
Finally, if you think that the Cassidy study in Spine supports the conclusion that the risk of stroke is the same for patients seeing a chiropractor as those seeing a family physican, I suggest you have another look at the data — not Cassidy’s unsupported conclusion from the data, but the data itself.
[...] in Daily life, Medical, Science at 12:46 pm by LeisureGuy Harriet Hall in Science-Based Medicine: An article written by 3 chiropractors and a PhD in physical education and published on December 2, [...]
[...] Science-Based Medicine here. Leave a [...]
chiro1 said, “you do not provide any evidence that even any chiropractors perform manipulation or adjustments to treat non-musculoskeletal conditions directly.”
FYI, many chiropractors in the UK perform adjustments to treat non-MSK conditions. For example, in a survey conducted in 2007, 76% of UK chiropractors deemed traditional chiropractic beliefs (chiropractic philosophy) to be important to them and the same survey gave a figure of 63% for chiropractors who considered the fictitious ‘subluxation’ lesion to be central to chiropractic intervention. Interestingly, the survey also revealed that the responding chiropractors considered asthma (64%), gastro-intestinal complaints (61%) and pre-menstrual syndrome (PMS) (70%), as conditions that could benefit from chiropractic management (although opinions on the treatment of osteoporosis (43%), obesity (26%), hypertension (42%) and infertility (30%) were less conclusive). As for childhood musculoskeletal and muscular conditions, infantile colic, otitis media and asthma, they were perceived to benefit from chiropractic intervention by more than 50% of the respondents. You can read the results of the entire survey here:
http://tinyurl.com/599vfs
[Ref. Aranka Pollentier and Jennifer M. Langworthy, The scope of chiropractic practice: A survey of chiropractors in the UK. Clinical Chiropractic, Volume 10, Issue 3, Pages 147-155. September 2007]
The findings quoted above also go a long way towards supporting the findings of previous survey of 1,418 active and semi-active UK chiropractors [Wilson FJH, A survey of chiropractors in the United Kingdom, European Journal of Chiropractic, 2003:50:185-198]. It had a response rate of 58% (816), and its participants included members of the British Chiropractic Association (BCA) and Scottish Chiropractic Association (SCA), educated at accredited colleges, and members of the British Association for Applied Chiropractic (BAAC) and McTimoney Chiropractic Association (MCA), educated at unaccredited colleges but grandparented to practise in the UK. A strong majority considered organic or visceral conditions (69%) and the management of children (98%) to be within the scope of chiropractic practice. It’s also worth noting that 36% agreed that “chiropractors should be allowed to prescribe medication on a restricted basis (e.g. mild analgesics, *NSAIDS*, and muscle relaxants).”
chiro1 said “SMT is as or more effective and safe than comparable therapies for back pain.”
Here in the UK, a responsible risk/benefit assessment for chiropractic spinal manipulation as an intervention for back pain has been shown to be largely unfavourable – as explained in the following quote which is lifted from a critique of the recently released (UK) NICE guidelines for low back pain:
Quote
“…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.”
http://tinyurl.com/y8dmwcs
[Ref: Ernst, E. Spinal manipulation for the early management of persistent non-specific low back pain - a critique of the recent NICE guidelines, Int J Clin Pract, 18th August 2009. Reprints available from author.]
Don’t really know where to start, but most of the arguments that get directed to chiropractors seem to be circular. I use adjustments and manipulation, because to me it is just semantics. The studies being quoted refer to chiropractors believing an effect on visceral conditions or possibly that there treatment has had an effect, but they do not demonstrate that the majority of chiropractors treat non-musculoskeletal conditions directly. Whether they believe there is a possible secondary effect doesn’t prove your points. I am well aware and ashamed that some chiropractors use subluxation theory as a marketing technique, but I still have not been shown sufficient evidence that chiropractors are using it for such. Your evidence have simply showed that many chiropractors believe that they may be having this effect. The truth is, that chiropractors would be out of business if they treated non-musculoskeletal conditions. The reality is that regardless of theoretical beliefs, chiropractors treat back pain and do it quite well. That is why people seek chiropractors.
I did not say that chiropractic was shown to be superior than all other comparable treatment modalities for back pain, I said that it has been shown to be just as or more effective. There has been sufficient evidence to justify chiropractic treatment for many forms of back pain.
Informed consent is required by most associations. Malpractice insurance have spent considerable amounts of time familiarizing chiropractors in consent vs. informed consent. I don’t have data to support that most do or do not give informed consent. My association requires it and it would be professional misconduct if I didn’t. Please don’t make accusations if you don’t have the data, as the onus would be on you to prove it.
So if I ignore the Bone and Joint Decade Task Force, which I won’t, the best studies show a range of VBI stroke risk (which by the way is an extremely rare stroke to begin with) at 1 in 500,000 to 1 in 1,000,000. The medical treatment for run of the mill neck pain is what? NSAIDS? Morbidity/mortality rate for this treatment is what?
@chiro1,
You still haven’t answered the question why you would snap the neck of someone who, you think, has the early symptoms of a VB stroke.
Surely, you are aware that Sandra Nette was asymptomatic when a chiro gave her a bilateral VB artery dissection; which the ED neurologist recognized as a chiro-dependent injury before he knew it was a chiro.
Bilateral artery dissection is your pathonomonic gift to humanity.
chiro1 wrote: “The truth is, that chiropractors would be out of business if they treated non-musculoskeletal conditions.”
Would they? Don’t many of them depend on the ‘bait and switch’ to keep business going?
Quote
“Chiropractic is perhaps the most common and egregious example of the bait and switch in medicine…someone may go to see a chiropractor and think they will be seeing a medical professional who will treat their musculoskeletal symptoms, but in reality they will see the practitioner of a cult philosophy of energy healing…The bait – claims that chiropractors are medical practitioners with expertise in the musculoskeletal system. The switch – practitioners of discredited pseudosciences that have nothing to do with the musculoskeletal system…A more subtle form of the bait and switch among chiropractors is the treatment of musculoskeletal symptoms with standard physical therapy or sports medicine practices under the name of chiropractic manipulation. Ironically, the more honest and scientific practitioners among chiropractors are most likely to commit this subtle deception. The problem comes not from the treatment itself but the claim that such treatments are ‘chiropractic’… But by doing so and calling it ‘chiropractic’ it legitimizes the pseudoscientific practices that are very common within the profession – like treating non-existent ‘subluxations’ in order to free up the flow of innate intelligence.”
http://www.sciencebasedmedicine.org/?p=156
chiro1 wrote: “I did not say that chiropractic was shown to be superior than all other comparable treatment modalities for back pain, I said that it has been shown to be just as or more effective.”
You said that SMT was “as or more effective *and safe* than comparable therapies for back pain”, but have made no reference to the comments I cited from the Ernst paper which criticized the UK NICE guidelines for back pain.
chiro1 wrote: “I don’t have data to support that most do or do not give informed consent. My association requires it and it would be professional misconduct if I didn’t. Please don’t make accusations if you don’t have the data, as the onus would be on you to prove it.”
Here’s some data for you:
Quote:
Consent: its practices and implications in United Kingdom and United States chiropractic practice
Results from this survey suggest a patient’s autonomy and right to self-determination may be compromised when seeking chiropractic care. Difficulties and omissions in the implementation of valid consent processes appear common, particularly in relation to risk.
http://tinyurl.com/yar4jxl
Consent or submission? The practice of consent within UK chiropractic
Results suggest that valid consent procedures are either poorly understood or selectively implemented by UK chiropractors.
http://tinyurl.com/559ued
Indeed, if you watch this short video clip (3 mins 12 secs) which outlines tetraplegic chiropractic victim Sandra Nette’s harrowing experience at the hands of her chiropractor, you’ll learn that she didn’t get the chance to make an informed choice about her treatment:
http://watch.ctv.ca/news/latest/class-action-lawsuit/#clip59878
chiro1 wrote: “The medical treatment for run of the mill neck pain is what? NSAIDS? Morbidity/mortality rate for this treatment is what?”
A comparison of spinal manipulation with NSAIDs would have to take into account the following:
Quote
No prospective randomized trial conclusively demonstrates that chiropractic management reduces the incidence of serious NSAID complications, such as fatal gastrointestinal bleeding. NSAIDs taken at recommended doses for a short time are generally very low-risk for appropriately selected patients — particularly the relatively young not on corticosteriods, anticoagulants, alcohol or tobacco and without a history of ulcers or severe comorbid illness. Many patients continue to take NSAIDs while undergoing spinal manipulation. Moreover, spinal manipulation can frequently cause an exacerbation of pain, which might cause some patients to increase or initiate NSAID therapy. [Ernst E. Prospective investigations into the safety of spinal manipulation. Journal of Pain and Symptom Management, 21(3): 238-242, March 2001]. Herbal recommendations seem to be common among DCs; some remedies have actions similar to NSAIDs, while others directly affect bleeding per se . A recent set of reports by the North American Spine Society includes an 18-page reference chart listing approximately 70 herbs with their uses, potential side effects, and (known) potential interactions.
http://www.chirobase.org/18CND/03/03-03.html
It’s also worth remembering that packets of NSAIDs contain patient information leaflets detailing risks. However, as highlighted above, it is evident that not all chiropractors warn patients about the risks associated with their manipulative treatments.
I would also venture that because the rate of people taking NSAIDs is bound to be massively higher than those receiving spinal ‘adjustments’, NSAIDs are likely to be far safer (in addition to the fact that they work). More here:
Quote
“It is, of course, important to present any risk-benefit assessment fairly and in the context of similar evaluations of alternative therapeutic options. One such option is drug therapy. The drugs in question—non-steroidal anti-inflammatory drugs (NSAIDs)—cause considerable problems, for example gastrointestinal and cardiovascular complications. Thus spinal manipulation could be preferable to drug therapy. But there are problems with this line of argument: the efficacy of NSAIDs is undoubted but that of spinal manipulation is not, and moreover, the adverse effects of NSAIDs are subject to post-marketing surveillance while those of spinal manipulation are not. Thus we are certain about the risks and benefits of the former and uncertain about those of the latter. Finally, it should be mentioned that other therapeutic options (e.g. exercise therapy or massage) have not been associated with significant risks at all.”
http://jrsm.rsmjournals.com/cgi/content/full/100/7/330
Chiro1:
You wrote:
“Furthermore, you do not provide any evidence that even any chiropractors perform manipulation or adjustments to treat non-musculoskeletal conditions directly.”
Here’s the literature from the Index to Chiropractic Literature on ADHD (a non-musculoskeletal condition)
http://www.chiroindex.org/?action=doSearch&search1=adhd&type1=all
ADHD
Wittman R, Vallone S, Williams K J Clin Chiropr Pediatr: Jun 2009(10:1): 612-620 Chiropractic management of six-year-old child with attention deficit hyperactivity disorder (ADHD) [case report]
Stone-McCoy PA, Przybysz L J Pediatr Matern & Fam Health – Chiropr: Win 2009(1:1):Chiropractic management of a child with attention deficit hyperactivity disorder & vertebral subluxation: A case study [case report]
Blum CL, Cuthbert S J Pediatr Matern & Fam Health – Chiropr: Sum 2009(1:3) Developmental delay syndromes and chiropractic: A case report
Cassista G J Vert Sublux Res: 2009(Apr:20): Improvement in a child with attention deficit hyperactivity disorder, kyphotic cervical curve and vertebral subluxation undergoing chiropractic care
Hermansen MS, Miller PJ Clin Chiropr: Dec 2008(11:4): 182-192 The lived experience of mothers of ADHD children undergoing chiropractic care: A qualitative study
Bedell L J Vert Sublux Res: 2008(JUN :23): Online access only pp. 1-7 Successful care of a young female with ADD/ADHD & vertebral subluxation: a case study
Blumenthal J J Vert Sublux Res: 2008(MAY:7): Online access only p. 15 Retained primitive reflexes: Their relation to pervasive developmental disorders, autistic spectrum disorders, attention deficits, and learning difficulties
Shara K, Madock D J Vert Sublux Res: 2008(MAY:7): Online access only p. 16 An introduction and review of the diagnosis and treatment of Attention Deficit Hyperactive Disorder
Yannick P J Vert Sublux Res: 2007(AUG:23): Online access only 9 p. Improvement in attention in patients undergoing Network Spinal Analysis: a case series using objective measures of attention [case report]
Young A J Vert Sublux Res: 2007(SEP:6): Online access only 4 p Chiropractic management of a child with ADD/ADHD [case report]
Blum C, Lovett L J Vert Sublux Res: 2006(:OCT:4): Online access only 6 p 19368 Behavioral and learning changes secondary to chiropractic care to reduce subluxations in a child with attention deficit hyperactivity disorder: a case study [case report]
Pauc R Clin Chiropr: Dec 2005(8:4): 189-198 Comorbidity of dyslexia, dyspraxia, attention deficit disorder (ADD), attention deficit hyperactive disorder (ADHD), obsessive compulsive disorder (OCD) and Tourette’s syndrome in children: a prospective epidemiological study
Harrison DE Haas JW Bastecki AV J Manipulative Physiol Ther: Oct 2004(27:8): Online access only 14 p Cervical kyphosis is a possible link to attention-deficit/hyperactivity disorder [case report]
De Maria R Todays Chiropr: May/June 2004(33:3): 68-69,78 ADHD To Alzheimer’s
Krawchuk C, Epstein EC DC Tracts: Sum 2003(15:2): 3-7 Diagnostic corner. Chiropractic management of children with ADHD.
Elster E J Vert Sublux Res: 2003(JUL:12): Online access only, 5 p. Upper cervical chiropractic care for a nine-year-old male with Tourette Syndrome, Attention Deficit Hyperactivity Disorder, depression, asthma, insomnia, and headaches: a case report
Schetchikova NV J Am Chiropr Assoc: Jul 2002(39:7): 28-34+ 15612 Children With Adhd: Medical Vs. Chiropractic Perspective And Theory
Schetchikova N J Am Chiropr Assoc: Aug 2002(39:8): 34-36+ 15994 Children With Adhd: Medical Vs. Chiropractic Perspective And Theory (Part 2)
Liesman NJ ICA Rev: Oct 1998(54:5): 54-61 A Case Study Of Adhd From Kentuckiana.
Peet P Chiropr Pediatr: Jun 1997(3:1): 12-13 Child With Chronic Illness: Respiratory Infections, Adhd, And Fatigue Response To Chiropractic Care
Barnes TA J Clin Chiropr Pediatr: Apr 1996(1:2): 59-65 Attention deficit hyperactivity disorder and the triad of health
======
Here’s the literature from the Index to Chiropractic Literature on Dyslexia (a non-musculoskeletal condition)
http://www.chiroindex.org/?action=doSearch&search1=dyslexia&type1=all
Cuthbert SC, Barras MJ Manipulative Physiol Ther: Oct 2009(32:8): 660-669 20768 Developmental delay syndromes: Psychometric testing before and after chiropractic treatment of 157 children [case report]
Blum CL Cuthbert S J Pediatr Matern & Fam Health – Chiropr: Sum 2009(1:3): Online access 4 p 20712 Developmental delay syndromes and chiropractic: A case report
Pauc R Clin Chiropr: Sep 2008(11:3): 130-137 The occurrence, identification and treatment of convergence failure in children with dyslexia, dyspraxia, attention deficit disorder (ADD), attention deficit hyperactive disorder (AD/HD), obsessive compulsive disorder (OCD) and Tourette’s syndrome
Yannick P J Vert Sublux Res: 2007(JAN:15): Online access only p 1-12 The effects of chiropractic care on individuals suffering from learning disabilities and dyslexia: A review of the literature [review]
Young A Pauc R Clin Chiropr: Dec 2006(9:4): 182-185 Foetal distress and birth interventions in children with developmental delay syndromes: A prospective controlled trial
Pauc R Clin Chiropr: Dec 2005(8:4): 189-198 18594 Comorbidity of dyslexia, dyspraxia, attention deficit disorder (ADD), attention deficit hyperactive disorder (ADHD), obsessive compulsive disorder (OCD) and Tourette’s syndrome in children: a prospective epidemiological study
Young A Clin Chiropr: Mar 2004(7:1): 5-9 16842 Developmental dyslexia associated with peri-natal trauma [case report
=========
Here's the literature from the Index to Chiropractic Literature on autism (a non-musculoskeletal condition)
http://www.chiroindex.org/?action=doSearch&search1=autism&type1=all
Heying K ICA Rev: Spr 2009(65:1): 42-48 Vision and autism: A tale of understanding vision therapy
Fallon J J Clin Chiropr Pediatr: Mar 2008(9:1): 541-542 Chiropractic and autism: the natural choice
McCormick J J Clin Chiropr Pediatr: Mar 2008(9:1): 553-557 Positive behavioral changes following chiropractic care in a child diagnosed with autism
Hoffman N Russell D J Vert Sublux Res: 2008(APR:7): Online access only pp. 1-4 20085 Improvement in a 3-year-old autistic child following chiropractic intervention to reduce vertebral subluxation [case report]
Bloink T J Vert Sublux Res: 2008(MAY:7): Online access only p. 17 Autism and language delay, integration of SOT cranial therapy and tomatis auditory therapy to stimulate the auditory cortex: A case report
Jennings J Barker M Clin Chiropr: Mar 2006(9:1): 6-10 Resource document. Autism: a chiropractic perspective
Gleberzon BJ Clin Chiropr: Dec 2006(9:4): 176-181 Chiropractic and the management of children with autism [review]
Sweat RW, Khorshid KA Zemba DA Zemba BN J Vert Sublux Res: 2006(MAR:9): Online access only 7 p. Clinical efficacy of upper cervical versus full spine chiropractic care on children with autism: a randomized clinical trial [randomized controlled trial]
Ferrance RJ J Can Chiropr Assoc: Mar 2003(47:1): 4-7 Autism–another topic often lacking facts when discussed within the chiropractic profession
[no author] ICA Rev: Fall 2001(57:5/6): 51-64 Kentuckiana Children’s Center Helps Fight Autism
Khorshid K ICA Rev: Fall 2001(57:5/6): 59-60 Two Special Children And Their Parents Are Fighting Autism And Winning
Provan L ICA Rev: Fall 2001(57:5/6): 60-62 Kentuckiana And Oklahaven Children’s Centers Help Lawrence To Defeat Autism!
