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Spinal Fusion: Chiropractic and Subluxation

A spirited exchange about chiropractic arose in response to a recent post proposing “The Cure” for the legalization of implausible and unproven diagnostic methods and treatments. Some comments pointed to the implausibility of the chiropractic “subluxation” and the lack of robust evidence of efficacy/effectiveness for spinal manipulation, as well as the difficulty of understanding what exactly “chiropractic” is, or does, that distinguishes it from other manual therapists.  In response, other comments were posted positing that the Science-Based Medicine blog “is not informed  on contemporary chiropractic practice,” that “the profession does not support [the chiropractic] subluxation as a cause of disease,” that chiropractors who treat the chiropractic subluxation are “on the fringe,”  and that the chiropractic “subluxation” is no longer taught in chiropractic colleges as a clinically relevant concept, but merely as an artifact of chiropractic history.

However, a review of recent chiropractic literature does not appear to support the latter opinions.  The same concerns as raised on SBM are shared by chiropractors themselves and are discussed in articles appearing in peer-reviewed chiropractic journals. Nor is the chiropractic literature as sanguine on the demise of the chiropractic “subluxation” as a clinically relevant condition which is both diagnosable and treatable.

Despite the concerns expressed by chiropractors themselves, the chiropractic literature continues to discuss the chiropractic “subulxation” as if it were a clinically relevant condition subject to diagnosis and amenable to treatment for both non-musculoskeletal and musculoskeletal conditions.  This same view of the “subluxation” is taught in chiropractic colleges in North America and Australia.

Chiropractic 101: the subluxation

A June, 2011, article in the journal Chiropractic and Manual Therapies explored, as the title explains, The prevalence of the term subluxation in North American English-language Doctor of Chiropractic Programs.  The authors, one from the School of Education at the Indiana Institute of  Technology and the other a D.C. on the faculty of Bridgeport College of Chiropractic in Connecticut and the School of Chiropractic and Sports Science at Murdoch University in Australia, studied the academic catalogs of 16 North American chiropractic colleges for use of the term “subluxation.”  The authors chose these catalogs as an indication of “what domains of knowledge are taught in the  classroom and what domains are evaluated in assuring student competence.”

Their conclusion?

The concept of the subluxation in chiropractic is a controversial subject with a paucity of evidence. With the exception of three schools, all English-language DCPs [Doctor of Chiropractic Programs] in North America mention the concept of the subluxation either in course titles or descriptions and/or their respective missions. Despite the lack of evidence for the subluxation construct, it appears to be very much a key part of chiropractic education.

Some schools may state that they are not subluxation-focused or heavily engaged in the teaching of subluxation. Nonetheless, most schools continue to teach about the subluxation in what seems to be more than just a historical context. We believe that this puts the profession in an awkward position because the skeptic and/or critic of subluxation can point to chiropractic education as outdated and unscientific. Chiropractic education will have to address this issue if the chiropractic education enterprise wishes to become scientifically competitive with other healthcare sciences and produce graduates who are critical thinkers prepared as the evidence changes to change their practice and throughout their careers.

The authors specifically rejected the notion that the subluxation was taught simply as an historical concept:

One might argue that a historical presentation of the subluxation may be all we are finding references to in our research of the DCP curricula. This would be a reasonable argument if the subluxation was mentioned in only one course in a DCP program or if it was only in what was described as a philosophy course. This, in fact, only occurred at two colleges (Texas Chiropractic College and the University of Bridgeport College of Chiropractic), however, with an aggregate average of 13.5 appearances [in the catalogs] and many of those in technique classes it seems unlikely that this is purely to explain the history of [the] term in the chiropractic profession.

In support of their conclusions, the authors referenced other research finding:

  • Over 88% of chiropractors surveyed favored retaining the term vertebral subluxation complex.
  • Over 70% of chiropractors reported that subluxation is important to their clinical decisions and guides their clinical care of patients.
  • A strong majority (over 75%) believed that subluxation was a significant contributing factor 50% or more of visceral disorders.

The article concluded with a prediction that just the sort of examination of current statutory scope of practice for chiropractors I’ve been advocating could occur: “Future research should determine if changes in regulation and research change the prevalence of the use of the term subluxation in chiropractic curricula.” [Emphasis added.]