Fallon JD ICA Rev: Fall 2001(57:5/6): 66-71 Ear Infection In Childhood Autism: Is There A Relationship?
Gleberzon BJ, Rosenberg-Gleberzon AL Top Clin Chiropr: Dec 2001(8:4): 42-57 On Autism: Its Prevalence, Diagnosis, Causes, And Treatment
O’Shea T Todays Chiropr: Sep/Oct 2000(29:5): 30-35 Autism And Vaccines
Warner SP, Warner TM Todays Chiropr: May/Jun 1999(28:3): 82-85 Case Report: Autism And Chronic Otitis Media: Challenging Cases
Amalu WC Todays Chiropr: Sep/Oct 1998(27:5): 32-47 Autism, Asthma, Irritable Bowel Syndrome, Strabismus And Illness Susceptibility: A Case Study In Chiropractic Management.
Koren T Am Chiropr: Nov/Dec 1996(SUPPL.:1): 14+ Autism, Encephalitis, & Vaccination
Barnes TICA Rev: Nov/Dec 1996(52:6): 43-46 THe Story Of John: A Little Boy With Autism.
Rubinstein HM Chiropr Pediatr: Apr 1994(1:1): 23 Case Study – Autism
Koren T Todays Chiropr: Sep/Oct 1994(23:5): 91-92 Autism And Vaccinations
====
And how about the Carrick Institute and “chiropractic neurology”?
http://www.carrickinstitute.org/CIAbout.asp
And I’d be glad to share with you my collection of online and print ads from chiropractors urging chiropractic care for ADHD over medical care.
chiro1 said,
“The reality is that regardless of theoretical beliefs, chiropractors treat back pain and do it quite well.”
I have never disputed that. My problem is with those who treat somatovisceral disorders and offer health maintenance, and with those who use neck manipulation inappropriately.
“I did not say that chiropractic was shown to be superior than all other comparable treatment modalities for back pain, I said that it has been shown to be just as or more effective.”
I never said you did. I simply quoted your own words. And I said that the evidence shows that SMT is not more effective for long term outcomes than other treatments. Anyway “chiropractic” is not a treatment modality, SMT is. And the efficacy of SMT is irrelevant to the subject of the post – it does not demonstrate the subluxation or the rationale for chiropractic as a separate discipline.
And please don’t bring up that tired old argument about NSAIDS. (1) It is a logical fallacy called the false dichotomy, since manipulation and NSAIDS are not the only two possible options for treating neck pain. (2) The risks of NSAIDS are irrelevant to a discussion of whether a different treatment carries risks and (3) risks alone are meaningless outside the context of the risk/benefit ratio.
It was a mistake for you to bring up the risks of chiropractic treatment, because my post didn’t mention that. It was about the fact that the subluxation construct is not supported by evidence. If you do not believe in the subluxation construct, you are not practicing “chiropractic” but simply taking advantage of your chiropractic license to provide some of the same modalities provided by physical therapists.
As for chiropractic informed consent, you imply that you are required to do it rather than volunteering to do it for patient welfare. The chiropractic consent forms I’ve seen are closer to my concept of propaganda than to my concept of fair informed consent. Perhaps you can provide us a copy of what you ask your patients to sign.
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.” It has been my observation that subluxation-based chiropractors never fail to find a “vertebral subluxation complex” in every section of the spine in every patient they see, just as an upper cervical “specialist” always finds a subluxated atlas.
Only a few chiropractors have openly renounced the chiropractic vertebral subluxation theory. Many chiropractors dance around the 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.
A simple google search of web sites for chiropractic clinics belies any claim that chiropractors have abandoned the “science, philosophy, and art” underlying the chiropractic vertebral subluxation theory.
Chiropractors would do well to pay attention to the findings of Mirtz, et al, who concluded that a review of current evidence fails to support promulgation of the chiropractic subluxation. The knee-jerk response of chiropractors who reject criticism of the chiropractic vertebral subluxation theory or who maintain that manipulating the spine for any reason will improve health is a clear indication of the problems associated with placing proper limitations on chiropractic care. From the approach of anatomy, physiology, and neurology, the claim that a misaligned vertebra or a “segmental dysfunction” in the spine can cause organic disease is so implausible that I suspect that future science-based literature will continue to support the conclusions of the landmark paper by Mirtz, et al.
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Harriet,
I believe some of the confusion is that I was responding to multiple posters in addition to yours. I’ll try to be less general with my responses.
Harriet said:
“I have never disputed that. My problem is with those who treat somatovisceral disorders and offer health maintenance, and with those who use neck manipulation inappropriately.”
You are correct and I share the same concerns. However, you are using science that attempts to show what chiropractors believe, not what they actually do in practice. Your statement earlier sums up your thoughts on this matter, but it is not evidence: “As for evidence that chiropractors use manipulation for non-musculoskeletal conditions, that is common knowledge.”
Harriet said:
“Anyway “chiropractic” is not a treatment modality, SMT is. And the efficacy of SMT is irrelevant to the subject of the post – it does not demonstrate the subluxation or the rationale for chiropractic as a separate discipline.”
This is pretty silly. Chiropractors, by far, use SMT the most and often exclusively. They also have the most training hours in SMT. SMT is the core treatment modality for almost every single chiropractor regardless of their belief system or regardless of the stances taken by some associations in regards to these beliefs. This is also why the efficacy of SMT is relevant to the subject.
Harriet said:
“It was a mistake for you to bring up the risks of chiropractic treatment, because my post didn’t mention that.”
You are correct and I apologize. Again, I was mixing my responses to other poster’s agendas. Did not mean to lump you in. My comparison to NSAIDS was not in response to your posts.
But it is frustrating when, from my perspective, other treatments are not held to the same level of scrutiny. For example, many of the reviews concerning SMT and low back pain show SMT to be at least as effective as NSAIDS, physical therapy, exercise etc. I might be incorrect with this assertion, but if NSAIDs carry greater risk of serious adverse events than SMT for low back pain, why is this rarely talked about when it is a very common medical treatment for low back pain? But, you are correct this specific discussion was not relevant to your original article and I will move on.
Regarding your concerns regarding informed consent, what I meant was that chiropractors are required by law in most countries to provide adequate informed consent. If they do not, they are committing professional misconduct, so I would hope that most do. You do not have evidence to support your assertion that we do not provide informed consent, but I also cannot prove that we do. This is the same for any other health care provider. Please don’t paint our profession with the same brush based on your own personal experiences. Also, as I’m sure you are fully aware that informed consent doesn’t just mean that you have a good form for them to sign, it involves having a candid discussion with your patient involving the known treatment benefits and its risks but also the alternative treatments. Would you like transcripts or a voice recording as well?
lizditz,
Giving a list of research articles that attempt to research a hypothesis is proof that most chiropractors manipulate for the sole purpose of treating non-musculoskeletal conditions? That’s quite the stretch.
Joe,
That case is very tragic and it is right to spend a lot of time investigating it. However, in terms of science it is one case that has many variables. If we made treatment decisions based on adverse events with individual cases, the practice of medicine would cease to exist. We must do our very best that when making treatment decisions that we are weighing the benefits versus the risks, comparable treatments and their associated benefits and risks, and seeking proper informed consent to the one ultimately making this decision…the patient.
chiro1 said, “Your statement earlier sums up your thoughts on this matter, but it is not evidence: “As for evidence that chiropractors use manipulation for non-musculoskeletal conditions, that is common knowledge.”
Let me see if I understand correctly. Are you really questioning whether chiropractors use manipulation for non-musculoskeletal conditions and demanding to see evidence before you will accept that they do?
chiro1 said “you are using science that attempts to show what chiropractors believe, not what they actually do in practice.”
You are insulting your colleagues by implying that they don’t practice what they believe!
I said “chiropractic” is not a treatment modality, SMT is.”
chiro1 argues that they amount to the same thing. He said “SMT is the core treatment modality for almost every single chiropractor”
Yes, and that’s a problem. Most of them don’t limit SMT to evidence-based indications as other providers like PTs do. If you don’t accept the subluxation, what are your indications for doing SMT? A chiropractor who manipulates every patient is a bit like a surgeon who operates on every patient. When the only tool you have is a hammer, everything looks like a nail.
This is really ironic. On a previous thread I was warned against conflating chiropractic with manipulation. I was taken to task for referring to the risks of “chiropractic” neck manipulation instead of referring to the risks of spinal manipulatons as practiced by anyone, including non-chiropractors. Now you’re trying to claim SMT as your own special province.
poor chiro1. Everyone’s beating up on him.
Growing up I believed that a ‘chiropractor’ was a glorified back-cracker for people with lower back pain. A profession for a need though. Made sense to me since 8 out of 10 people experience lower back pain at some point in their life. I know a few people that see a chiropractor for pain relieve and they swear by their results. Finding out that a lot of woo is involved in the sales pitch was new to me only a year ago when I stumbled across SBM.
Anyways, I foresee a paradigm shift to what defines a ‘chiropractor’, from sublexation to pain management. It wouldn’t be the first time a medical profession has changed their core beliefs. Remember humours, bloodletting, poultices, snake oils, ect.? What’s baffling is that ‘chiropractics’ hasn’t adapted to the times of modern medicine. What’s really taking so long for the profession to really say, “Let’s cut the bullshit”?
Fun Gallup poll:
http://www.gallup.com/poll/1654/Honesty-Ethics-Professions.aspx
Sam,
Those are nice surveys, but I don’t really think they are that helpful. Nor are your references to google searches and anecdotal evidence of unethical practices. Diversified technique is a great example and I think reinforces what I had stated in my first post. This technique is a collection of maneuvers that apply manual forces in certain directions to achieve the desired SMT. I’m sure it started out as maneuvers that tried to ‘push one bone back in place’, but it has evolved. Now, chiropractors use this technique because it tends to be the easiest, most comfortable method to perform SMT. I liked Diversified when I was a student, because it felt the most comfortable when other students worked on me. It had nothing to do with it being the most effective at ‘putting the vertebrae back in place’ or ‘removing nerve interference’.
I think that the reason the term ‘subluxation’ has survived within the chiropractic community is the idea that all practitioners, especially those who work with musculoskeletal conditions, need something that we can look for that is more tangible than a simple pain description by the patient. Chiropractors, just like physical therapists, massage therapists, or even orthopedic surgeons have assessment methods to determine diagnosis and the location to direct treatment. All of these practitioners have methods, some are more objective or reliable than others, to do this including postural analysis, range of motion, orthopedic tests, and palpation. Most of these are weak for very similar reasons: poor reliability or poor validity. But, all of these practitioners have some of these in their repertoire. With chiropractors, we do many of these tests but we also check for joint stiffness or fixation, muscle tightness, and tenderness (which is closer to the modern version of the subluxation theory) to ascertain which level to apply our manipulation. Regardless of the theory behind the subluxation concept, chiropractors use spinal manipulative therapy to address the patient’s complaints of which ‘back pain’ is the most common, using techniques that attempt to focus in closer on where the practitioner believes the problem is stemming from.
In my opinion, there are scenarios that probably arise from traditional chiropractic theory. Here are some examples:
1. That the chiropractor attempts to determine the location of the subluxation or joint dysfunction with patients presenting with back pain, to be more specific with their application of force. or 2. The chiropractor uses the nerve interference explanation with their client with back pain to show how an SMT, or adjustment as they would call it, can cure some visceral condition. In the first case, I don’t necessarily disagree with as long as SMT is indicated for the region of the complaint and that the patient has given proper informed consent. Of course, the second case is clearly unethical. There is no evidence that demonstrates how many of the practitioners who believe in the concept of ‘subluxations’ fall into either category. There are also many chiropractors, like me who do not use subluxation theory in any part of their practice. The premise that, because many chiropractors believe in some components of the traditional or modern subluxation theories, does not mean that it is reflected by chiropractors behaving unethically or unprofessionally.
Please also note that while chiropractors utilize SMT frequently, and some exclusively, many use other potentially effective strategies such as therapeutic exercise, ergonomic counselling, and physical therapy modalities and others for a variety of conditions. Hopefully, one day we can be defined by the good that many of us do and not by a traditional belief system that doesn’t truly reflect how we actually treat our patients.
“Hopefully, one day we can be defined by the good that many of us do and not by a traditional belief system that doesn’t truly reflect how we actually treat our patients.”
You can. Just stop defining yourselves as chiropractors.
Harriet,
Yes, I am absolutely demanding evidence for the assertion that MOST chiropractors perform manipulation for non-musculoskeletal reasons. I know that there are some that do, unfortunately. But with comments such as, “End of Chiropractic”, “Death knell for chiropractic”, “Superstition never dies, particularly when it is essential to livelihood.”, you better have something better. I am completely comfortable with criticism, chiropractors should listen to it more often, but you’ve gone to far towards the sensational.
Harriet’s comment: “You are insulting your colleagues by implying that they don’t practice what they believe!”
Please see my response to Sam, I think that my reply addresses this.
Harriet’s comment: “Most of them don’t limit SMT to evidence-based indications as other providers like PTs do.”
Again, this is your opinion, but it is quite the accusation.
Harriet’s comment “Now you’re trying to claim SMT as your own special province”
I did not say that. I was simply stating that SMT is the most common treatment performed by chiropractors and is therefore not a term exclusive to physical therapists, despite your above stated opinion.
I posted the story (including the abstract of the paper) to an alt-med forum under the heading “No subluxations, so is chiropractic dead?” just to see how long it would take for someone to dismiss the study.
32 minutes.
For the chiropractors it will be business as usual. After all, they have been regularly redefining “subluxation” to suit the Zeitgeist almost since Palmer invented the word. (*)
(*) I know he didn’t invent the word itself, but as for most non-medical people the only time they hear it is in association with chiropractic so he might as well have invented it.
[...] The End of Chiropractic: and I say good riddance. [...]
chiro1 said, “Yes, I am absolutely demanding evidence for the assertion that MOST chiropractors perform manipulation for non-musculoskeletal reasons.”
Please try to read more carefully. I never claimed that MOST chiropractors did. What I said was that according to a study by chiropractors themselves, 75% of chiropractors believed that subluxation was a significant contributing factor to 50% or more of visceral disorders. I don’t know what percentage are actually performing manipulation for nonmusculoskeletal reasons (because there are no published data on that), but I have evidence that a lot of them are. Plenty of them say so themselves. They advertise so on their websites, and enough members of the British Chiropractic Association apparently do so that they felt it was necessary to sue Simon Singh for saying that such treatments are bogus.
I said that most chiropractors accept the subluxation construct. That is indisputable. Chiropractic is defined legally and by its own organizations in terms of the diagnosis and treatment of the chiropractic subluxation. There is no evidence to support the claims of chiropractic theory that it causes interference with the nervous system and causes disease. Therefore, the whole rationale for chiropractic vanishes. Individual chiropractors can claim that they don’t believe in subluxations, but that means they are no longer practicing “chiropractic.” Their only hope for a rational future is to distance themselves from “chiropractic” and re-define themselves.
“SMT is the most common treatment performed by chiropractors and is therefore not a term exclusive to physical therapists, despite your above stated opinion.”
I never said SMT was exclusive to physical therapists! It isn’t, of course. And of course it is the most common treatment performed by chiropractors, because it is required by chiropractic theory. The evidence shows that SMT benefits patients with low back pain. The evidence does not show that it benefits the many other conditions that chiropractors use it for.
Dr. Mirtz tells me that more than one critic of his paper had failed to actually read it. You have certainly failed to read carefully what I wrote.
Most of the 100+ adjustive techniques used by chiropractors are designed to correct “vertebral subluxations” and cannot be compared with generic spinal manipulation used exclusively as a treatment for back pain and related musculoskeletal problems.
All I want to hear from a science-based chiropractor is open renouncement of the implausible chiropractic vertebral subluxation theory and a recommendation that chiropractic be limited to care of musculoskeletal problems.
While there are some science-based chiropractors who do not practice in a traditional chiropractic mode, it’s unlikely that the chiropractic profession will ever be properly limited if the definition of chiropractic is not changed in chiropractic colleges and in state laws and if surveys continue to indicate that the majority of chiropractors believe in the chiropractic vertebral subluxation construct.
chiro1,
Let’s look at it from a different angle. For the sake of argument, let us assume that the chiropractic subluxation may be completely discarded as a meaningful concept. (From your posts so far, I expect that you would agree to this anyway, but I’m hoping to make it completely clear where I’m starting from.)
Given that, what is the rationale for the existence of chiropractic as a distinct concept or profession? If there is something that chiropractors know or do regarding SMT that can be objectively demonstrated to be superior to the practices of physical therapists, evidence-based PTs would adopt it. Then, a chiropractor is just a PT with more restricted scope of practice and a pile of antiscientific baggage.
And if there is NOT something that can be so demonstrated (which is the case based on my understanding of the current evidence), then there’s no need even for evidence-based PTs to adopt said practice before there’s no justification for chiropractic to exist.
All chiropractors really have to bring to the table to distinguish themselves are subluxations and non-SMT woo.
Sam,
“Most of the 100+ adjustive techniques used by chiropractors are designed to correct “vertebral subluxations” and cannot be compared with generic spinal manipulation used exclusively as a treatment for back pain and related musculoskeletal problems.”
I disagree, because in the real world most chiropractors look for ‘vertebral subluxation’, in the same way a PT would look for joint dysfunctions or derangements (or a dozen other names it has been called). The current subluxation model has been slowly heading away from the non-musculoskeletal connections.
If other positions are going to be posted exclusively without attention to others, here is the American Chiropractic Association:
‘The most common therapeutic procedure performed by doctors of chiropractic is known as “spinal manipulation,” also called “chiropractic adjustment.” The purpose of manipulation is to restore joint mobility by manually applying a controlled force into joints that have become hypomobile – or restricted in their movement – as a result of a tissue injury. Tissue injury can be caused by a single traumatic event, such as improper lifting of a heavy object, or through repetitive stresses, such as sitting in an awkward position with poor spinal posture for an extended period of time. In either case, injured tissues undergo physical and chemical changes that can cause inflammation, pain, and diminished function for the sufferer. Manipulation, or adjustment of the affected joint and tissues, restores mobility, thereby alleviating pain and muscle tightness, and allowing tissues to heal.’
Harriet,
We are going around in circles. Neither of us are contributing anything new anymore to the argument and either we are misunderstanding each other, or we are not truly recognizing what the other is saying.
Draal,
No worries about getting beat up, I subscribe to a number of science-based sites and blogs and am well aware of what I was getting into. I also realize that chiropractors have made themselves easy targets by not evolving fast enough with the science. Also, it is apparent that as a profession we haven’t done a good enough job with cohesion and direction. I agree with the paradigm shift, but I believe that it has already started and is closer than you think.
Scott,
‘Subluxation’ as an entity that leads to non-musculoskeletal disease is somthing that I can easily agree to discard. Subluxation as a concept in regards to Vertebral Subluxation Complex, or joint dysfunctions as described by the above ACA quote is different and while not perfect is the attempt to find physical signs to go along with pain descriptions as a reason for SMT. PT’s use a very similar approach in how they determine when to use SMT.
What do we bring to the table to differentiate ourselves from PT’s then? My scope of practice is nearly identical to that of a PT who has a musculoskeletal practice. Why is it always assumed that we don’t? I can’t think of a single modality that PT’s treating back pain can do that I can’t. In fact, in my practice I involve my patients in more strength and conditioning programs, postural exercises etc. than most PT’s I’ve spoken to in my area. It is definitely more common for PT’s to use electrical modalities, which have very little supporting evidence for effectiveness, than chiropractors in my area. Perhaps this is the difference? Or, maybe it is that PT’s, in my area anyway, have received very little training in SMT and don’t feel comfortable with applying the treatment? We can speculate all we want, but why do chiropractors who have a similar scope of practice have to differentiate themselves from PT’s and not the other way around? I understand your logic, but from my perspective PT’s use very similar methods to apply SMT than chiropractors. It’s easy…the most reliable and valid objective tool to determine SMT is the presence of indicated back pain without contraindications. This where my arguments come back full circle.
“Rule #1, never let a chiro touch your neck.
There is some evidence that chiro manipulation can be as effective as massage and other, standard treatments for short-term low back pain.
If two or three visits don’t do the job- try something else.
Don’t get regular check-ups or “maintenance” adjustments.”
Interesting. I go to a chiro for my back, but I always feel as if I am squinting at them, daring them to say something woo to me.
The reason? Chiro is covered by insurance, massage is not.
PS, I did not know that about stroke, interesting. I suffered two migraines after neck manipulations. Correlation or causation? I will go with the latter, as I have only had a migraine 3x in my life.
Interesting posts, thanks!
The reason chiropractors need to do the distinguishing is twofold:
1. Chiropractors are the ones whose history (and for many, current practice) is based around false premises.
2. PTs can do many other things.
So you appear to have effectively agreed that you are, in essence, a more restricted PT whose field (as a whole, not as a statement regarding your individual practice) is not soundly based on science. I think that such characterization is probably sufficient to show the problem; if not please let me know and I’ll try to articulate it more explicitly.
One additional point that bears particular mention:
While you may so restrict yourself, many chiropractors (effectively all I checked in a recent Google survey of those in my area – certainly not rigorous, but illustrative) do not. Which, in my mind, is a problem even for those such as yourself.
When the chiropractic profession does not effectively self-regulate to prohibit such practices among its members, how is a layperson to tell whether a particular treatment recommended by a particular chiropractor is legitimate? The inevitable answer is that they cannot. So, the ONLY safe course which a layperson can follow to avoid such is to avoid chiropractors entirely!
I have to hand it to you for sticking this out, Chiro1. You’ve been tenacious and polite, and you’ve taken increasing care to respond to specific points. Thanks for that.
To a great degree, your objections seem to hang on this idea that there is no evidence that chiropractors use subluxation as a justification for treating disease. This is a tissue-paper-thin concern. You’re like a man standing neck deep in the tide demanding to see evidence that the water is rising.
Have you actually spoken to any of your colleagues?! It really seems like you’re being willfully oblivious to the fact that belief in the power of subluxations is still a major force in chiropractic. Nearly every chiropractor I’ve ever seen as a patient has offered to treat non-musculoskeletal conditions.
And I’ve been publishing on the subject of spinal manipulation for a decade, and I have buckets of email from chiropractors, a great deal of it rudely asserting that chiropractic adjustment is good medicine for essentially anything. What little friendly mail I have from chiropractors is invariably on the other side of the controversy, expressing frustration and outrage at the ubiquitous indefensible practices of other chiropractors!
For instance, there is an vast movement in chiropractic devoted to selling chiropractic manipulation to asymptomatic children for “prevention and wellness.” Many chiropractic offices in Vancouver have bulletin boards devoted to pictures of their child-patients. How does this square with your contention that there’s “no evidence” that chiropractors treat non-musculoskeletal conditions?
Dr. Hall is not actually obliged to write bloodless headlines just to avoid irritating chiropractors. The headline expresses the possible implications of a simple news item: a major philosophical pillar of chiropractic was publicly attacked by your own colleagues. There’s no underlying claim there that needs rigorous validation, as you’ve asserted. She does need to prove what chiropractors actually do with the idea of subluxation — it is quite adequate for the purposes of this article that subluxation clearly is a philosophical pillar of your profession, as is self-evidently true after decades of controversy about it.
It’s true that a good science-based chiropractor who uses manipulation appropriately will use it to restore mobility and relieve back pain, using a generic form of manipulation similar to that used by physical therapists and other practitioners who use manipulation in the treatment of back pain. It’s important to remember, however, that a chiropractic adjustment to correct a “vertebral subluxation complex” may be different from manipulation used by physical therapists who manipulate the spine primarily to restore mobility. And chiropractic adjustments used to correct elusive vertebral subluxations may vary in technique from one chiropractor to another.
Since there is no loss of mobility associated with an undetectable “vertebral subluxation complex,” the method used to adjust such subluxations may be any one of a number of techniques that are as dubious as the subluxations they are designed to correct. Such chiropractic techniques as cranial adjusting, applied kinesiology, Logan basic, concept therapy, Activator, sacro-occipital, bio-energetic synchronization, neuro-emotional, neural organization, directional nonforce, and countless other techniques used to correct chiropractic subluxations do not resemble generic manipulation used by physical therapists and other practitioners who use manipulation in a consistent manner to restore mobility in affected spinal joints. Some chiropractic techniques do not involve manual manipulation of the spine. In 2003, for example, 69.9% of chiropractors were using a spring-loaded Activator mallet to tap vertebrae into alignment. Nearly 40% of chiropractors were using nonsensical applied kinesiology as a method of determining when and where to adjust the spine, using any one of more than a hundred techniques–from upper cervical/HIO to a Logan basic sacral adjustment.
Science-based chiropractors should separate themselves from such nonsense by denouncing such methods, making sure that the public does not confuse appropriate manipulation with a great variety of nonsensical adjustive techniques used by subluxation-based chiropractors. Until the chiropractic profession is properly limited and specialized so that all chiropractors use manipulation in an appropriate and consistent manner, chiropractors cannot be recommended across the board. Lay persons will it difficult to find a science-based chiropractor, unable to distinguish a science-based chiropractor from a subluxation-based chiropractor.
Conscientious, science-based chiropractors have an obligation to speak out and not allow certain dubious chiropractic adjustive techniques to receive blanket approval under the umbrella of science. Few chiropractors, however, will have the courage or the commitment needed to question or publicly denounce inappropriate treatment methods used by the majority of their colleagues.
Before we carve up the chiropractic profession with sensationalistic headlines in a supposed science forum can we at least first validate or invalidate whether or not chiropractic adjustment of misalignment (subluxation/fixation) of C1 does indeed work as well as dual drug therapy for hypertension?
Some very esteemed scientists seem to think it might and so far the science seems to show that it does. I look forward to the larger study as I would hope all self described scientists (on this forum and elsewhere) would as well.
http://www.uchospitals.edu/news/2007/20070314-atlas.html
gramaticus,
Funny you should mention that. A chiropractor has already written an article on that subject on this very blog. See http://www.sciencebasedmedicine.org/?p=606
Gramaticus,
This article is not an analysis of subluxation theory — it reported on one.
Critics of chiropractic are not obliged to address every conceivable point of contention in every article on the subject. A lot of this stuff has been discussed ad infinitum for decades. Failing to repeat that part of the discussion in this article does not make it an “unscientific” article. The point is that your own colleagues evaluated and rejected such evidence as part of their analysis of subluxation theory.
I wrote to the editor of Chiropractic & Osteopathy shortly after the release of this paper, noting that the learned authors seemed to have failed to review a whole series of basic science articles that had been previously published about the impact of the spinal subluxation.
I also sent them a list of the omitted papers, but the editor rejected my comments because it wasn’t inserted in a “scholarly short piece”…hehehe. Luckily, none of your readers wrote them either, since few of these 79 posts seemed very scholarly either.
There does seem to be genuine interest by your readers for reviewing “real live” science that might help explain what the subluxation is, and how it might effect health. If that’s actually the case, then these omitteed articles should pique your interest more than the authors of the Chiropractic & Osteopathy review.
The main author (Chuck Henderson) has been using an animal model (for years) to demonstrate how spinal fixation leads to degenerative changes (yes, that IS spinal pathology, aka disease), and his conclusion from the last article is:
“This study suggests that the external link model can be a valuable tool for studying the effects of spine fixation and misalignment, cardinal features of what has been historically described as the chiropractic subluxation. Significant residual stiffness and misalignment remained after the links were removed. The progressive course of this lesion is consistent with subluxation theory and clinical chiropractic experience.”
They articles the authors chose to ignore are:
Degenerative Changes Following Spinal Fixation in a Small Animal Model
J Manipulative Physiol Ther 2004 (Mar); 27 (3):141–154
http://www.chiro.org/research/ABSTRACTS/Degenerative_Changes_Following_Spinal_Fixation.shtml
Introducing the External Link Model for Studying Spine Fixation and Misalignment: Part 1—Need, Rationale, and Applications
J Manipulative Physiol Ther 2007 (Mar); 30 (3): 239-245
http://www.jmptonline.org/article/S0161-4754(07)00051-6/abstract
Introducing the External Link Model for Studying Spine Fixation and Misalignment: Part 2, Biomechanical Features
J Manipulative Physiol Ther 2007 (May); 30 (4): 279-294
http://www.jmptonline.org/article/S0161-4754(07)00074-7/abstract
Sadly, these are abstracts, but if any of your readers are actually interested in reviewing these full-text articles for critique, I will be happy to e-mail them.
DrFrankmeister,
Please spell it out for us: how are these papers relevant to this discussion?
The first paper you cite, even if we accept its conclusions at face value, shows only that joints “fixed with a specially engineered vertebral fixation device” suffer some degenerative consequences, which I don’t think is a surprise to anyone. I am confident that my joints would suffer too, if artificially fixated. However, I think that I would carry on feeling safe from “disease” in general — yet that’s the very link you seem to be making. Why? Did these nasty artificial fixations cause the rats to suffer in extraordinary ways other than joint degeneration? Did the data demonstrate that subluxation causes other kinds of “disease”? Aren’t other kind of disease quite pathophysiologically distinct from joint degeneration?
The second and third papers concern the “external link model,” which appears to simply be a method of simulating subluxation for the purposes of studying it — but, again, it is does not in itself have anything to do with the hypothesis that subluxation causes disease, as far as I can tell.
It seems many young Australian chiropractors don’t buy the subluxation hypothesis, if this paper is anything to judge by
Failure to Use Vertebral Subluxation Complex as a Diagnostic Term: A Flaw of Reductionistic Diagnosis with Resultant Compromise of Student and Patient Outcomes in Chiropractic Teaching Clinics
Chiropr J Aust 2007; 37:84-91.
To quote part of the abstract..
“The resulting 400 reports were then reviewed by the authors and the diagnostic categories identified and collapsed into themes. Results: There were 355 patients with a spinal complaint for whom a working diagnosis of vertebral subluxation complex could have been appropriate, however this diagnostic term was used in only 13 cases. The more common diagnostic term was biomechanical joint dysfunction”
The authors note with concern that their final year students have what they call a ‘a limited, mechanical paradigm’ ie they don’t believe in subluxations or innate intelligence and appear to see themselves as similar to PTs.
In my home state it appears that the hokey old vitalistic theories are well and truly dead in younger chiropractors..
I must say that I agree with Paul Ingraham’s astute response to the references submitted by Dr. Frankmeister.
It’s well known that vertebral fixation or loss of mobility, like injury or disc degeneration, can initiate or contribute to degenerative changes in the affected spinal joints. Such degenerative changes in humans are common and have never been associated with development of a visceral disease.
It’s not surprising that immobilizing two or three segments of a rat’s spine with a metallic fixation device would result in degenerative changes in the artificially locked joints.
Apparently, despite the localized degenerative changes (which were referred to as “subluxations”) and the suffering endured by the poor rats, there was no development of visceral disease, a result that would seem to disprove the chiropractic vertebral subluxation theory.
Sam and Paul
I don’t recall mentioning that subluxation causes visceral disease, so I’m curious why that’s all you seem interested in discussing? Read on please.
You contend that “It’s well known that vertebral fixation… can initiate or contribute to degenerative changes in the affected spinal joints” How unscientific of you! It was also well known at one time that the world was flat!
At least Henderson has scientifically and clinically demonstrated that joint fixation (a primary component of the subluxation hypothesis) actually causes those degenerative changes. Last time I looked, ICD-9 contains multiple diagnostic codes to describe degenerative changes within the disease continuum. Ergo, spinal fixation caused that disease. So, you can’t state that subluxation does not cause disease. It’s a small point, but it’s valid, and it tends to hamstring your overall “theory”.
Shall I play your game and maintain that it’s “well known” that chiropractic reduces joint fixation, increases ROM, and thereby reduces the risk (and suffereing) of degenerative joint disease?
I believe the best article on the topic [1], defines the slow progress of chiropractic thinking away from the bone-out-of-place causes dis-ease model of the 1890s to the current understanding that somatic dysfunction (yup, the subluxation) can reproduce symptoms that MIMIC visceral disease symptoms. The author states:
“It is now well-established that afferent fibers that transmit nociceptive information from deep somatic structures converge on the same central neuronal pools as do the independent afferent fibers that transmit noxious stimuli from regionally-related visceral structures. Unfortunately for the diagnostician, the subsequent relaying of either of these two sources of afferent information by this convergent pool of neurons into other common central pathways can often result in overt patterns of signs and symptoms that may be virtually indistinguishable with respect to their somatic vs. visceral etiologies.”
They go on to say that: “As discussed earlier, the theory that somatic dysfunction is capable of actually causing true visceral disease (see Figure 3) is one for which scientific evidence is seriously lacking. On the other hand, the fact that somatic dysfunction can often mimic, or simulate, the symptoms of visceral disease (and therefore may be easily mistaken for it), is supported by an impressive amount of both experimental and clinical scientific data [65-350]. ”
I don’t TREAT a child’s asthma. And yet, many of my youthful patients have been able to give up using steroidal-based inhalants that will inevitable give them emphysemia, as the connective tissue of their liungs loses elasticity. The impact of steroids on connective tissue elasticity is well documented. In my opinion, the child never had asthma in the first place…they had over-reactive smooth muscle in their lungs, leading to reduced expiration, congestion and etc.
Somehow (and I don’t pretend to be the neurologist or clinical researcher-poser) the chiropractic adjustment reduces this over-reactivity, and normal breathing ensues.
Our website tithes more than 50% of our income to support chiropractic research, and over time we will learn more about what spinal subluxation is, how (or IF) it affects health, and how and why spinal adjusting seems to accomplish what it does.
REFERENCE:
1. Somatic Dysfunction and the Phenomenon of Visceral Disease Simulation
J Manipulative Physiol Ther 1995 (Jul); 18 (6): 379–397 (FULL TEXT)
http://www.chiro.org/research/ABSTRACTS/Visceral_Disease_Simulation.shtml
Good Heavens! Chiropractors have discovered that pain in any particular area could arise from many different sources including viscera bones joints and other tissues!
And from this rather belated awareness of the basics of differential diagnosis, we are asked to find “scientifically sound alternative explanation for the apparent effectiveness of a variety of somatic therapeutic interventions” meaning “chiropractic, acupuncture, rolfing, and Qi Gong, to name but a few”.
These are sweeping conclusions from rather mundane observations.
I think someone predcited that chiropractors would find some way of keeping the subluxation alive. Now it doesn’t actually cause the viscerak disease it just mimics it.
The reference cited by Dr. Frankmeister (Nansel D, Szlazak M. Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manipulative and Physiological Ther. 1995;18:379-397) actually concluded that “At present, there have been no appropriately controlled studies that establish that spinal manipulation or any other form of somatic therapy represents a valid curative strategy for the treatment of any internal organ disease. Furthermore, current scientific knowledge also fails to support the existence of a plausible biological mechanism that could account for a causal segmentally or regionally related ‘somato-visceral disease’ relationship. On the other hand, it has now been firmly established that somatic dysfunction is notorious in its ability to create overt signs and symptoms that can mimic,
or simulate (rather than cause), internal organ disease.”
As the title of the article implies, referred pain that simulates the symptoms of a visceral disease does not mean that visceral disease is present or that referred pain from a spinal segment can be a cause of visceral disease.
No one doubts that symptoms caused by “fixation” or degenerative changes in the spine, such as loss of mobility, can often be relieved by appropriate manipulation, but this has nothing to do with the cause or treatment of visceral disease.
The chiropractic vertebral subluxation theory states that a vertebral subluxation “compromises neural integrity and may influence organ system function and general health” (Association of Chiropractic Colleges), but according to Nansel and Szlazak, both chiropractors and authors of the 1995 study cited above, there is no evidence to suggest that spinal manipulation will cure any organic disease. And according to the 2009 study by 3 chiropractors and and a PhD in physical therapy (An epidemiological examination of the subluxation construct using Hill’s criteria of causation), “No supportive evidence is found for the chiropractic subluxation being associated with any disease process….This lack of supportive evidence suggests that the subluxation construct has no valid clinical applicability.”
Offering proof that loss of mobility in the spine can cause localized degenerative changes and that manipulation will relieve symptoms associated with such changes does not validate the chiropractic subluxation theory.
Good luck with your research. It would be wonderful if proof can be offered that adjusting a certain vertebra would cure a certain disease.