A closer look at Canadian Memorial Chiropractic College

Despite the fact that the study found “no mention of the term subluxation” at Canadian Memorial Chiropractic College [CCMC] another article in the chiropractic literature,  Attitudes of clinicians at the Canadian Memorial Chiropractic College towards the chiropractic management of non-musculoskeletal conditions, revealed that “although the concept of chiropractic treatment for non-MSK conditions is controversial, students at the Canadian Memorial Chiropractic College . . . are exposed to a variety of opinions on the subject.”  In a survey of clinicians supervising interns at one of six clinics in the Toronto area, all of whom had been educated at CMCC, 50% either “agreed” or “strongly agreed”  that chiropractic could be effective for the treatment of asthma, chronic pelvic pain, constipation, dysmennorhea, infantile  colic and vertigo.”

This study was published in the Journal of the Canadian Chiropractic Association, which describes itself as “the official, peer reviewed, quarterly research publication of the Canadian Chiropractic Association.”

To understand the significance of 50% figure, one must realize that the referenced treatment of non-MSK conditions by chiropractors is subluxation-based:  the detection of spinal “misalignments” and their “correction” through adjustments.”   Without ever using the term “subluxation,” this is evident in the article’s explanations for treatment of various non-MSK conditions.  [Note also the improper use of “case studies” as “evidence.”]

Asthma:

Chiropractic treatment [that is, adjustments] has been thought to be beneficial in the treatment of this condition as it posited that it may modify the autonomic system and elicit viscerosomatic reactions to it. Additionally, it has been hypothesized that misalignments at the levels of the upper C-spine create spinal reflexes that can induce asthma and correcting the misalignments could potentially alleviate the symptoms.

Constipation:

In a study conducted by Alcantara and Mayer on three pediatric patients, they found successful resolution of the condition after a regiment [sic] of spinal manipulative therapy by observing an increased frequency in bowel movements, with less straining and pain. Similarly, a case study done of a 64 year old Caucasian female demonstrated a positive resolution to chronic constipation after ten treatments of spinal manipulative
therapy.

Infantile colic:

Since an‘adjustment’ theoretically causes sympathetic stimulation which, based on physiology, in turn relaxes the smooth muscle of the gastrointestinal tract, reduces peristalsis, and inhibits bowel function, infantile colic could be  effectively treated through manual therapy.

Vertigo:

A retrospective study conducted by Elster showed 100% positive response with either symptoms having improved or completely reversed within one to six months of care using a treatment plan of upper cervical adjustments.

In sum, while the CCMC does not openly mention the chiropractic subluxation in its academic catalog, its students are trained by chiropractors who accept the existence and clinical significance of the subluxation and the utility of detecting and correct it for a variety of conditions, as described in an article which wholly fails to question the concept.

National University of Health Sciences

Another institution which, according to the study of academic catalogs, did not mention the subluxation is the National University of Health Sciences (NUHS), which educates naturopaths and acupuncturists as well as chiropractors.    However, had the authors examined a broader range of the school’s literature in divining support for the chiropractic subluxation and its putative effect on human health they would have found it in the form of the Journal of Chiropractic Medicine, published by NUHS and described on the school’s website thus:

Published quarterly, this peer-reviewed indexed journal meets the modern-day chiropractic physician’s need for practical and cutting-edge information with concrete clinical applications.

A review of the first 25 articles, published  during 2010-2011 (a full fifteen of which were case reports) appearing in a
PubMed search for the Journal of Chiropractic Medicine, turned up the  following:

Applied  kinesiology methods for a 10-year-old child with headaches, neck pain, asthma,  and reading disabilities:

According to  Quackwatch, “applied kinesiology is a pseudoscience based on the anatomically  and physiologically impossible notion that muscle-testing enables the  practitioner to determine ‘weaknesses’ of organs throughout the body that  ‘correspond’ to nutrients placed under the tongue.” Application of various  applied kinesiology diagnostic methods and treatments is described in this  Journal of Chiropractic Medicine article, including:

Insalvation refers to the fact that the taste buds on the tongue can detect extremely small concentrations of substances within a fraction of a second of stimulation. Oral nutrient evaluations are used in AK because they are clinically useful in the assessment process. Exposure to taste elicits a variety of neurologic, muscular, digestive, endocrine, cardiovascular, thermogenic, and renal responses . . . [T]here is considerable evidence in the literature of extensive efferent function throughout the body from stimulation of the gustatory and olfactory receptors with actual insalivation . . . Insalivation of choline (a component of the neurotransmitter acetylcholine) corrected this finding.” [It is unclear what “finding” was “corrected.”]

In a swipe at the  patient’s pediatrician, the article adds:

The previous treatments did not deal directly with the craniosacral system, nor did they appear to evaluate adequately the sensory input into the nervous system from the musculoskeletal and viscerosomatic system (adrenal glands and lungs). Applied kinesiology theory suggests that to resolve biomechanical, biochemical, psychosocial, and sensory problems, many areas of the body must be examined and corrected to achieve long-lasting symptomatic relief.

Cessation of  cyclic vomiting in a 7-year-old girl after upper cervical chiropractic care: a  case report.  The lead author is an  Assistant Professor at Palmer College of Chiropractic.  From the abstract:

A 7-year-old girl had a history of cyclic vomiting episodes for the past 4 ½ years. She also had a 2-month history of headaches and stomachache. . . The patient received low-force chiropractic spinal manipulation to her upper cervical
spine. [As described in the article, “The directional misalignment was determined as an anterior-right misalignment by using pediatric Duff analysis on her upper cervical radiographs.”] There was improvement in her symptoms within an hour after the chiropractic manipulation. . . This case study suggests that there may be a role for the use of chiropractic spinal manipulative therapy for treating cyclic vomiting syndrome.

Use of multimodal  conservative management protocol for the treatment of a patient with cervical  radiculopathy.  The author is an  Assistant Professor in the Department of Chiropractic at D’Youville College,  Buffalo, NY.  The article describes  chiropractic treatment following “Gonstead chiropractic protocols”  of a patient with a disk protrusion at C5-C6.  Here’s a description of the Gonstead  System from the Gonstead Clinical Studies  Society, quoted in Keating JC, Charlton KH,  Subluxation: Dogma or Science?  Chiropractic & Osteopathy. Vol. 13, August 10, 2005:

Minor displacements of the spinal bones, known as vertebral subluxations, can cause endangering stress to the spinal cord which acts as the main line of intelligence for the whole body. These displacements, or subluxations, are the cause of many of the unwanted health conditions that people suffer from every day. Although there have been many valuable techniques that have been developed in the chiropractic profession, the Gonstead System is considered a ‘gold standard’ for chiropractic techniques because of its record of safety and effectiveness in correcting vertebral subluxation . . .

In addition to  the articles describing “subluxation”-based treatment, of these 25 most recent  articles in the Journal of Chiropractic Medicine, three discussed diagnostic  techniques for the detection of chiropractic “subluxations.”

Standard  deviation analysis of the mastoid fossa temperature differential reading: a  potential model for objective chiropractic assessment.  The author is an Assistant Director of  Research at Sherman College of Chiropractic:

The mastoid fossa  temperature differential (MFTD) reading is described as having been used in  chiropractic since the 1950s.  A  temperature is obtained, without making contact, in the mastoid fossa area on  both sides.  An MFTD “is calculated by  subtracting the mastoid fossa temperature on one side from the other  side.”  While “the clinical significance  of the MFTD readings has yet to be determined,” nevertheless “one method for  interpreting MFTD readings is with pattern analysis, where an abnormal set of  baseline readings are identified and thought to be related to the condition  known as vertebral subluxation.”

Computer modeling  of selected projectional factors of the 84-in focal film distance  anteroposterior full spine radiograph compared with the 40-in film distance  sectional views.  Two of the authors are  chiropractors in private practice and also involved in research at the Gonstead  Clinical Studies Society:

While  acknowledging that the role of the full-spine anteroposterior full spine  radiograph is “controversial,” the authors conclude that “working knowledge of  the A-P full spine view is important . . . [as it] may be used for scoliosis
evaluation; and additionally, there are doctors of chiropractic who use the A-P  full spine as part of their assessment when viewing of the full spine.”  And what might they be “assessing” in the  “full spine?”  Although not specifically
admitted in the article,  full-spine  radiographs are used by chiropractors for the “detection” of   “subluxations.”  Peterson DH, Bergmann TF, Chiropractic  Technique, Principles and Procedures,  2nd ed. (Mosby 2002), 75-79.

Geometry of  colplanar stereoscopic radiographic pairs for analysis of the lateral cervical radiograph: a study using mathematical models.  The author is a Research Assistant Professor at Sherman Chiropractic  College.  The article is of interest only  to those who use X-rays to detect the presence of cervical “subluxations.”