Dr. Mirtz has been unable to register due to some computer glitch, so I am posting this on his behalf:
Frankmeister
As lead author of the review study “An epidemiological examination of the subluxation construct using Hill’s criteria of causation” I wish to respond to your claim “studies that the authors chose to ignore.” I would like to submit to you that we did not “choose” to ignore any works. Our primary goal was to find evidence of the subluxation construct that would fulfill Hill’s criteria of causation. As you should know the definition we chose to use was the ACC’s Paradigm. This paradigm states that a subluxation as “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.”
As per Hill’s criteria, the experimental evidence can be applied to the animal model.The only studies found pertaining to subluxation and animal experiments was DeBoer and Hansen’s [27] and Henderson et al [28] work. These studies failed to isolate the subluxation as a quantifiable lesion.
[27] DeBoer KF, Hansen JM. Biomechanical analysis of an induced joint dysfunction (subluxation-mimic) in the thoracic spine of rabbits. J Manipulative Physiol Ther. 1993;16(2):74-81.
[28] Henderson CR, Cramer GD, Zhang Q, DeVocht JW, Fourmier JT.
Introducting the external link model for studying spine fixation and
misalignment: part 2, biomechanical features. J Manipulative Physiol Ther. 2007:30:279-294.
You cite Cramer’s 2004 work. We did not include this work for the simple reason is that one cannot argue that “spinal fixation” is a subluxation as indicated by the ACC Paradigm. The Cramer (2004) study did not find a “subluxation” that would be defined as “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.” Arguing that spinal fixation, a component of the subluxation, as a “subluxation” that offers “proof-positive” of the entire chiropractic lesion is untenable in reason. I will give two examples so you understand why one cannot advocate the spinal fixation = subluxation because all the criteria for the subluxation as defined by the ACC Paradigm are left, for the most part, unfulfilled. My first example is in the realm of cryptozoology. Just because someone has seen something in a lake does not mean that there exists a Loch Ness monster. Another example may be more extreme but I use this because it hammers home the point I am attempting to make. For example, just because a group uses a crucifix (such as the Ku Klux Klan) does not make them a Christian denomination. Thus you cannot suggest that something exists (subluxation) because it fulfills one of the many criteria (spinal fixation) of the “something” (subluxation) you want to exist.
As per the studies you bring forth, they were not “ignored” they simply did not fulfill the Hill’s criteria of subluxation as a causative agent in the process of disease. When reviewing these studies, none the of the results indicated a compromise of neural integrity and an influence on organ system function and general health.
Again in case you have failed to comprehend what it is that I am attempting to suggest: all you have is ONE paper that is suggestive of partially fulfilling “a complex of functional and/or structural and/or pathological articular changes”. Where is the animal models/research that demonstrates the portion “that compromise neural integrity and may influence organ system function and general health”? This is where the evidence you provided that you somehow suggest we chose to ignore is simply not robust enough. Your simply going to have to find a bunch of independent studies on a bunch of rats, quantify the that they have a subluxation (complex of functional and/or structural and/or pathological articular changes) and that this subluxation compromises neural integrity and that these rats, because they have subluxation will have end-organ dysfunction and a lack of general health.
What is interesting to note that Cramer (2006) noted that “while animal studies are both informative and provocative the small number of studies is inadequate as an evidence base.”
Cramer G, Budgell B, Henderson C, Khalsa P, Pickar J. Basic science research related to chiropractic spinal adjusting: the state of the art and recommendations revisited. J Manipulative Physiol Ther 2006;29;726-761.
I believe Dr Hall stated it best (and I repeat it here):the burden of proof falls on chiropractors to show
1. that the subluxation can be objectively demonstrated,
2. that it does cause interference with the nervous system, and
3. that it does cause disease.
The animal experiments you cited that you claimed we intentionally ignored do not fulfill #1, nor do they they fulfill #2. They also fail to fulfill #3.
Timothy A. Mirtz DC, PhD, CHES, CAPE
Assistant Professor
Division of Health, Physical Education, and Recreation University of South Dakota Vermillion, South Dakota http://www.usd.edu/
Um . . . that is asthma. I find it very peculiar how stridently you assert that you do not treat asthma, right before going on to boldly claim that after treating children with chiropractic, their asthma symptoms were relieved.
Why the double-speak?
Oh, and you claim that long-term steroid use will cause emphysema. Are you aware that steroids are used to *treat* emphysema? Or that untreated asthma can be lethal? I think death today is quite a bit worse than living long enough to develop emphysema in 50 years. (Though I’d like to see a reference for your claim that steroids can cause emphysema. My grandmother, who has been a heavy steroid user for many years due to her severe asthma, has never developed emphysema. She has skin that bruises if you look at it funny, but not emphysema. Another relative who has largely tried to avoid treating her asthma *does* have emphysema, however. Interesting, eh?)
These are just my own general observations, since that seems to be what this post has turned into, so if something is unclear, I’ll gladly clarify. When I refer to “most recent graduates” I mean most recent graduates from my school, I unfortunately can’t speak for the other schools. As a recent chiropractic school graduate, I have to agree with what chiro1 is saying. The general climate of the “chiropractic paradigm” is finally starting to change. The problem with the “subluxation” is that it has been overemphasized. There still seems to be an ever shrinking minority that wants to tie the “subluxation” to a plethora of visceral symptoms. “Subluxation” by in large has come to be interchangeable within the profession as joint restriction, or an aberrant motion segment, not “everything under the sun that it could have even a .00000001% possibility of causing.” The subluxation theory, like the theory of relativity, is just that, a theory, it is something that needs to be researched further to be proven or disproven.
Having taken the time to actually read the article in questions (which I did) the question to me is this: Since when… EVER… has The Absence of Evidence meant the Evidence of Absence? Meaning- just because something hasn’t been thoroughly researched (subluxation theory has yet to be properly and completely researched) does not mean that said thing doesn’t exist (which is the conclusion being drawn)- what’s being used in this article is known as a logical fallacy. (I’m sure that will raise some ire!)
However I do agree that the onus is on the profession to find a way to show some objective proof subluxation exists, I don’t know that the technology yet exists to document the slow, subclinical visceral changes that theoretically could occur with the “subluxation”.
I and most recent grads do not hang our hat on subluxation, because one universal definition doesn’t even exist, the chiropractic schools define it one way, the ACA another, the ICA another, so what is it? Does facet syndrome have a definition? Yes. Does SMT help resolve facet syndrome? Yes. Is a “subluxation” involved in a facet syndrome? By most definitions- Yes. Would a facet syndrome cause visceral symptoms? I wouldn’t risk my license on it.
The ONU study is 6+ years old, which is probably around the time this shift really started. I was in undergrad in 2003 when the study was released, and as an athletic training major, subluxation meant “less than a dislocation, or a self-reducing dislocation” that’s how I still define it because that is how the rest of the medical world understands subluxation. If I want to describe a chiropractic “subluxation” to another medical professional, I describe my subjective and objective findings, or with a diagnosis another medical professional can understand which is what most recent grads do, rather than slapping “subluxation” on it, because I personally have yet to treat anyone who only has a “chiropractic subluxation” and nothing else. Let the bashing begin…I’ll try to check back periodically, but no guarantee on a quick response.
@ face
you said:
“Since when… EVER… has The Absence of Evidence meant the Evidence of Absence? Meaning- just because something hasn’t been thoroughly researched (subluxation theory has yet to be properly and completely researched) does not mean that said thing doesn’t exist (which is the conclusion being drawn)- what’s being used in this article is known as a logical fallacy. (I’m sure that will raise some ire!)”
Right. Totally wrong. the null hypothesis is non-presence, non-existence, no difference, non-effectiveness…and so on. By your standard we should not fully discount the tooth fairy, spagetti monster, nose goblins or anything at all, based on the premise that they *might* exist and we simply have not done our homework. You’re basically talking about proving a negative.
Likewise, your hypothesis testing languge is a bit off. the “conclusion being drawn” is to “fail to reject the null” – you never “accept” the null.
the “conclusion” is:
“we see no convincing evidence – therefore, we have no reason to believe in its existence”
NOT
“we see no evidence, therefore it *does not* exist.”
get the diff?
However, you go on to say it anyway…
“…However I do agree that the onus is on the profession to find a way to show some objective proof subluxation exists…”
that is really the point here.
Eric G, point taken to the extreme regarding the tooth fairy, however duly noted, I understand your point. The problem is that by stating a profession should be eliminated because of lack of evidence of one series of diagnoses is somewhat ignorant. Granted some chiropractors base their practice around this series of diagnoses, and try to make them out to be more than they are, much to the disappointment and dissatisfaction of those of us others who try to hold themselves to a higher standard.
In my observation, our profession has been held back by the Palmerites, who feel that chiropractic was only meant to be what DD and BJ Palmer accomplished during their lifetime, and want to neglect any and all scientific advancements that have been made since. These chiropractors devote themselves to what BJ and DD professed during their lifetime, as if the Palmers would not want the profession to advance and change with the times. For far too long Chiropractors have accepted the statement “Chiropractic works” and neglected trying to find the reason it works. There are still idiots in chiropractic schools who think we don’t need research because “Chiropractic works” and that’s just good enough. These are the same people that say they don’t have time to put together a case study documenting how it works. It seems that many chiropractors failed to make the transition from the industrial age to the information age, and hopefully the chiropractors in my generation can make strides to close that gap and prove our worth.
face said,
“stating a profession should be eliminated because of lack of evidence of one series of diagnoses is somewhat ignorant.”
Yes, but this is not “one series of diagnoses;” it’s the whole basis of chiropractic and the only rationale for its existence as a separate discipline.
When one surgical procedure, the internal mammary artery ligation, was proven no better than placebo, the operation was eliminated and it would have been ignorant to call for the elimination of surgeons. But if all surgical procedures had been proven no better than placebo, the justification for the whole profession of surgery would have collapsed, even if the surgeon could show he also did a lot of non-surgical things that helped patients. He might apply very effective non-surgical treatments, and he might still try to call himself a surgeon, but he would not be doing “surgery.”
You are no longer practicing “chiropractic” but a kind of physical therapy. Why not admit that, reinvent a reformed evidence-based discipline under another name, and avoid being confused with the many chiropractors who are true believers in the subluxation construct, who reject vaccination, who do applied kinesiology, etc. When I look for a chiropractor in the phone book listings, I have no way to know whether I’ve found someone who holds to a higher standard or a quack.
“Having taken the time to actually read the article in questions (which I did) the question to me is this: Since when… EVER… has The Absence of Evidence meant the Evidence of Absence? ”
Always?
I must be a glutton for punishment… Moron- I mean moran There was an absence of evidence that the world was round when Columbus started his voyage.
Harriet- If looking in the phone book to find a surgeon, I also wouldn’t know if I was going to the best surgeon in the region, or a complete butcher. Like surgical procedures, the practice of chiropractic is meant to be fluid, and able to change. You then went from arguing the legitimacy of a diagnosis to arguing the legitimacy of a procedure. So if I read your original post and follow ups correctly, you have a problem with the subluxation construct not with SMT, so why the switch in your logic?
face on 18 Dec 2009 at 8:42 am “I must be a glutton for punishment… Moron- I mean moran There was an absence of evidence that the world was round when Columbus started his voyage.”
Moron, I mean ‘face’ it was well-known to scholars that the world was round when Columbus started his voyage.
The Foundation for Chiropractic Education and Research (FCER) announced in 2006 that it would become an “Evidence Based Resource Center in 2007.” In October of 2009, the FCER filed for bankruptcy.
Simultaneously, the Foundation for Chiropractic Progress, which conducts a public relations campaign for the chiropractic profession, announced that it had received $650,000 in pledges from vitamin companies, chiropractic schools, and other chiropractic organizations and vendors.
Both these announcements appeared in the October 7, 2009, issue of Dynamic Chiropractic.
It would appear that research may be less of a priority for the chiropractic profession than a public relations campaign.
If I may add, according to the foundation for chiro progress “Over the foundation’s history, volunteers contributed more than 33,000 articles and helped fund over 152 randomized, controlled trials concerning chiropractic manipulation, as well as supported over 100 research fellowships leading to MS and/or PhD degrees.” http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=54144
Yet, in all that, they never provided any evidence for the existence of subluxations of the benefit of “chiropractic adjustments.”
face said,
“If looking in the phone book to find a surgeon, I also wouldn’t know if I was going to the best surgeon in the region, or a complete butcher. Like surgical procedures, the practice of chiropractic is meant to be fluid, and able to change. You then went from arguing the legitimacy of a diagnosis to arguing the legitimacy of a procedure. So if I read your original post and follow ups correctly, you have a problem with the subluxation construct not with SMT, so why the switch in your logic?”
You missed the point of my analogy. Competent or not, every surgeon listed in the phone book does surgery, and does it for reality-based indications. No listed surgeon operates to remove evil spirits.
Not all of the chiropractors listed do chiropractic. So I have no way of knowing whether a listing is for one who rejects the subluxation construct or for one whose entire practice is based on a myth.
I don’t see any switch in my logic. SMT is legitimate when done to relieve mechanical low back pain; it is not legitimate when done to treat an imaginary subluxation. If the diagnosis of chiropractic subluxation is not supported by any evidence, any treatment for that diagnosis is unacceptable.
As an analogy, medical phlebotomy for hemochromatosis is acceptable, but diagnosing an imbalance in the four humours and removing blood for that diagnosis is unacceptable. If you did only medical phlebotomy, would you want to be lumped in with medieval bloodletters in the phone book, or would you want a separate listing so your potential customers would have some basis for judging what you really offer?
I don’t see how chiropractic can be rescued from the subluxation morass. While individuals may reject the subluxation construct, the schools and organizations simply can’t. It is written into law in 44 states and required for Medicare reimbursement. As I see it, your only hope is to distance yourself from “chiropractic” and re-define what you do under another name.
@ Face
“The problem is that by stating a profession should be eliminated because of lack of evidence of one series of diagnoses is somewhat ignorant.”
you are still asking for proof of a negative. why should you be allowed to practice if you cannot demonstrate it is effective? *I* can cure cancer with my x ray eyes, wouldn’t you like some evidence of that before you pay me? Would you like some assertion of how safe it is as function of how effective? Sorry, regulations and safeguards are reality.
“chiropractic works” – as a stand alone statement…not as you advocating that statement.
i had a conversation about this last night, and realized something that may be of great hinder to the chiro community. As far as I can tell (based on my chiro friends, your statements and the state of the field) chiros in general are simply *not taught* how to properly conduct research within DC school (as denoted by a course in research methods) and as well not taught how to appropriately evaluate evidence. WAIT! some surely are, some surely do…however, i was taught in highschool stats how to detangle all of the hypothesis wording, it was hammered in as I pursued my field (psychology). As a consequence, I possess the ability to evaluate research (of which subject matters I can fundamentally understand to begin with) and conduct my own (cross your fingers for my submission!). By the time I finished my M.S. i had something like 24 semester hours of stats and research methods (HSchool, B.S., M.S. together), without which there is no way I could properly evaluate research *or* conduct my own. have you been through similar rigor? this is not a competitive statement, simply a testament to the focus of the subject matter. Likewise, I could be mistaken.
if you start in undergrad kinesiology or physiology, and then go right into a DC program, where are you learning your research methods? maybe I am wrong, but the complete disjoint between the actual need for research/evidence and the perceived need, that you attest to within your field, definately suggests a deficieny in the education to begin with. *especially* if you wish to bring full validation to the field.
To say this a different way
chiropractic may be the true one excellent way to health. too bad for the field at large, they feel no need/are not capable of actually offering evidence needed to get credence from the sbm community.
Chiro1 has basically created a practice for himself wholly unoriented towards the BJ and DD approach. perhaps a career in research would suit you well; it appears it is needed.
Dr. Mirtz
Because 4 of your 32 references were written by my favorite critical thinker (Dr Joe Keating) I must assume you approve of his writing.
This is a definition from one of his articles:
• Subluxation complex—A theoretical model of motion segment dysfunction (subluxation) that incorporates the complex interaction of pathologic changes in nerve, muscle, ligamentous, vascular, and connective tissue. [1]
and this definition is quite reasonable. It also parallels the classic definition of the subluxation complex, which I was taught at Palmer in the early 1990′s:
The Five Components
Basic to this integrative review of the components of the Vertebral Subluxation Complex is the component nomenclature involved in the model:
Component #1 – Spinal Kinesiopathology — spinal pathomechanics, including alignment and motion irregularities
Component #2 – Neuropathophysiology/Neuropathology — compressed or facilitated nerve tissue
Component #3 – Myopathology — muscle spasm, muscle weakness/ atrophy
Component #4 – Histopathology — inflammation, edema and swelling of tissue, usually local to the traumatized area
Component #5 -Pathophysiology/Pathology — pathophysiologic and pathoanatomical changes due to the previous four components usually seen locally as degeneration, fibrous tissue and/or erosion local and peripherally as a loss of global homeostasis.
Please note that not one of these components mention visceral disease. The fact that chiropractic organizations have inserted the phrase “may influence organ system function and general health” is not a huge concern to me. I do think you agree that neck or low back pain do constitute an impediment to “general health”.
I mentioned in my previous post that I do NOT treat asthma, but have noted significant long-term improvements in patient’s symptoms after adjusting their spines. Make of that what you will. I have my own therory as to “why” SMT helped them, but let’s leave the heavy lifting to the researchers. [2]
You likely already know of other studies that tie together all 5 of these components.
• Facet joint inflammation induces radiculopathy. [3]
I await further work from Henderson to demonstrate that joint fixation can be a cause of that joint inflammation. Once that is demonstrated, the rest of the components of the subluxation complex all make sense.
• A theoretical framework exists from which hypotheses about the neurophysiological effects of spinal manipulation can be developed. An experimental body of evidence exists indicating that spinal manipulation impacts primary afferent neurons from paraspinal tissues, the motor control system and pain processing. Experimental work in this area is warranted and should be encouraged to help better understand mechanisms underlying the therapeutic scope of spinal manipulation. [3]
Dr. Pickar and Dr. Henderson continue to peck away at basic science. Over time, I believe they will help flesh out the facts associated with the subluxation complex…both physiologic and neurologic.