In sum, a review  of the most recent 25 articles in the NUHS- published Journal of Chiropractic  Medicine reveals that NUHS has hardly rejected the chiropractic subluxation,  even though its academic catalogue does not mention the term.

Life University College of Chiropractic

A recent article  about chiropractic education shows how instruction in the detection and  correction of subluxations is part and parcel of the core training of  chiropractic students at Life University College of Chiropractic.  The article, Self-Perceived Skills  Confidence:  An Investigative Study of  Chiropractic Students in the Early Phases of a College’s Clinic Program, was  written by an Associate Professor at this chiropractic school.   Categories of student self-assessment  surveyed for the article

. . . were those used in the early clinical curriculum. They included radiograph interpretation of the pelvis, occiput, atlas, and vertebral spine, using full-spine listings (Gonstead type) with the spinious process as a reference, and descriptive listings (fixation, malposition, misalignment, restriction) with the vertebral body as a reference, and motion palpation assessment of the corresponding anatomical areas.

Spinal manipulation categories were those used in the clinical curriculum. They included basic manual intersegmental full-spine (Gonstead-type) and diversified procedures . . .

This description  is, quite literally, a textbook example of student training in the detection  and correction of the chiropractic “subluxation.” Scaringe JG, Gaye, LJ,  Palpation: The Art of manual Assessment (Chapter 10), Scaringe JG, Cooperstein  R, “Chiropractic Manual Procedures (Chapter 12) in  Redwood D, Cleveland CS, eds., Fundamentals
of Chiropractic (Mosby 2003).   It was  accepted for publication in a peer-reviewed chiropractic journal, the Journal
of Manipulative and Physiological Therapeutics (May/June 2010), and won a  chiropractic research reward.

More  “subluxation” in recent chiropractic literature

The chiropractic journal articles  summarized above demonstrate that the chiropractic “subulxation” is still  taught in North American chiropractic colleges as a clinically relevant  condition capable of “detection” and “correction.”  They also show that the putative  “subluxation” is uncritically presented as such in current peer-reviewed chiropractic  literature.

Even those chiropractic  journals which appear to be more oriented toward an evidence-based assessment  of manual therapies have recently published articles which uncritically accept  subluxation-based chiropractic diagnostic techniques and therapies. In addition  to the articles noted above, we find:

From the Journal  of Manipulative and Physiological Therapeutics:

Interexaminer  reliability of supine leg checks for discriminating leg-length inequality  (2011):  Discusses functional leg-length  inequality,” a bogus diagnostic method used to determine “subluxations.”

A retrospective  study of chiropractic treatment of 276 Danish Infants with infantile colic  (2010):  Without ever describing the  proposed mechanism of action by which “chiropractic manipulation” is purported  to affect infantile colic, reaches the conclusion that “the findings of this  study do not support the assumption that effect of chiropractic treatment of  infantile colic is a reflection of the normal cessation of this disorder.”

Running posture  and step length changes immediately after chiropractic treatment in a patient  with xeroderma pigmentosum (2009): “A 5-year-old female patient with XP (type  A) volunteered to participate in the experiment with the consent of her parents  . . . [T]he patient was assessed for spinal dysfunction and adjusted (full  spine) using diversified techniques . . .  Adjustments were delivered in an attempt to correct any or all of the  spinal dysfunctions that the clinician [a chiropractor] found at the time of  the experiment.”

Journal of the  Canadian Chiropractic Association:

Chiropractic care  for patients with asthma: A systematic review of the literature (2010):  States, without criticism of the lack of  scientific plausibility underlying the concept, that “in treating asthmatic  patients, the objective of chiropractic spinal manipulative therapy (high  amplitude, low velocity thrusts) is  . . . to affect nervous system activity.”

Chiropractic care  of a pediatric patient with symptoms associated with gastroesophageal reflux  disease, fuss-cry-irritability with sleep disorder syndrome and irritable  infant syndrome of musculoskeletal origin (2008):  “it was determined that the patient had  spinal segmental dysfunctions of the atlas and the 4th thoracic vertebrae.  The atlas was determined to have a right  posterior rotation and right laterally malposition with respect to the C2  vertebral body (VB).  The 4th thoracic VB  had a posterior malposition with respect to C3VB.  Following craniosacral technique procedures,  cranial distortions of the right parietal and temporal bones were determined as  well as aberrant motion of the mandible at the right temporomandibular joint  (TMJ).” And so on.