REFERENCES:
1. the quality of clinical practice guidelines
J Manipulative Physiol Ther 2003; 26 (3)
2. Effect of Chiropractic Treatment on the Endocrine and Immune System in Asthmatic Patients
Proceedings of the 2002 International Conference on Spinal Manipulation. 2002 (Oct)
http://www.chiro.org/research/ABSTRACTS/Effect_of_Chiropractic_Treatment.shtml
3. Does Facet Joint Inflammation Induce Radiculopathy?
An Investigation Using a Rat Model of Lumbar Facet Joint Inflammation
Spine 2007 (Feb 15); 32 (4): 406–412
http://www.chiro.org/research/ABSTRACTS/Does_Facet_Joint_Inflammation_Induce_Radiculopathy.shtml
3. Neurophysiological Effects of Spinal Manipulation
Spine J (North American Spine Society) 2002 (Sep); 2 (5): 357–671
http://www.chiro.org/LINKS/ABSTRACTS/Neurophysiological_Effects_of_Spinal_Manipulation.shtml
Joe- You must have been burned bad by a chiro to have such a chip on your shoulder…former lover? It was also “well known by scholars” that the Earth was the center of the universe, the point of my statement was that science makes progress.
Harriet- Interesting redirect on the analogy, however people don’t look in the phone book for a chiropractor to get their subluxations fixed, they look for a chiropractor for low back, neck pain or headaches. I would gladly list myself in the phone book as a manual therapist, however people don’t know what a manual therapist is. We’re going down a dead end road with this yellow pages discussion as there are PTs, DOs and Massage therapists who are listed under the chiropractic sections in yellow pages throughout the country. Oh and last time I checked there weren’t a whole lot of medieval bloodletters advertising in the yellow pages.
The switch in your logic occurs here:
“When one surgical procedure, the internal mammary artery ligation, was proven no better than placebo, the operation was eliminated and it would have been ignorant to call for the elimination of surgeons.”
You discuss a surgical procedure- internal mammary artery ligation and state it was found to be no better than placebo, and was thus eliminated. So SMT, a procedure, has been found to be a legitimate intervention for mechanical low back pain, and better than placebo. Subluxation is not a procedure, you follow?
I do agree, it is doubtful that subluxation and chiropractic could ever be effectively separated, but as an entity regardless of proof or disproof it does exist on paper as an entity, much like a person may incorporate their own name, and exist as separate from themself and only on paper. It is funny that you mention the idea of separation, I found it particularly interesting and approached our research department about doing a survey to determine if irreconsilable differences existed within the profession and if the “manual therapist chiropractors” should separate from the “subluxation chiropractors” alas the student research advisor did not feel that such a schism existed so I was encouraged to go another route.
EricG- As has been previously discussed, no one “owns” SMT, chiropractors do have far and away the most experience with it, but DOs, PTs and even some MDs use it. SMT, therapeutic exercise, mobilization, PNF and sound nutritional advice are all proven methods to deal with a wide variety of diagnoses beyond the subluxation diagnoses. I can order labs and imaging to arrive at the diagnosis and apply an intervention that has been demonstrated as effective that has nothing to do with subluxation. Unless I’m misunderstanding you, you seem to be neglecting the fact that chiropractors can diagnose beyond subluxation and apply effective interventions for non-subluxation based care.
With our initial go-round I was making a statement from a position of logic, and yours was from a position of research, rarely are they at odds, but I think that is where the initial misunderstanding came into play. You are correct, our research methodology course doesn’t come along until most students are satisfied with the “chiropractic works” statement. To combat this we started a journal club at school, but the people that needed their eyes opened the most were obviously not the ones at the meetings. The dynamics of chiropractic research have been pointed out, the FCER went bankrupt, only to be propped up by the schools and vitamin companies…if only we could get billions of research dollars from drug companies, perhaps we could start to pump out some “high quality” research (I’m accepting donations too). Lack of funding is a key contibutor to lack of research in any field. Aye- there’s the rub. I do hope to contribute to research as I can with case studies, case series’ and literature reviews, but I also have to eat, which reduces the likelihood of conducting research that has a higher quality ranking.
DrFrankmeister,
I am posting Dr. Mirtz’s response for him because he still is not able to log on due to some kind of subluxation in the website.
Frank
Your reference from Keating [the quality of clinical practice guidelines J Manipulative Physiol Ther 2003; 26 (3)] is in error.
Keating did not state what you believe he suggested i.e. the five components of the subluxation. Keating stated in that Letter to the Editor that:
“What chiropractic researchers have accomplished to date is not wrong or inappropriate; it has, however, sidestepped the issue of subluxation to directly address the question of patient benefit. I hasten to suggest that clinical improvements following adjustment/manipulation may not be mediated by subluxation reduction.”
Keating, in your reference, also noted: “I suggest that subluxation may be trivial or profound in the health and illness of patients (I don’t know; where are the data?).”
I ask you this: where is the data that the subluxation is real as chiropractors wish it to be? Where is the data that such a thing, with all the five components, is happening? You simply cannot go around and say “oh yeah, we’ve got some neurophysiology here, yup, we’ve got ourselves a subluxation” or “hey, look, we’ve got some myopathology, see what I told you, we’ve got ourselves a subluxation.” Sorry Frank, you simply cannot do this.
It’s like this Frank. Let’s say you believe in a North American Ape that roams around the forests of Washington State. Ok, we have tracks…..sorry, we don’t have a Bigfoot. Oh look, we see some poop here, hmmm, looks like we got ourselves a bigfoot. Oh wait, you saw one? In your backyard? Was reading the Swimsuit issue of Sports Illustrated? Wow, very intelligent Bigfoot you saw.
You see, you cannot take any of of these components of the existence of Bigfoot and call it real. You have to have the whole thing: a body and/or skeletal remains. Until an 18 wheeler hits one like a deer in South Dakota and we see it lying on the side of the road, will we all be convinced that a North American Ape exists. Until you have the whole subluxation will people be convinced.
And Frank, please, by all means, do not go into the old chiropractic diatribe of “they laughed at the Wright Brothers or they laughed at Copernicus.” Just because people laugh at the Three Stooges does not make the subluxation any more real.
Your second reference provides no evidence that a subluxation exists.
Your third reference concluded that: “When inflammation was induced in a facet joint, inflammatory reactions spread to nerve roots, and leg symptoms were induced by chemical factors. These results support the possibility that facet joint inflammation induces radiculopathy.”
This does not mean that a subluxation is present as chiropractors wish it to be.
Your fourth reference stated that the purpose was: The purpose of this review article is to examine the neurophysiological basis for the effects of spinal manipulation.
Again, there is no evidence that a subluxation exists.
Simply put Frank, all you have shown us is that there are effects of spinal manipulation. This is all well and good but it does not demonstrate the subluxation in your five component model.
In fact, I would venture to say that spinal manipulation can be easily carried out by any health care provider without any need to formally recognize the concept of “subluxation.”
Keating, in your first reference, suggested: In his brilliant but still overlooked essay,11 Nelson reminds the profession that:. . .”The question remains whether a subluxation theory can be formulated which retains some of the simplicity and explanatory power of Palmer’s and can survive experimental tests. If in the end the spine/health relationship is so complex and unpredictable that no definitive statements or distinctions can be made, then we will have concluded subluxations do not exist in any meaningful way. . .”
As well, Keating, in the same reference, noted: “If subluxation has no significant influence on health or illness, then there would be little point in attempting to reduce or eliminate subluxation.”
I agree. And this is what my team of researchers concluded from examining the evidence (or lack thereof) for subluxation using Hill’s Criteria.
Here is something that you should be concerned about: You stated that The fact that chiropractic organizations have inserted the phrase “may influence organ system function and general health” is not a huge concern to me. I do think you agree that neck or low back pain do constitute an impediment to “general health”.
It should be a huge concern for you. If you agree that neck and low back pain is an impediment then DC’s are caught in the realm of only being able to do that: neck and back pain. In fact, a DPT can be trained in spinal manipulative therapy and they do not concern themselves with the concept of subluxation…do they? In fact, I can have low back pain and not even be concerned at all that there is even a subluxation present. What do you think about that?
And really Frank, do not even attempt to change the argument because you know good and well that the neurophysiological aspect of the subluxation also means the “nerve chart of effects” and is essentially trying to mask the chiropractic objective of treating visceral-type disorders.
Again, you are using a strategy used by many a DC in past, present, and more than likely future debates: obfuscation. For example, someone is able to criticize the subluxation construct as essentially meaningless but there is always a DC that will come out of the woodwork and try to propose something that sounds scientific and may kind of, if you look at in very different light, is a subluxation. Also, these DC’s usually try to come out and say “well, this isn’t really the subluxation that I understand or is used by the profession, let me tell you what is really being said about subluxation.”
The attempt is noble but it fails miserably, has failed miserably, and will continue to fail miserably. DC’s who do come out of the woodwork and try to sound like there actually is evidence for the subluxation are only, in reality, fooling themselves.
Timothy A. Mirtz DC, PhD, CHES, CAPE
Assistant Professor
Division of Health, Physical Education, and Recreation University of South Dakota Vermillion, South Dakota http://www.usd.edu/
@ face
“Unless I’m misunderstanding you, you seem to be neglecting the fact that chiropractors can diagnose beyond subluxation and apply effective interventions for non-subluxation based care.”
Ok, i got you. but, well…in any event, let me try and overtly succinct.
this article discusses the evidence for subluxation, for which, it has concluded little exists. since the author has provided additional evidence that subluxation and chiro may be inextricably tied ( a point you appear to essentially reject, making you thus otherwise more of a PT or …something) the grounds for being a “straight” chiro (at the very least) are unfounded.
that is separate from a person, who happens to have a chiro background, practicing SMT, good nutrition counseling, ROM consultation etc.
I am adding that the lack of research methods in the DC curriculum has hindered the field in 2 ways:
1) not perceiving the need for research (based on some flavor of dogmatic adherance to BJ and DD palmer teachings)
2) not being able to correctly conduct research in order to validate the dogma and effectively transform it in to evidence.
“if only we could get billions of research dollars from drug companies, perhaps we could start to pump out some “high quality” research (I’m accepting donations too). Lack of funding is a key contributor to lack of research in any field.”
I would assert that is also partly due to curriculum deficiency. My co-author is a professor, I am a recently graduated student that now works full time. None of his work has ever received funding. Mine will not either. Apart from teaching classes, what are all the DC profs doing with their time? Whatever happened to all of the elder students experimenting on the newbies and making their thesis/dissertations out of it? Likewise, my brother is a student in an exercise science masters program. he is conducting research on neural adaptations and Olympic lifting and benefits to cycling. his N will be roundabouts….30! he will have to recruit everyone himself and gets nary a dime of support. are those not similar experimental conditions for a study on chiro?
Likewise, you say that a journal club had to be started in order to (i gather) in part “open people’s eyes.” that makes me laugh. from what? constant indoctrination? Funny, in my program, the professors made us repeatedly read articles and tear them apart to come to our own conclusions. We could scarcely even guess the profs political leanings much less their biases towards certain bodies of research. Their attitudes were veiled to the point of frustration…they felt it damn near a moral obligation to let us objectively come to our own conclusions.
“You are correct, our research methodology course doesn’t come along until most students are satisfied with the “chiropractic works” statement”
that is also highly suggestive of indoctrination. at some point they become resilient to reason? It is good that there is course material on the subject, but in what colossal folly would I have to similarly reject the need for research methods because “lewin’s theory of: unfreeze, change, refreeze ‘works’” and subsequently apply it to every organizational dysfunction I come across. what about *how* it works, under what circumstances it works, who is excluded etc. etc.
I’m not trying to attack you our your peoples, but i get this sense of extreme intellectual laziness. additionally, I am trying to understand, so i apologize in advance if I am being overly blunt or crass in assessment of the field.
just to put it out there, this is rehashed from elsewhere in the sbm forum.
if you want to cite wright brothers, old flat earth stuff, center of the universe etc. etc. etc. then…
“Alas, to wear the mantle of Galileo it is not enough that you be persecuted by an unkind establishment; you must also be right.”
face,
Are you deliberately trying to misunderstand me? If the diagnosis is wrong, treating that diagnosis is wrong too.
The chiropractic subluxation is a diagnosis that no more deserves a place in modern medicine than does the diagnosis of an imbalance of the four humours.
SMT is effective for relieving symptoms of low back pain; it has not been proven effective for most of the other things chiropractors use it for.
“the student research advisor did not feel that such a schism existed”
Does he feel that Timothy Mirtz and Sam Homola have no disagreement with the “straights” in the ICA? It sounds to me like he is out of contact with reality.
Dr. H. stated:
“the chiropractic subluxation is a diagnosis that no more deserves a place in modern medicine than does the diagnosis of an imbalance of the four humours.”
Hear, hear. I’ll add:
‘than does the naturopathic diagnosis that toxins, bowel transit time, and supplement deficiencies are impeding the vital force’.
-r.c.
Nonsense. NCCAM is tossing billions of dollars at “alternative medicine research.”
http://nccam.nih.gov/research/
Chiropractic has had over a century to prove the core concept of the profession. They haven’t.
EricG posts: >>”if you start in undergrad kinesiology or physiology, and then go right into a DC program, where are you learning your research methods?”<<
I am curious—if you start in undergrad kinesiology or physiology, and then go right into a MD program, where are you learning your research methods?
Bugguy- I was talking about chiropractic research only, since chiropractic is not the only alternative medicine, I’m not sure why you even brought up NCCAM as giving billions to alternative medicine, it’s not all going to chiropractic research, not even the majority, check your link to see where most of it is going.
Harriet- I really expected more from you… It’s ok, you can admit that you were ruh-ruh-ruh…ruh-ruh-ruh wrong when trying to illustrate your point using an invalid procedure instead of an invalid diagnosis. I’m not arguing that the diagnosis is not currently valid other than on paper as an accepted ICD entity. I’m with you, it hasn’t been proven yet, but it also hasn’t been completely defined with only one profession wide accepted definition. Regarding the gentleman I spoke with, I thought he was out of touch too, I thought it would have been an interesting piece, and one I might follow up with.
Eric- Thank you for keeping me in this, and curse you for wasting my time on a Saturday when I could be doing more productive things like putting together a study to prove the existence of the tooth fairy. You’re discussing research conducted in a setting that has the equipment and infrastructure in place, like I said before chiro schools are playing catchup, finally bonds are being formed for access to other universities, and joint research opportunities, but again due to lack of financial solvency, and lack of intellectual urgency, chiropractic research until recently was placed on the back burner. I can give a variety of reasons for it, the largest being professional bigotry within the medical and chiropractic fields. The manner you describe is the way we had to conduct research, however we didn’t always have all the necessary equipment to bring to the altar at the church of the RCT.
There is some indoctrination that occurs within the schools, but just as much that challenges the indoctrination (again I’m speaking only from my experience) however more of it occurs in the chiropractic community outside of the schools, which allows the folly to perpetuate itself because those students who are more succeptible to accepting things at face value are woo’d by the “straights” at weekend seminars. On some occasions this acceptance eroded their reason and some became zealots, again just an observation, but nonetheless what happened to 3 in my class.
Oh and by the by, if you wanted to avoid being crass, you should’ve withheld your 2nd statement, I am new to the site and not trying to rehash old statments, nor am I trying to don Galileo’s mantle, I was simply stating that science is in a constant state of flux, new discoveries are made everyday, or am I wrong about that too?
Face, I mentioned NCCAM because you were complaining about the lack of funding and I was pointing out a very large funding source for research. I can’t help it if chiropractors do not take advantage of it.
Considering some of the stuff that NCCAM has funded, I would think that serious chiropractic proposals would have little trouble being funded.
You have professional organizations. You have educational institutions and you have friendly corporations (like the companies that make the devices that so many chiropractors like to use). The research money is there if you really want it.
I still find it very odd that after over a century, chiropractors have not yet proven the core concept of their profession.
When I attended chiropractic college there was little talk regarding the theory of the “subluxation” complex. Rather my core chiropractic education was based on clinical human biomechanics and associated neuromusculoskeletal(NMS) conditions. When the “subluxation” complex was discussed it was explained as theory and would require much needed research. I consider myself a NMS practitioner with a philosophy of optimizing function/”health” of the human frame. I personally, don’t refer to the “subluxation” complex but rather osseous/segmental frame dysfunction. This may be similiar to some physical therapists and osteopathic physicians. Of course, many know that some osteopathic physicians use manipulation as do a growing number of physical therapists. For those interested in evidence-based literature regarding manipulation refer to the recent study that was published in The Journal of Human Hypertension 2007(May); 21(5): 347-352…we conclude that restoration of the Atlas Alignment is associated with marked sustained reduction(s) in blood pressure(BP)similiar to the use of a two drug combination therapy(17 point decrease). Does this reveal some proof regarding the “subluxation” complex it depends who you ask. The “subluxation” complex is currently a theory and a work in progress.
Face, re research into chiropractic theory—.
Harking back to the glib “absence of evidence does not mean evidence of absence” saying — even if the subluxation complex is conceived in the broadest possible terms, i.e. that “something can go on in the spine that can be relevant to the treatment of a range of human systemic and visceral illnesses”, we would ask “where are the grounds for such a speculation?”
The available clinical evidence can be adequately explained by other well-known phenomena. There is nothing in it to distinguish this area of chiropractic practice and theory from medical “systems” making similar dubious claims, such as homeopathy and naturopathy.
There is even contrary evidence in this case, as “chiropractic” effects are not observed in patients with genuine spinal pathology or spinal trauma of infinite variety.
Here lies the problem. Why should we consider the subluxation complex a serious scientific hypothesis, and thus worthy of research funds?
face said,
“it also hasn’t been completely defined with only one profession wide accepted definition”
tahoe69 wants to re-name it “osseous/segmental frame dysfunction” – whatever that means.
I see this confusion of terminology as even a bigger problem for chiropractic than the lack of evidence for “subluxation.”
A diagnosis like diabetes can be easily defined so that anyone can determine whether a patient has diabetes or not on the basis of a quantitative blood test. The causal lesions that chiropractors cite as a reason for chiropractic adjustments don’t even begin to approach that kind of clarity. Until they become more precise and figure out what they are really treating, it seems they are making up whatever words they choose to use as a justification to adjust the spine of any patient they choose. And it is impossible to do research on something that isn’t well-defined.
No, tahoe69, NUCCA still looks like hogwash, despite the hypertension study. Conscious or unconscious manipulation of the results or other error is far more likely than that this technique will have any reliable and durable effect on blood pressure.