More criticism of  chiropractic, by chiropractors

Admirable for  their criticism of the “subluxation,” other recent articles in the literature  critical of chiropractic reveal the “subluxation’s” continued presence in the  current practice of chiropractic in North America and in Australia.   As well, they demonstrate that some of the  same criticisms of chiropractic posted on SBM have been expressed by
chiropractors themselves.

An article  published in Chiropractic and Manual Therapies this year, authored by 3  chiropractic academics, found that “patients searching the Internet for  chiropractic wellness information will often find a lot of poorly done, useless
information that will not help them maintain health or become well.”  Significant to our discussion here, of the
sample studied:

  • 77% of sites  contained information on chiropractic “subluxation”
  • 60% had  information on “innate”
  • 34% contained  obvious anti-vaccination information
  • 34% had  information that was anti-drug (prescription or medical use of drugs)

The authors  concluded that “the depth of information on the sites analyzed was poor and was
rarely evidence-based.”

Another article,  published in Chiropractic and Osteopathy (as the journal Chiropractic and  Manual Therapies was formerly named) in 2010 surveyed a sample of  non-practicing chiropractors and their reasons for leaving chiropractic practice.  Due to the small sample size  and low rate of response, the authors state that “generalizations to broader populations should be made with caution.”  Yet, the results reveal a notable congruence between the negative opinions about chiropractic expressed on SBM and those who had actually left  the practice of chiropractic:

  • 80% agreed that  business ethics in chiropractic were perceived as questionable.
  • 62% disagreed  with the statement that chiropractic education is an asset when pursuing  another career.
  • 60% agreed that  dogma and philosophy of chiropractic were reasons to abandon active practice.
  • 71% believed that  associates in a chiropractic practice are often encouraged to prolong the care
    of patients.
  • 74% believed that  the chiropractic profession lacked cultural authority.
  • 58% agreed that  the political problems in chiropractic were factors in being perceived as a
    quality clinician.

This frustration  with chiropractic was shared in another recent article in the same journal  authored by an Australian chiropractor and based on a lectured delivered at the  Annual Conference of the Chiropractic & Osteopathic College of Australasia,  in 2010.  The author bemoans the fact  that

  • The Chiropractors  Association of Australia (CCA) “actively promotes subluxation based  chiropractic.”
  • “Chiropractic  trade publications and so-called educational seminar promotion material often  abound with advertisements of how practitioners can effectively sell the VSC  [vertebral subluxation complex] to an ignorant ublic.”
  • The CCA and the  Australian Spine Research Foundation (ASRF) “are promoting ‘wellness care,’  which involves the detection and adjustment of VSC’s,” noting a recent  statement in the ASRF’s newsletter  that  “. . .  it is not possible to be well if  vertebral subluxation complex is present as a vertebral subluxation complex  represents a non-homeostatic state . . . . which makes a state of wellness  impossible.”
  • Of the three  chiropractic teaching institutions in Australia, the program at RMIT University
    promotes what the author calls “the subluxation myth.”

Conclusion

Criticisms of  chiropractic on Science-Based Medicine are not the reflection of  misunderstanding of contemporary chiropractic  practice in that, according to chiropractic literature:

Subluxation dogma  continues to be a part the education and training of chiropractors in North American and Australia.

Subluxation-based  chiropractic remains an integral part of chiropractic practice in North America  and Australia, as demonstrated by the uncritical acceptance of articles  discussing its implausible diagnostic methods and treatments in peer-reviewed  chiropractic journals, its presence in surveys of chiropractic practice in  peer-reviewed chiropractic literature, as well as the aforementioned inclusion  in chiropractic education.

 

Posted in: Chiropractic

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254 thoughts on “Spinal Fusion: Chiropractic and Subluxation

  1. DugganSC says:

    This is an issue near and dear to my heart because my fiancee is a regular attender of chiropractic adjustment sessions for issues with her hips, shoulders, back, and neck. She’s not overboard in my opinion — she distrusts any chiropractor who suggests infant manipulations for example, and both she and her chiropractor agree that chiropractry does nothing to heal ills outside of joints and back pain — but it’s still one of those things where I worry that she’s not getting effective treatment (the adjustments work for her in terms of reducing her pain, but she has to go about twice a month to stay out of pain). Are there any good arguments to bring up once you get an agreement that subluxations don’t exist?