I am not thinking only of the extreme implausibility of NUCCA claims.
The lack of essential steps in validating the methodology makes it look like the typical pseudoscience of the naive enthusiast. Just as chiropractors thought they could find subluxations on X-ray until they were tested out under controlled conditions, it is extremely doubtful if such tiny degrees of misalignement of the atlas could be consistently detected, and be “corrected”, let alone have any relevance to general health.
I see this is a rough crowd. Like i said before I don’t use “subluxation” complex as that was not the basis of my chiropractic core education. Rather I use many neuromusculoskeletal/orthopedic normenclature/terms used in “physical medicine”. I said the theory of the “subluxation” complex was taught to me as theory that would require research. You can belittle my definition of what I dx./treat with conservative chiropractic care/treatment but I have very good relations with medical physicians that seem to understand my diagnosis/treatment plans. All types of physical/orthopedic procedures/practitioners are being challenged regarding “evidence” of care provided. I was just on the American Pain Society web site and it refered to a recent study done by Stanford researchers published in Health Affairs. It shows that areas of the country with the highest number of MRIs have the highest incidence of surgery for lower back pain. Although, most of us are aware previous studies have shown that increased surgery for back pain doesn’t improve outcomes.” The net result is increased risks of unnecessary surgery for patients and increased costs for everyone else” said Dr. John Birkmeyer professor of surgery University of Michigan(not involved in study) regarding this study in Health Affairs. Maybe there’s plenty of finger pointing to do regarding “evidence”/unnecessary treatment/care.
@face on 18 Dec 2009 at 5:29 pm “Joe- You must have been burned bad by a chiro to have such a chip on your shoulder…former lover? …”
I have never been involved with a chiro in any way because, even when I was a child, it was clear they are idiots. It is really sad that high school graduates can believe in chiros.
ahoe69 on 19 Dec 2009 at 5:41 pm “I see this is a rough crowd. Like i said before I don’t use “subluxation” complex as that was not the basis of my chiropractic core education.”
Well, according to the above-cited Association of Chiropractic Colleges (cited below, again), you were cheated. You should sue your college since subluxation is the core value of chiropractic. You have spent money on a sham (well, all of you do that).
See the Association of Chiropractic Colleges http://www.chirocolleges.org/paradigm_scope_practice.html
“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.”
wow, I see this is the wrong place for me. I’m not only one of the “idiots” but I also was cheated during my professional education when I was told the “subluxation” complex is a theory. Now I have a busy chiropractic practice that refers and receives referrals from other health care providers. I have good intentions. I provide conservative chiropractic care for NMS patients/ conditions that you would find in many physical therapy/osteopathic clinics. Many of us in the chiropractic profession understand our professions short-comings. Many of the chiropractors I associate with don’t refer to the “subluxation” but rather “physical medicine” jargon/terminology. BUT speaking of “evidence” and the short-comings for that matter, a patient brought to my attention last month the “whistle blower” lawsuit against Pfizer and other PhRMA companies. I found it interesting because the “salepeople” of these drug companies were pushing the use of drugs for conditions not approved by the FDA. Pfizer has been fined/fees several billions of dollars over the last 10 yrs. The prosecutor in the recent case stated,” they’ve repeatedly marketed drugs for things they knew they couldn’t demonstrate efficacy for. That’s clearly criminal.” The latest drug I believe was Bextra that Pfizer was having it’s salespeople push it was found dangerous and taken off the market. Could it be that medications are being prescribed for conditions they’re not approved? I don’t see how that could be when all I hear is how all medicine is done/performed in absolutes/”evidence based”. Maybe it’s just “theory” that doctors/allied health care only listen to “salespeople” regarding the prescription/use of drugs.
When someone suggests that a person should not let a chiropractor touch their neck, does that concern apply to ALL physical therapists, osteopathic and medical physicians that perform cervical manipulation?
Regarding “evidence”/proof of medical procedure/care/treatment, I came accross this article; that about 15% of all drug sales in the U.S. are for unapproved uses without adequate evidence the medications work according to medical professor Randall Stafford at Stanford University. He estimates that doctors write MORE than 10 million such prescriptions.
Could it be that doctors are prescribing medication for which there’s inadequate “evidence”? GOOGLE the drug Zyprexa for which Lilly pleaded guilty $1.42 billion in fines/penalties January 2009. Is it that some doctors are listening to the “salespeople” and not the literature and/or the lack thereof. Maybe there’s lot’s of “idiots”.
@tahoe69 on 19 Dec 2009 at 7:23 pm
Am I to understand that you are proud to be an idiot and to cheat people out of their money on a daily basis? You know, if other people cheat, it doesn’t make you legit. The tuo quoque argument you tendered is how I know you are an idiot.
But, hey, don’t let me interfere with your grifting. Do tell us how many spinal maintenance adjustments a person needs to keep you financially flush …
tahoe69,
The defects of conventional medicine are not relevant to this discussion. You are attempting to distract our attention and are using the tu quoque logical fallacy. It would be much more productive if you would respond directly to the points in the article. Why is what you do “chiropractic” rather than physical therapy? It is a historical fact that the subluxation construct was the basis of chiropractic; and if you think the situation has changed, you should provide us with data rather than telling us what “many of the chiropractors you associate with” have said. Specifically, how many practicing chiropractors today believe that they are diagnosing chiropractic subluxations that cause nerve interference and disease?
“When someone suggests that a person should not let a chiropractor touch their neck, does that concern apply to ALL physical therapists, osteopathic and medical physicians that perform cervical manipulation?”
The concern applies to neck manipulation itself, not to the type of provider. The concern is greater when the treatment is given for a spurious diagnosis that is not known to cause nerve interference or disease. Or when neck manipulation is the primary treatment used by the provider for the great majority of patients.
Your correct regarding the procedure of cervical manipulation vs. the provider. But of course that question should apply to all who manipulate the cervical spine(is it worth the risk?). I’m not making such attempt to distract attention away from the topic. As I read through many of these entries I see many negative and hateful like comments. I said it earlier, I’m fully aware of the short-comings of the profession I have choosen. I will repeat this one more time I do not use the term “subluxation” and/or the theory “subluxation complex”. I also know many chiropractors who do not use that term but rather physical medicine jargon/terminology. You’ve belittled me with my other references/comments and others have used derogatory comments regarding chiropractic/chiropractors. I don’t have to believe/adhere to the “subluxation theory” nor do I, to be a licensed doctor of chiropractic. The university I attended did not emphasize the “subluxation” complex as I mentioned. I brought up medical doctors prescribing medication for conditions for which they have inadequate evidence since they’re often are the profession that seems to judge/condemn with ABSOLUTEs that chiropractic as lacking “evidence”. My diagnosis/treatment is based on neuromusculoskeletal(NMS) conditions found in physical medicine text/treatment facilities. I often get/give medical referrals. Your using a broad brush because you want to put every chiropractor in a box. It’s a theory. I provide conservative chiropractic care for physical medicine conditions. I suppose me commenting on the unnecessary lower back surgeries is inappropriate also. Again, these are the same people pointing fingers that prescribe and perform surgeries without adequate “evidence”. I guess doing it for profit at all cost is okay like the “spinal maintenance” comment “financially flush”. I don’t use the “subluxation” reference and I have a conservative approach to NMS conditions but I’m a terrible/predatory human being…….pathetic.
Theory:
I don’t think it means what you think it means.
Subluxation is not a theory. There is nowhere enough evidence to support the concept as a scientific theory. Or, as the authors of the article under review show, there is no evidence supporting subluxation.
tahoe69,
I am not your enemy. I support chiropractors who limit their practice to short-term treatment of musculoskeletal conditions, who reject the subluxation myth and quack methods like applied kinesiology, and who don’t discourage immunization (over half of chiropractors do). Some of these individuals are very skilled at SMT and have a lot of experience and can help patients. I just don’t think those individuals are doing “chiropractic” and I think they will have to distance themselves from that designation and re-invent what they do under another name.
This website is dedicated to criticizing non-science-based practices wherever they are found, in quackery, alternative medicine or conventional medicine. The medical journals are full of discussions of problems like unnecessary surgery, and we are trying hard to do better. Conventional medicine at least tries to be self-policing and self-correcting, and it is steadily increasing its percentage of evidence-based practices. Conventional medicine is constantly changing its practice to give up treatments that have been found ineffective. If chiropractic had been similarly science-based and self-policing, we would not be having this discussion. Chiropractic has no such tradition. The only thing I have ever found that the ENTIRE chiropractic community gave up was BJ’s nerve tracing nonsense where he claimed to palpate non-anatomical nerves through the skin.
Enemy or not is of no consequence. I have good intentions for patients and provide conservative chiropractic care for neuro-musculo-skeletal conditions. Again, I do not support or discuss with patients the “subluxation” complex. I have/maintain professional relationships with other health care providers. I consider myself part of the community physical medicine team that specializes in clinical human biomechanics/NMS conditions that uses/performs manual manipulation/mobilization of osseous joints that lack mechanical function. I also encourage a lifestyle to enhance the human frame ie. exercise, proper/optimal ergonomics and sound nutrition. I often refer patients to other medical professionals.
This discussion brought on an interest to the osteopathic lesion/philosophy. I will try to read a bit about the “osteopathic lesion”. It’s been a while but if my memory is correct the osteopathic philosophy has been/is concerned/interested in the functional disturbance of the osteopathic lesion. I believe early osteopathic doctors were preoccupied with the vascular system as opposed to the nervous system. Like I said I can’t recall, but it seems to me osteopathic doctors were taught/believe somatic dysfunction to preclude long-term sequelae. I have a friend wh happens to be a chiropractic who teaches at a osteopath college, I have a good reason to give him a call. You mentioned how the unnecessary surgeries can be explained, I also find it interesting drugs are being prescribed for conditions with inadequate evidence. Why prescribe a medication without refering to the absolute evidence based literature not a PhRMA sales person? Just asking of those asking of me. I will and do limit my practice of chiropractic to neuro-musculo-skeletal conditions…I hope that’s okay with you.
Enemy or not is of no consequence. I have good intentions for patients and provide conservative chiropractic care for neuro-musculo-skeletal conditions. Again, I do not support or discuss with patients the “subluxation” complex. I have/maintain professional relationships with other health care providers. I consider myself part of the community physical medicine team that specializes in clinical human biomechanics/NMS conditions that uses/performs manual manipulation/mobilization of osseous joints that lack mechanical function. I also encourage a lifestyle to enhance the human frame ie. exercise, proper/optimal ergonomics and sound nutrition. I often refer patients to other medical professionals.
This discussion brought on an interest to the osteopathic lesion/philosophy. I will try to read a bit about the “osteopathic lesion”. It’s been a while but if my memory is correct the osteopathic philosophy has been/is concerned/interested in the functional disturbance of the osteopathic lesion. I believe early osteopathic doctors were preoccupied with the vascular system as opposed to the nervous system. Like I said I can’t recall, but it seems to me osteopathic doctors were taught/believe somatic dysfunction to preclude long-term sequelae. I have a friend who happens to be a chiropractor who teaches at an osteopath college, I have a good reason to give him a call. You mentioned how the unnecessary surgeries can be explained, I also find it interesting drugs are being prescribed for conditions with inadequate evidence. Why prescribe a medication without refering to the absolute evidence based literature not a PhRMA sales person? Just asking of those asking of me. I will and do limit my practice of chiropractic to the treatment of neuro-musculo-skeletal conditions…I hope that’s okay with you.
tahoe69 went to chiropractic school, has a diploma that says “Doctor of Chiropractic”, has a chiropractic license, practices according to chiropractic scope, using the knowledge and skills taught at chiropractic school, ………..and now Harriet declares he is not “doing chiropractic”! Really Harriet? Wow that’s rich!
“An article written by 3 chiropractors and a PhD in physical education and published on December 2, 2009 in the journal Chiropractic and Osteopathy may have sounded the death knell for chiropractic.”
I doubt it. Homeopathy has been found to be unsupported by scientific inquiry and, yet, it’s still going strong. Peter Popoff was thoroughly exposed as a fraud in the ’80s, went bankrupt, and is now back in business and filthy rich again. Yes, chiropractic is nonsense but it’s unlikely to go away just because it’s been shown to be nonsense.
The nonsense will remain popular and very little will change.
tahoe69, if you are fighting against the subluxation end of the spectrum, great. But you should realize that you are coming across as defending those same practitioners as you defend the entire field.
You and others that think like you really need to start addressing the regulatory definitions or otherwise, Dr. Hall is right, you are not practicing chiropractic, as defined by the relevant regulations and laws. For example, Florida Statues, Title XXXII, chapter 460.403 (emphasis mine):
The legal definitiion of the practice specifies subluxations and also says that chiropractors do more than skeleto-muscular adjustments and treatment.
A quick survey of local chiropractor websites found statements supporting subluxation, the treatment of infant cholic (one of the things the BCA is suing Simon Singh about) and one even claimed that the Hep B vaccine was linked to autism. These were all in the top 5 Google search results for my area.
If you really want good, evidence-base care, then the people here are your allies, not your enemies.
[...] The article has the effect of relegating chiropractic to doing the same as physical therapy, when used for lower back pain, and of being completely useless when it comes to any other medical condition. Thus, with osteopaths and physical therapists, chiropractors have no place in modern medical practice. Here is the key quote, taken from the blog Science-Based Medicine: [...]
@Harriet Hall on 20 Dec 2009 at 12:23 am “tahoe69,
I am not your enemy. I support chiropractors who limit their practice to short-term treatment of musculoskeletal conditions, who reject the subluxation myth and quack methods like applied kinesiology, and who don’t discourage immunization (over half of chiropractors do).”
Doctor Hall, this is what I do not understand about your stance. When yo consider that 50% of chiros oppose vaccination, 90% believe in subluxations, 75% believe they can treat visceral illnesses etc.- 99.99% of them make the rest look bad. Those you think are rational are mere masseurs with delusions of grandeur. They would like us to think they are substitutes for PTs; but they don’t have that education unless they learned it ad hoc. I don’t trust ad hoc medical education.
I know I must be getting it about right when I am criticized both for being too mean to chiropractors and for being too nice.
I have sympathy for the rational chiropractors who are victims of their education and who are trapped in an unfortunate situation. Samuel Homola was one. He couldn’t afford to start over in a new profession, and he managed to separate the wheat from the chaff and help patients who otherwise would have resorted to a less scrupulous chiropractor. I’m in favor of trying to leave people like Sam a means of livelihood.
Ah, back in the action.
@ nobs – Sure. Might an MD briefly share where and when they received their research methods training? I am not pretending to assume they recieve it.
@ face – ah, ‘the debate” is strong in you as well?! I willed myself to avoid this site all weekend for that reason, sorry to compel you further…
I accept your position and merely reinforce that the burden of proof rest sqaurely on the shoulders of those making the claims. I am sorry your field lacks the tools and funding (or whatever it may be) to do better research. I am not sure any level of understanding will shield it from further criticism, not that you imply it would…but all the same.
My eyes widen at some of things you are witnessing, in that, this seemingly underfunded, intellectually resistant, minimally researched, folly-perpetuating field is the same field that we should trust to provide quality care? Not exactly stoking confidence in the practice, for me personally.
Not trying to twist your statements here, but I keep hearing, “yea, we got a lot of problems, but we’re working on it! Just give us a sec!”
The Gallileo comment was more directed at whoever cited the wright brothers and to anyone else who tempted to fall back on that fallacy. It just happened to come to mind immediately after a post directed at you. As well, *I* rehashed that quote from elsewhere in the site (as in, I’m not taking credit), not a slight to you. Apologies for lack of clarity.
@ Tahoe – my question is simple:
Can you or can you not provide evidence to support subluxation theory? That is, after all, the point of this blog entry. Your personal experience, though having made for a sufficiently engaging exchange, has seemingly evoked unnecessary back and forth barbs if you don’t agree that subluxation is the lynchpin on which the entire practice of chiro rests.
I was able to find a few minutes to discuss this site/topic with a couple other doctors of chiropractic. One of the chiropractors mentioned the voice and power of the anitvaccination minority( a small minority). I was also directed to an article published in The Journal of Chiropractic Humanities: Survey of U.S. Chiropractor Attitudes and Behavior about Subluxation. I looked this article over rather quickly as my Vikings were getting beat by the Carolina Panthers. Anyways, out of 67,217 chiropractors 5,931 were surveyed “nearly” 50% responded. Of those responded 48% reported their chiropractic education was predominately “subluxation” based. It went on to say that ‘most chiropractors typicaly reported that over 75% of their clinical approach to neuromusculoskeletal or biomechanical disorders such as back pain was “subluxation based”. Conversely, most chiropractors also reported less than 20% of their clinical approach was “subluxation based” for patients deemed to be principally problems with circulation, digestion or similarly visceral in nature.
Although, not allowed here… I consider myself a progressive and change-orientated doctor of chiropractic. My core chiropractic education did not emphasize the “subluxation” complex nor do I use that teminology instead I use physical medicine jargon/terminology. There are several schools that have rejected the historical concept of the chiropractic subluxation. Instead biomechanical terms are used like joint complex dysfunction. As I mentioned earlier, I’m well aware of the professions short-comings as are many others. The old school/vocal minority is lingustically framed to be perceived as the majority by many who can’t resist the broad brush approach at the expense of others.
tahoe – i like that response. however, lets put it this way.
suppose 80% of all chiro reject subluxations. The term “chiropractor” still encompasses those that do not. this provides shelter to those who believe in archaic terms and mystical origins of ill-health.
I think what HH is getting at (and please feel free to disagree, HH or anyone else) is that chiro needs a makeover, a “member review” or to somehow make a distinction between the two – as demonstrated by the call to label your type as a PT or something else. can you really feign surprise that someone would broad stroke brush it, given the context you just discussed?
a chiro can either be a woo based quack or a science based “neuromusculoskeletal or biomechanical” practioner. you of course are the latter. busting subluxation helps to separate you from the quacks, i see the findings as beneficial if you wholly represent everything you have thus far claimed to be.