  2. ConspicuousCarl says:

    What exactly do they teach in chiropractic colleges when they aren’t teaching the subluxation stuff? Do they explicitly describe how pressing on a particular bone results in the same effects as would be understood by a real physical therapist, or are the real benefits still just incidental effects of “adjustments” motivated by some new, non-subluxation theory?

  3. Hey DugganSC, I’m not a medical person, just a medical consumer. I can offer a personal anecdote on chronic pain. I have also had problems with hip/back and shoulder pain. I did see a chiropractor when much younger for the hip/back pain, but didn’t get any meaningful benefit. The pain would feel worse, then better temporarily, then come back. Eventually it died down well after I quite with the CP. When it became worse much later I went to see my doctor who did tests to rule out disc ruptures, arthritis and lupus.

    Since those were negative I was sent to the physical therapist who did a detailed analysis of my leg, hip structure. She believed my pain was due to a basic structural problem (one of my legs is longer than another and not great arches) She recommended OTC shoes inserts and gave me a series of stretches, mobilizations and self adjustment exercises that I could do at home when I have problems, as well as some particular back saving tips. They have been really helpful, now when I detect some pain or do an activity that I know can cause pain, I do my exercises, which prevents the pain from becoming chronic.

    I also have some issues with shoulder impingement. A physical therapist gave me a couple of self-adjustment I can do that most often correct the impingement and keep my shoulder in better working order.

    Also, I have thyroid disease, that I understand appears to be linked to some of the chronic inflammation, pain issues. Having the thyroid hormones regulated is quite helpful for me in the general muscles, joint pain department.

    Sorry, I sound like my grandma, don’t mean this to be a survey of my aches and pains, just throwing out a few common things that a CP isn’t trained to recognize, test or treat.

    While I couldn’t say if your girl friend has any of these similar problems, it would be a shame if she is continuing to be reliant on CP adjustments for pain relief, when a doctor or physical therapist may be able to give her a more long term solution that she can follow at home.

  4. lizditz says:

    Looking at the archives for the Journal of Pediatric, Maternal & Family Health, in 2011 4 issues were published for a total of 20 articles. Seven of the articles has “subluxation” in the title.

    CASE STUDY: Resolution of Autistic Symptoms in a Child Undergoing Chiropractic Care to Correct Vertebral Subluxations: A Case Study

    Tai A. Scelfo D.C. Bio & Patricia L. Chelenyak D.C. Bio

    Journal of Pediatric, Maternal & Family Health – Chiropractic ~ Volume 2011 ~ Issue 4 ~ Pages 106-110

    —-
    on a somewhat related note, some chiropractors are aggressively promoting the mistaken notion that chiropractic can “help” with autism and ADHD. In fact, one chiropractor (Robert Melillo) preaches the notion that ADHD and autism are two aspects of the same thing: a “disconnection” between the left and right hemispheres. Naturally, he’s developed a therapeutic routine that will correct this problem, which he markets through “Brain Balance”. Harriet Hall has discussed this here.

  5. nwtk2007 says:

    I went to Parker College of Chiropractic and can at least verify that the subluxation is a concept discussed frequently and promoted by the administration of the school but in most classes the subluxation was not held in the same light as your research would indicate. But none the less, it has not stopped me from treating many thousands of patients and never once, billed for the treatment of a subluxation. I really don’t know what that makes me except to say that some chiro’s claim to treat non-spinal/non-musculocutaneous conditions by practicing the removal of subluxations and many do not. In fact, most that I am aquainted with do not and for me, the removers of subluxation are, as had been pointed out, on what I see as the fringe of believable practice if not in the minority as well.