I was just searching for this article that was mentioned to me when I came across some info. about a nearby M.D. H.M.D practice that specializes in cancer chelation treatment/therapy just 30-40 miles from here. I’ll look into that later. Anyways, it was mentioned earlier that all those terrible chiropractors are against vaccinations. So I was directed to a few articles. Here’s one:Chiropractors and Vaccination: A Historical Perspective it’s published in Pediatrics Vol. 105 4 April 2000, p. e43; To determine the prevalence of antivaccination attitudes within the community, Colley and Haas conducted a survey of about 1% licensed chiropractors. Although, the response rate to the the survey was VERY small 36%/171 respondents believed there is no scientific proof that immunization prevents disease. IN the discussion portion it was stated: Today this antivaccination sentiment continues to be espoused by what seems to be a minority of chiropractors. More progressive evidence-based chiropractors have embraced the concept of vaccination. I wonder if a devilish chiropractor was/is behind all those health care workers (worldwide) that have/are refusing the H1N1 vaccine?
Many of the chiropractors who say they are not anti-vaccine are not pro-vaccine either, and they tell their patients to choose for themselves in such a way that tends to discourage them from vaccinating. For more on chiropractic and vaccinations (with references cited), see http://www.chirobase.org/06DD/chiroimmu.html
An excerpt:
“In 1999, Dynamic Chiropractic invited readers to state whether they have immunized their children. This method is not precise way to collect such data, but the answers were still interesting. Of 140 responses, the results were:
My children have received absolutely no vaccinations: 59 (42%)
My children received only some of the usually required vaccinations: 31 (22%)
My children have received all of the usual required vaccinations 50 (36%)”
There are still chiropractors who deny the germ theory. There is at least one in my local community. He told me “If germs caused disease, we’d all be dead.”
wow, I see no matter what I say/claim it’s wrong/false. Now chiropractors don’t believe in the “germ theory”. I have to laugh. The strategy of giving full attention to the vocal minority(very small) is somewhat like the strategy of a false attack. I was hoping to learn something in this thread instead it was often a written(verbal) beat down. NO nuance, but guilty by association/black and white thinking/your either with us or against us…..pathetic. I suspect many here are of a different/earlier generation. I admitted that short-comings existed in the profession of chiropractic, but I know of the claims made are of a very small/shrinking minority. I have been criticized by others for attending a school that didn’t emphasize the “subluxation” complex but instead the joint dysfunction complex/clinical human biomechanics. I can assure you I have a very good understanding of the “germ theory” from biology class in high school. I did take a history of medicine class that did mention the “soil or seed” mental battle(s) between Bernard and Pasteur. Well, I tried my best to climb out of the box I was put in. No worries…… we are getting 8-10″ of white powder tonight……the skiing will be great.
tahoe69,
Did you even read the link I provided, showing the published statements of the major chiropractic organizations and other data?
The statistics from the 1999 Dynamic Chiropractic poll indicate that chiropractors who accept immunizations for their own children are the minority. How about the info on the chiropractic pediatric text? How about the 2002 study showing that anti-vaccine opinions increased as students progressed through chiropractic school?
No one has put you personally in an anti-vaccine or germ theory denial box, or even in a subluxation box. You put yourself in a “chiropractic” box. We are simply trying to show that the chiropractic box contains a lot of pro-subluxation, anti-vaccine individuals. You tell us the bad apples in that box are in the minority, when many of us believe they are a majority. Even if they are a minority, how can the consumer know what he is getting when he picks an apple out of that box at random? Can’t you see the advantage to both you and your patients of moving all the good apples to a separate box? Or getting rid of the bad apples? Some people want to throw out the whole box; I personally think the good apples are worth saving.
My children have received absolutely no vaccinations: 59 (42%)
My children received only some of the usually required vaccinations: 31 (22%)
My children have received all of the usual required vaccinations 50 (36%)”
Personally, no offense I’m not going to waste my time with stephen barrett board “certified” psychiatrist. Regarding this 10 yr. old poll,
out of 140 respondents=(some vacs.31+all vacs.50)=81/58%
(absolutely no vacs…….59)=59/42%
Well, it’s been somewhat interesting. Thanks for the input. If you ski check out tahoe. Maybe you can tell me about the M.D.,H.M.D. using chelation/homeopathics for cancer treatment in my area.
tahoe69,
I’m disappointed to see you falling into the same tired old logical fallacies other chiropractors use when trying to defend their livelihood.
“Personally, no offense I’m not going to waste my time with stephen barrett board “certified” psychiatrist.”
What? Stephen Barrett has nothing to do with this. I linked to his website as a convenient source of information. He referenced a vaccine attitude study published in a chiropractic magazine. He also mentioned other references that you choose to ignore, like the article showing increased anti-vaccine attitudes as students progress through chiropractic school.
If you are ignoring any references cited on that website because of the person who cited them, you are committing the worst kind of ad hominem fallacy.
“Maybe you can tell me about the M.D.,H.M.D. using chelation/homeopathics for cancer treatment in my area.”
I warned you about the tu quoque fallacy earlier. Medical sins do nothing to confirm chiropractic virtues. As a matter of fact, we have already “told you” about doctors like the one you mention. There are several articles on our website condemning chelation, homeopathy, and bogus cancer treatments.
Chiropractic was and is based on the subluxation construct. Your attempts to deny this fact are not convincing.
Well, maybe we can agree to disagree. I realize my profession is less than perfect. I also realize I’m less than perfect. To me this is much more than science so I often (not always) follow the money and the
culture club/politics trail. I was often (purposely) misunderstood here but that’s ok, I understand the strategy. I have a best practice/evidence based approach to patient care of NMS conditions. I don’t bad mouth other practitioners and I read the literature(medscape)routinely. My skin has thicken being a chiropractor(second class citizen/professional) so the insults don’t damage.
HH-
“Even if they are a minority, how can the consumer know what he is getting when he picks an apple out of that box at random? Can’t you see the advantage to both you and your patients of moving all the good apples to a separate box? Or getting rid of the bad apples? Some people want to throw out the whole box; I personally think the good apples are worth saving.”
well put, i speculated that this was your ultimate point. Not sure why tahoe is choosing to ignore it twice, when the conclusion is ultimately to his(?) benefit.
[...] They have never been shown to cause disease. Critics of chiropractic have been pointing this out for decades, but now chiropractors themselves have come to the same conclusion.” – Full Article Source [...]
I don’t know why I’m responding to this, but I just couldn’t help myself. It’s hilarious how chiropractic is still branded, by the ignorant, as the quacks that rant on about subluxations and schedule patients appointments 3x/wk for a patient’s lifetime. I finished chiropractic school earlier this year and among all the students and faculty I encountered, less than 10% ever even used the word “subluxation.” Way too much time is spent trashing the false precepts of some of the older practitioners instead of educating yourselves in what is currently being taught at the majority of institutions.
In the same way that modern medicine was absolutely not founded on empirical evidence, chiropractic wasn’t either. The end of subluxation (which is actually just a matter of syntax as it has nothing to do with how a practitioner actually renders treatment) will not end chiropractic. Chiropractic has continually evolved over the years and will continue to serve the public as a non-invasive means of treatment by a provider who has passed 4 parts of national boards and undergone 10 semesters of graduate training in physical diagnosis, manipulation, physical medicine, differential diagnosis, diagnostic imaging, and a wide array of other courses required to earn the brand of Primary Care (and in my state to be licensed by the board of medicine).
To bash and banter about the machine known as chiropractic is futile, because it’s too big to stop now and too valuable to the public for anyone to just shrug their shoulders and say… “well it was a good run, but it’s finally over.” All this energy would be better spent (for the patients and practitioners) trying to IMPROVE the profession to the safest, most effective, research-based level of treatment within the chiropractic scope. Maybe that doesn’t sound appealing though… maybe it’s simply more fun to preach to the same chaps that will chime in with you, and snicker with fellow colleagues about the worthless chiropractors and their silly ways which will SOMEDAY finally come to an end.
Let’s deconstruct this point by point, shall we?
“All the professional organizations and schools are lying through their teeth, not teaching what they claim to teach, and don’t believe what they claim to believe” presented as a reason to have confidence in chiropractic. Hilarious.
Utterly false. Being founded on evidence is what DEFINES modern medicine.
No, just the end of any reason for it to actually exist. Other than making lots of money by defrauding victims – er, excuse me, patients.
Now compare that to the training of REAL doctors, and observe that “Primary Care” and licensing are determined by politicians rather than people with the faintest clue what they’re talking about.
Argumentum ad populum.
Evidence that it has ANY meaningful value to the public outside the very narrow field of uncomplicated back pain, please.
Observing that the profession is unscientific and primarily offers quackery, and should therefore not be patronized by anyone, is a crucially important task until and unless those facts are addressed by the profession.
Protecting people from wasting their money on quackery that might kill them isn’t worthwhile now?
You reinforce my point, Scott. You’ve successfully “deconstructed” everything I’ve written with nothing other than your own narrow opinions and fallacious arguments. Instead of hearing anything constructive I wrote, you simply retaliate under the same false premise I described. Because… you enjoy it more. Bravo, thoughtful citizen!
Why don’t you actually provide some evidence that anything I said was inaccurate?
Actually I would be extremely interested in knowing what kind of things this recent chiropractic graduate has been taught to diagnose and treat, within his capacity as a “Primary Care” practitioner.
Care to advise us, user9876?
pmoran,
I completed internships at the university clinic, VA hospital, St. Patrick’s Medical Center, and a Sports Medicine orthopedic surgery practice. I did go above what was required, because I wanted to be the best practitioner I could. However, the academic opportunity, for virtually any current chiropractic student, is excellent to those interested in pursuing it. I can accurately diagnose most anything a competent general practitioner MD or DO could (be it fractures, infections vs viruses, CHF, UMNLs, sprain/strains, DJD, RA, etc.). I have close friends who went to medical school and it’s clear that our training differs mostly in treatment… not diagnosis.
As a primary care provider, this training is useful to be confident in where to refer the patients when necessary, not because I think I can treat cancer or cast fractures. It simply means that I’m competent enough to know how to rule out the red flags and send them elsewhere if it isn’t a mechanical NMS issue.
What I am authorized to do is SMT, rehab of damaged muscles or ligaments, exercise prescription, occupational or physiotherapy, and nutrition counselling. I’m fine with limiting my practice to this and I’m certainly not threatened by PTs or OTs. I know they’re effective practitioners, but chiropractic school appealed to me more due to being more thorough and versatile. Sadly, there’s more than enough hurting people, needing care, to go around to all physical medicine providers.
user9876-I’m an non-subluxation chiropractor as well but I had just a slight correction on what you said. You might have known this but I think it came across a little incorrectly.
Chiropractors are authorized to function as primary care physicians however what you described is more of a portal of entry provider. Primary care would be more of a doc who serves to moniter the general health needs of a patient (like high BP or obesity) while the patient is undergoing treatment by another provider for a specific condition. If a person is against using drugs and surgery but needs the care of an neurosurgeon for removal of a glioma, the chiropractor could serve to monitor their basic health problems and refer them to specific providers accordingly.
Personally I think it’s more of a burden to carry and prefer to function solely as portal of entry rather than primary care. Unfortunately I do believe chiropractors like us are more of the exceptions than the standard. Why are you on this site though? There are better ways of wasting time…lol. Happy New Years!
@user9876 on 31 Dec 2009 at 6:53 pm
The Assoc Chiro Colleges maintains that the central tenet of chiro is the subluxation, if you did not learn same, you were cheated. More likely, you just applied a different term because “sublux” has become as embarrassing as Innate Intelligence. The McDonald survey shows that 90% of chiros believe in sublux. The sources have been cited many times.
You are not the first person to try that dodge.
@user9876 on 31 Dec 2009 at 6:53 pm “I can accurately diagnose most anything a competent general practitioner MD or DO could”
In your dreams.
@user9876 on 31 Dec 2009 at 6:53 pm “What I am authorized to do is SMT, rehab of damaged muscles or ligaments, exercise prescription, occupational or physiotherapy, and nutrition counselling.”
Except for SMT, that is not chiro. You may be “authorized” by ignorant legislators, it doesn’t mean you are well-trained.
You are a masseur with delusions of grandeur.
@jasons on 31 Dec 2009 at 9:00 pm “user9876-I’m an non-subluxation chiropractor as well …”
And another chiro who claims not to practice chiro. Did it ever occur to you that there was more wrong with your “education” than sublux and II? Or do you still kinda believe believe in sublux, perhaps by some other name? You people are tiresome.
@user 9876:
“What I am authorized to do is SMT, rehab of damaged muscles or ligaments, exercise prescription, occupational or physiotherapy, and nutrition counselling.”
The various regulators of the separate (from you and from each other) professions known as physiotherapy and occupational therapy, would disagree. You are NOT authorized to “do” occupational or physiotherapy. Not by them. As a physiotherapist, I resent chiros who claim to be able to “do” PT. So go get some professional boundaries, would you?
@Diane, Chiro is a cult, not a profession. Once licensed, they do whatever they please. However, do you recall the Arkansas chiro board fining a PT for performing an “adjustment” rather than a “manipulation” of a patient’s back? It cost the guy $10,000 plus untold legal defense bills merely because the patient’s back made a popping sound.
@Joe, I do remember that incident.
Canada’s situation is a bit different. Here, individual PTs have never, to my knowledge, been legally predated in such a manner. We have always had/retained the right to perform manual treatment of any sort.
Diane,
I do apologize if you’re offended that I know how to do physiotherapy, but I had 2 years of PT classes in chiro school, have an additional master of science degree in rehab, and hold national board certification in physiotherapy and adjunctive procedures. Whether you like it or not, I’m authorized to do provide these services. I don’t think you should feel threatened or angered by this. I didn’t become a chiropractor so I could pretend to be a PT. I gained further rehab knowledge to have as many tools in my belt as possible to help patients. I think you guys are great at what you do and I’m sorry for the chiros that don’t know jack about PT, and claim they can do it as well as you.
Joe,
I don’t mind responding to people who actually have something to say, but like Scott, your comments aren’t even worth entertaining. Telling me how little I know and what I believe without ever meeting me is as dangerous as prejudging a man based on the color of his skin. You disgust me.
Some chiropractors may be qualified to diagnose, but they are the exception. One study showed that most chiropractors failed to recognize the classic symptoms of a heart attack and offered manipulation for it rather than sending the patient to a hospital. Another study showed that they did not know that fever in a newborn was a medical emergency. Chiropractors are not equipped to act as point-of-entry or family health care providers.
@user9876
>”I do apologize if you’re offended that I know how to do physiotherapy, but I had 2 years of PT classes in chiro school, have an additional master of science degree in rehab, and hold national board certification in physiotherapy and adjunctive procedures.”
In other words, your chiro school told you you were qualified, not actual PT or OT schools.
>”Whether you like it or not, I’m authorized to do provide these services.
Yup. Just like chiro has got itself legislated and continues to get itself legislated into legality of this or that, by continually ignoring boundaries of other professions. If there is a code for something, chiro will figure out a way to legally bill for it.
>”I don’t think you should feel threatened or angered by this. I didn’t become a chiropractor so I could pretend to be a PT.”
I’m sure you didn’t, you likely just want to be able to uninterferedly bill for it.
>”I gained further rehab knowledge to have as many tools in my belt as possible to help patients. I think you guys are great at what you do and I’m sorry for the chiros that don’t know jack about PT, and claim they can do it as well as you.”
Does that include you? Gee, I wonder why I feel patronized? Not threatened nor angered. No. More like annoyed and patronized.
user9876,
If you and your recent classmates are so grounded in science-based procedures, why are you not in the lead in fighting those “Old school” chiropractors that are diagnosing and treating subluxations? Why are you not fighting back against those the push all forms of quackery on the public? Why are you not working to get state licensing statutes (like that for Florida I quoted earlier in this thread) changed to reflect that your practice is not based on diagnosing and treating subluxations?
To me, it would be in your best interest to fight against these practices that make your profession look bad.
Please explain to me how I can search for chiropractors for almost any city in the US and find the top search hits include chiropractors that talk about subluxation, or mention treating infant cholic, or the value of maintenance adjustments on children and adults.
If you are among those that are trying to change the system, Great. This place could be a great resource for you. However, if you wish to defend the entire system, then you are going to have to expect people to wonder about your committment to science-based treatments.
Diane,
Oh my goodness! Another person I wasted a paragraph on. The level of hostility the PTs on this site bring to someone, based on nothing more than their profession, is ASTOUNDING! Were your families murdered by chiropractors or something???? How you could possibly turn my last post towards to you into what you did is remarkable. Well done. You’re a natural born antagonist.
Harriet,
It appears you’re about the only one on here without some sort of personal vendetta. I find those studies disheartening, but what I’m saying is that the focus should be on demanding better training for my colleagues rather than attempting to obliterate or end the profession that patients clearly appreciate (As it was surveyed by the public to be the most satisfying treatment for back pain – http://www.consumerreports.org/health/medical-conditions-treatments/back-pain/overview/back-pain.htm).
When I took Part IV of national boards, one of the patient actors actually did demonstrate symptoms of a heart attack we had to identify. Perhaps the NBCE heard about that study and is working to improve medical emergency protocol training.
Bug Guy,
You’re right. That is what I try to do. However, it’s difficult enough to get legislature in place, let alone, to change it. The written scope of practice in many states is still so ancient (talking about nerve energy and whatnot) that it is embarrassing, but it’s very difficult to get this stuff changed without complete support.
A lot of these older docs don’t want to change how they talk to patients. The BOOP model is incorrect, but it’s easy for patients to understand. It’s tough for a doc that’s been using that explanation and seen thousands of patients getting out of pain, for the past 30 years, to explain it differently. The changes will come as the older docs retire and the new generation is all that is left. Already, there is a paradigm shift in place.
I do continue to try to educate those docs, but with that said, I still think that the profession(as a whole) does MUCH more good than harm. It wouldn’t be right for me to just bash them completely. I know that some are absolute criminals and I have to trust that they will eventually be exposed and stop giving the rest of us a bad name.
@user9876 What “paradigm shift?” Below is the Association of Chiro Colleges “paradigm” for 2009:
“Chiropractic is Concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.”
http://www.chirocolleges.org/paradigm_scope_practice.html
That’s right out of DD Palmer. You’ll never get rid of it because, despite your claim that only 10% of your classmates talk about subluxations, 90% of chiros believe in it by some name.
So, your school gave you two years of PT training, did they offer dentistry and rocket-science too? Do you know how many years a PT studies in a real school these days?
@user9876 on 01 Jan 2010 at 2:35 pm “… The BOOP model is incorrect, but it’s easy for patients to understand.”
Okay, what is the correct model?
“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.”
http://www.chirocolleges.org/paradigm_scope_practice.html
What does that mean? “Anything we can bill for”?
“As it was surveyed by the public to be the most satisfying treatment for back pain”
Not an acceptable argument.
User9878 ” Telling me how little I know and what I believe without ever meeting me is as dangerous as prejudging a man based on the color of his skin. You disgust me.”
But you do come across as having the prevalent chiropractic delusion that primary patient care is easy.
Talk to any doctor, and they will tell you that they learnt far more about practical medicine (and their own limitations) during the first two or three years after finishing med school than in med school itself, during mandatory supervised experience under intense patient load within hospitals and group practices. No chiropractor has this kind of hands-on training or, for that matter, a patient load that will maintain clinical skills.
Yet even doctors with these advantages make basic diagnostic and management errors, not all of which get picked up before the patient comes to harm. Medicine is very complex, common illnesses can present in very atypical ways, and what looks easy on paper can be anything but in the real world.
So I ask you why we would feel comfortable with LESS well-trained personnel taking over a primary care role?.
Of course, a great deal of primary medical care IS easy. Most everyday medical complaints are either placebo responsive or get better on their own. Chiropractic practice is likely to be heavily slanted towards these kind of conditions through the self-selection of patients.
This helps create the general illusion among chiropractors that what doctors do, and *also have to take take full responsibility for*, is a piece of cake.
My favorite part is when they say, “YOU FEEL BETTER NOW.” Isn’t that great after 5-7 minutes? Somebody’s making big bucks! Oh, this has been discussed earlier. I was taking my 5 yr old to get vaccines from our MEDICAL doctor. The chiro stopped, looked at me in mortal dread. He then gave me loads of info about extreme dangers of vaccines to my children. Guess what! My daughter GOT THOSE VACCINES from her medical doctor anyway. AND we get the flu shot EVERY year!
A few chiropractors have weighed in here now, and at least three have flamed out, exiting the discussion with parting insults and ad hominems, often equating criticism with insult. Only chiro1, I think, was consistently polite despite being badly out-numbered and (in my opinion) out-gunned. The others, especially “DrFrankmeister,” “face”, “tahoe69″, and “user9876″, have generally dragged the level of discourse down.
DrFrankmeister repeatedly used the defense that people who disagree with him aren’t sincerely interested in science, while citing such weak and irrelevant science himself that it became difficult to believe we were having the same conversation.
Face called one of his critics a “moron” early on, and generally did his bit to portray criticism as attack: “let the bashing begin,” and telling Joe, “You must have been burned bad by a chiro to have such a chip on your shoulder….”
Tahoe69 stuck it for a long time but became increasingly defensive and finally took his marbles somewhere else with the parting shot “I don’t bad mouth other practitioners,” presumably implying that he’s been bad-mouthed here — when, on the contrary, I thought the SBM regulars made a real effort to recruit him as a potentially critical-thinking chiro.
And user9876 thinks that “the level of hostility” at SBM.org “is ASTOUNDING! Were your families murdered by chiropractors or something??” That was a hyperbolic exaggeration of (particularly) Diane’s mild annoyance.
Criticism is not bashing, bad mouthing or hostility. If the chiropractors who joined this conversation expected anything less than strong criticism from well-armed opponents, they were being naive. To dismiss that criticism as mean-spirited simply confirms for all observers that their own arguments are lacking in substance.
[...] in all den Unsinn, an den Hitler glaubte. Wie bei anderen alternativmedizinischen Methoden gibt es keine Belege, dass Chiropraktik (Manipulation der Wirbelsäule) irgendetwas bringt. Im Gegenteil. Der Skeptiker [...]
Views and opinions of a “science-based chiropractor”:
I spent 43 years in private practice as a chiropractor. If I had it to do over again, I would study physical therapy rather than chiropractic. Considering the controversy that continues to surround the practice of chiropractic, I would not recommend that anyone spend the time, effort, and money required to earn a degree in chiropractic. Physical therapy now offers better opportunity for those interested in science-based manual therapy.
After my second year in chiropractic college, I came to the conclusion that the chiropractic subluxation theory was not a credible construct. From perusal of orthopedic and physical medicine texts, however, I felt that spinal manipulation in combination with physical therapy modalities had something special and unique to offer in the treatment of back pain, a service that was not readily available in physiotherapy or in any other sub-specialty of medicine—a service that I could offer.
In an effort to separate the good from the bad in the use of manipulation by chiropractors, I published my book Bonesetting, Chiropractic, and Cultism in1963, renouncing the implausible chiropractic vertebral subluxation theory and suggesting that chiropractors should limit their use of spinal manipulation to treatment of back pain. Over the years, I wrote many articles critical of chiropractic, always suggesting that the definition of chiropractic be changed in chiropractic colleges and state laws so that the next generation of chiropractors would be properly limited. Science-based chiropractors could be separated from their subluxation-based counterparts under a new degree, such as a “Doctor of Chiropractic Therapy” (DCT) or a “Chiropractic Manual Therapist” (CMT). I suggested that it would not be necessary for chiropractors to practice as “doctors”—they could practice as therapists offering non-surgical, drug-free treatment for back pain and related musculoskeletal problems, a new specialty combining use of manipulation with physical therapy modalities. Needless to say, this change never occurred and I was labeled a “chiropractic heretic” by my colleagues.
Today, the educational requirements for obtaining a degree in chiropractic have been raised. But the basic definition of chiropractic has not changed. As currently defined by the Association of Chiropractic Colleges, “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.” Although most chiropractic college applicants now have undergraduate degrees, the majority of chiropractors still adhere to some version of the subluxation theory (How Chiropractors Think and Practice, 2003). Few chiropractic college graduates may able or willing to abandon a belief system they must depend upon for an income.
That said, I still think that spinal manipulation is not yet as readily available in medical practice as it should be, leaving an opening for the services of a good, science-based chiropractor who combines manipulation with physical therapy modalities. But it would be necessary for such a chiropractor to openly renounce the chiropractic vertebral subluxation theory (more of a belief than a theory) and publicly state that his or her practice is limited to care of musculoskeletal problems. Unfortunately, as indicated by the Association of Chiropractic Colleges Paradigm, such chiropractors may be in the minority, even among recent graduates.
Physical therapy is now beginning to include use of high-velocity, low-amplitude spinal manipulation in its treatment armamentarium, but such treatment is not yet commonly used by physical therapists. For this reason, orthopedists and neurologists who are familiar with manual medicine are often willing to refer back-pain patients to a good chiropractor for manipulation as well as to steer patients away from subluxation-based chiropractors. Physicians can often locate good chiropractors by reading their office notes and by talking with their patients.
Most cases of back pain are self limiting, and spinal manipulation is not often more effective than other physical treatment modalities in affecting the final outcome. But in many cases, appropriate spinal manipulation provides more immediate symptomatic relief than other forms of therapy. And in special cases, thrust-type manipulation may be the best way to restore mobility in spines stiffened by post-traumatic adhesions. Use of manipulation combined with instruction, physical therapy, and rehabilitation may be the best way to relieve back pain and keep the patient mobile until recovery is complete—provided, of course, that treatment is based on a correct diagnosis. A science-based chiropractor who works in concert with a patient’s physician, can often provide such a treatment regimen—as opposed to solo subluxation-based chiropractors whose primary concerns are locating and correcting vertebral subluxations.
Since the subluxation theory continues to form the foundation of chiropractic, it seems unlikely that the chiropractic profession will ever abandon the belief that adjusting spinal joints will restore and maintain health. Many chiropractors who say that they reject D.D. Palmer’s subluxation theory simply come up with new terminology that identifies some kind of vertebral joint “dysfunction” that allegedly affects the nervous system, thus interfering with the body’s ability to heal itself. Failure of chiropractic colleges to reject such vitalistic nonsense and make the changes needed to develop chiropractic into a musculoskeletal back-pain specialty (with commensurate changes in state laws) may simply allow chiropractic to continue as an alternative healing method, such as homeopathy or acupuncture, permitting its practitioners to treat the gamut of human ailments as “primary care providers.” It may then be necessary to depend upon physical therapists for appropriate use of manipulation based on credible research. Chiropractors who can no longer tolerate the stigma associated with chiropractic can retrain as physical therapists, making good use of their training in the use of manipulation. Forty-three states now grant physical therapists direct access to patients; that is, referral from a physician is not needed.
Although I am a critic of chiropractic, I would not hesitate to offer support to a good science-based chiropractor who has separated himself or herself from the herd by expressing views that oppose the implausible treatment methods that are so prevalent among chiropractors. When I was in practice as a chiropractor, I felt an obligation to speak out so that friends, patients, and health-care professionals would not assume that my approach represented chiropractic in general. I worried that a patient who was pleased with my services might assume that treatment by any other chiropractor would be the same. Unfortunately, chiropractic treatment based on the dubious vertebral subluxation theory may be so inconsistent and so dubious that treatment for any condition may range from an atlas adjustment to a sacral adjustment, all purported to be effective in improving health by removing “nerve interference.” So far, apparently reluctant to bite the hand that feeds them, chiropractic associations have failed to publicly renounce the vertebral subluxation theory or to condemn the multitude of dubious treatment methods based on subluxation theory. Science-based chiropractors continue to struggle…
Today, chiropractic treatment is like Forrest Gump’s box of chocolates: “You never know what you’re gonna get.”
____________________
In response to critics who often accuse me of being a hypocrite, bashing chiropractic only after ending my career as a chiropractor, I have provided links to published articles to show that I have always been a critic of the chiropractic vertebral subluxation theory. My use of manipulation as a chiropractor, from the day I graduated from Lincoln Chiropractic College in 1956 to the day I retired in 1998, was limited to treatment of back pain and related musculoskeletal problems.
Bonesetting, Chiropractic, and Cultism. Critique Books, 1963. Full text available online at:
http://www.chirobase.org/05RB/BCC/00c.html
Finding a good chiropractor. Archives of Family Medicine. 1998;7:20-23.
http://archfami.ama-assn.org/cgi/content/full/7/1/20
What a rational chiropractor can do for you. Inside Chiropractic, Prometheus Books, 1999.
Chapter 13. http://www.chirobase.org/07Strategy/goodchiro.html
How chiropractic subluxation theory threatens public health? Scientific Review of Alternative Medicine. Winter 2001. http://www.chirobase.org/01General/risk.html
Chiropractic: History and overview of theories and methods. Clinical Orthopaedics and Related Research. 443:236-242, March 2006.
http://journals.lww.com/corr/Abstract/2006/03000/Chiropractic_History_and_Overview_of_Theories_and.35aspx
Can chiropractors and evidence-based manual therapists work together? The Journal of Manual and Manipulative Therapy. Vol. 14, No. 2, 2006. http://jmmtonline.com/documents/HomolaV14N2E.pdf
@pmoran on 01 Jan 2010 at 4:19 pm “… Talk to any doctor, and they will tell you that they learnt far more about practical medicine (and their own limitations) during the first two or three years after finishing med school than in med school itself, during mandatory supervised experience under intense patient load within hospitals and group practices. No chiropractor has this kind of hands-on training or, for that matter, a patient load that will maintain clinical skills. ”
You may be amused by this, written by a chiro about his “training” and first experiences:
“Sometimes a patient asks me, “Who did you practice on when you were learning to adjust?” … [W]e practiced on each other and have the scars to prove it.
“As a greenhorn DC, I clearly recollect the first patient who told me, straight out, that he needed a “good cracking.” … Since I was just out of school and without any meaningful experience, this seemed perfectly reasonable.”
http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53681
Hi folks,
Thank you for the discussion thus far. It has raised some good points. I am a DC much along the lines that chiro1 (many thanks for your groundwork) has already laid out. I am also involved in academia at a chiropractic teaching institution completing my residence training. Yep, there are a few opportunities for chiros out there, they are just few and far between, but at our school, the opportunities are increasing.
There are growing numbers within chiropractic that are concerned with the same concerns this post has illuminated. These same folks are fighting for reform. We aren’t “true believers” in the S-word and treat it for what it is, history. We are definitely fighting an uphill battle.
I am not opposed to dropping the name chiropractor altogether if it would show separation. I have advocated a split of the profession based on those who would like to adhere to historical notions and those who would like to follow the evidence.
Thanks for the honest commentary and for giving chiros like myself and chiro1 the benefit of the doubt.
_boon
Wow, I have seen alot of funny commentary, mostly from people who read more than they do. While there are studies that show chiropractic to be ineffective, there are many studies to show chiropractic as highly effective.
There are actually a multitude of studies going on currently that will either make or break chiropractic. And as the research is going now, yes this is the death of the old Chiropractic, because the new research is showing that Chiropractic is not only beneficial in musculoskeletal problems but visceral problems as well.
Just look at the Chicago Hypertension Study, chiro manipulation out performed the leading 2 meds not only in temporary reduction but at the followup 8 week.
Its so funny how people talk about the division in chiropractic, when if you look around allopathic medicine you will not only find division but also more diverse.
Why you ask because MODERN MEDICINE IS FAILING.
We have more chronic illness and death than ever before. Several chronic illness studies show that 75% of all deaths in Western nations are diseases of civilization (lifestyle) which is rarely addressed in allopathic medicine and addressed daily in most chiropractic practices.
As modern medicine continues to fail natural approaches to care continue to rise. Want proof of that just look at my practice 40% of my patients are in the healthcare field. 10% are MD’s and their children!
Wow I can’t believe I wasted this much time reading this dribble and responding to it. To each his own. Knowledge is power, not information.
Why don’t you point us to those studies that show chiropractic to be effective that are as large, numerous, and high-quality as those that show it is not? When it’s the small, poorly designed studies that show an effect and the large, well-designed studies do not, the only rational response is to trust the latter.
I can’t see how you can claim that with a straight face, given that the already overwhelming mountain of evidence against is ignored. More studies will just provide more for quacks to ignore.
Cite. I suspect it’s already been comprehensively demolished.
By this same logic, we should be promoting the use of headstands as health care. See, you haven’t actually shown that chiropractic is any better!
True, because of the success of scientific medicine in reducing the toll of all the things that used to kill people before they had to worry about chronic illness. Not to mention various conditions that used to be a death sentence (type 1 diabetes, for instance) which have been reduced to chronic illnesses by, again, scientific medicine.
This is a straight-up lie. Mainstream medicine has stressed healthy lifestyle factors (proper diet, exercise, smoking cessation, etc.) for many decades. You do your cause no good by lying so blatantly.
As a chiropractic student, I have given and received many adjustments–gentle manipulative procedures. My instructors have done the same; some have done so for more than fifty years. The history of the manipulative professions shows a progression of thought worth considering. The progression I am referring to was made possible by the simple discovery that some people with muscle and joint complaints may be helped by physical manipulation. It is a simple observation that many can relate to.
Have you ever felt a sore muscle or an uncomfortable tightness of a joint following an injury or a period of inactivity? If you have, you are among the majority; this is not surprising. Have you ever considered the possibility that your problem may have been caused by your own behavior? If you have, you are probably among the minority. The problem with the mentality of the majority of people in this country is the lack of mindfulness applied during the execution of physical behaviors.
Those studying environmental psychology or ergonomics are quite aware of this issue; they work to improve the relationship between humans and their environment. Chiropractors and others in the manipulative professions seek to instruct people to become more mindful about their physical behavior. The goal is to break degenerative cycles of behavior and replace them with ones that support health.
Institutions such as my own emphasize patient education as the primary goal of our profession, emphasize science as the primary method of gaining knowledge for practice, and emphasize the concept of “primum non nocere”, or, “first, do no harm” as our guiding principle. The chiropractic profession has struggled to survive for many years, but has continued to progress successfully because of the efforts of those who proceed with integrity–with the patient’s best interests in mind at all times.
The profession has reached a position of prominence during recent years because of the congruence of the public’s desire for effective care of certain complaints and the ability of chiropractor’s to facilitate the alleviation of those complaints. This profession will never die if those among us continue to rise above the negative rhetoric, to seek answers through science, and to put our patients first. As the profession gains more attention and funding, significant studies will be done to put the question of the efficacy of our manipulative practices to rest. At this time, the best among us continue to confidently provide the effective care and patient education that we know changes lives for the better.
For those interested, the UK General Chiropractic Council recently commissioned an ‘independent’ review of the effectiveness of chiropractic. It has finally been published and you can read about it here:
http://www.zenosblog.com/2010/02/the-gccs-plethora/
[...] that most likely would have gone away on their own, or with proper science based medical attention. Let’s jump to December 2009 and see if anyone’s made any [...]
I’ve printed out this blog, the original PDF and also the Lancet Wakefield retraction to take to my chiropractor this afternoon. I imagine it will be an interesting visit.
@Blue Wode on 25 Feb 2010 at 11:34 am
Updating BW’s post, see it for the link. First, as BW knows, the review was undertaken after the debacle of the British Chiro Assn’s (BCA) “evidence supporting chiro” was shown to be a joke http://www.sciencebasedmedicine.org/?p=555
Second, the review (aka Bronfort) is not about chiro, it is about “manipulation.” The chiros want to claim all types of manipulation by all sorts of therapists (e.g., PTs) and pseudotherapists (e.g., exto-USA osteos) as endorsing chiro. That is ironic since chiro claim their work is unique and that they are more experienced and, therefore, better.
So, looking at the tabular summary at the end of Bronfort, it is easy to see that 32% of the recommendations are based on non-chiropractic treatments. Moreover, claims simply labeled “Manipulation/mobilization” are not attributed to chiro (PT is common), as well.
Then, one must wonder whether Bronfort was more discriminating than the BCA. After a limited review, the answer is “Not much.” They found two RCTs each for treatment of enuresis and carpal tunnel syndrome. In the former, both studies concluded that there was no difference between chiro and non- or sham-treatment; yet they called that “favorable.” Likewise, treatments for the latter were termed “favorable” despite both studies concluding the treatments were useless.
Chiro has yet to produce data that support it (beyond, possibly, low back pain).
Joe on 03 Mar 2010 at 12:48 pm “Moreover, claims simply labeled “Manipulation/mobilization” are not attributed to chiro (PT is common), as well.”
Should be “Moreover, many claims simply labeled “Manipulation/mobilization” are not attributed to chiro (PT is common), as well. “