  6. marcus welby says:

    This post makes it more clear:
    Whereas medical treatments developed on a base of scientific observation and methodical use of the scientific method of testing, chiropractic had a reverse course. It began in 1895 as an observation by
    Daniel Palmer that there may be subjective benefit to manipulating the spine. He capitalized on that observation with brilliant marketing of the placebo effect and this became an occupation which advanced their influence through political means. Now that there is increased emphasis on evidence-based examination and awareness of the pervasive influence of the placebo effect, along with a concern for limiting reimbursement to that which has proven effectiveness, chiropractors are scrambling to find some explanation for their belief in benefit of spinal manipulation. But they are struggling to do so, as there has been little evidence of benefit beyond the clinical interaction and placebo. Their core principle for 126 years was that BOOP, bone out of place, was adversely affecting neural function, and by extension, organ dysfunction was the result. However, the subluxation, or BOOP, was an imaginary concept always, could never be demonstrated reproducibly on imaging studies, a definition could not be agreed upon, and lately has come under increasing attack even within their own profession. Since the physical therapists and massage therapists can utilize manipulative techniques without the magical thinking and subluxation-reliance, if chiropractors are bereft of their subluxation, what do they have left? So we get efforts like in New Mexico to utilize political pressure to allow them to prescribe some pharmaceuticals and perhaps expand their practice horizon. Recall that very recently and currently, the chiropractors like to rail away at MDs for poisoning people with pharmaceuticals. As the chiropractic school in L.A. closes and enrollment drops at other private chiropractic colleges, we are witnessing a fringe in crisis.

  7. Cowy1 says:

    Strong work Jann, keep it up.

  8. nybgrus says:

    I read this last night, when there was some error that disallowed commenting. But thank you Jann, for writing this up. This is essentially what I was talking about in the “spirited discussion.” I will do my utmost to refrain for taking part in another such spirited discussion, which I honestly don’t think will be too much of a problem, as I have exams in 3 days.

    I did just want to quickly say though that this was exactly my point and that nwtk2007 further reinforces it:

    I really don’t know what that makes me except to say that some chiro’s claim to treat non-spinal/non-musculocutaneous conditions by practicing the removal of subluxations and many do not.

    In aforementioned spirited discussion, I was willing to grant that MSK interventions by chiros might have some utility just for the sake of argument. But even granting that, how is anyone supposed to determine who out there might be like nwtk2007 and eschew the blatant magical thinking that they are actually taught and tested on for licensure in their practice? And furthermore, as I believe weing raised, how does one justify practicing in a manner not wholly consistent with your licensure and training? These are the two most important and fundamental issues with chiropractic that I have and the focus of my discussion.

    The third important issue is that it is obvious that chiros value their SMT, because their profession is based on the subluxation theory, and to maintain that most science that they do is an attempt to demonstrate some utility of SMT. In other words – it is backwards science.

    But thank you Jann for doing all the work to dig this up and demonstrate unequivocally that we here, myself included, are not off our rocker when we criticize modern chiropractic practice. Something tells me we won’t be hearing from NMS-DC on the topic.

  9. NMS-DC says:

    @Jann, nybgrus

    I wouldn’t want to disappoint you and not turn this into a valuable thread at SBM. One cannot talk about SMT/adjustment if we don’t talk about joint dysfunction/subluxation. I’m going to do some writing, and present my rebuttal in due course.

    In the meantime:

    @ConspicuousCarl:

    “Other courses” taught at chiropractic school (http://www.cmcc.ca/Document.Doc?id=861) Starts at page 53.

    Good post Jann. It’s important to get an in depth analysis of the skeptics point of view and argumentation: It’s important to find eliminate/rebut logical fallacies or factual inaccuracies, or misinterpretations and miscommunications. I look forward to addressing each and every one of them.

    Very best,
    NMS-DC

  10. JPZ says:

    @nybgrus

    Many fields contain dissenters that subvert or ignore more common dogma in the field. Historically, I believe chemists did this as they broke away from alchemists. Currently, it is my impression that pharmacists and compounding pharmacists have a few fundamental differences of opinion. As long as the dissenters are distinguishing themselves by rejecting the mythology of their profession in favor of more sound practices, I don’t share your disdain for chiropracters who reject subluxations. They are potentially reformists (but I admit that I have not actually heard any of them posting here sounding reformist). There are many dogmatic assumptions in my field that I do not accept, e.g. just because it has been used for many years doesn’t automatically make it safe, so perhaps I should just admit my bias in that respect.

  11. nybgrus says:

    As I said, I really won’t get into this in significant depth. I’d actually very much like to hear others rebut whatever it is that NMS-DC happens to come up with to demonstrate that the extensively researched and referenced article Jann presents is somehow wrong.

    But JPZ, I understand how it could have easily gotten lost in my rhetoric, since it certainly wasn’t a focus on my part. However, I am all for those who wish to eschew the magical thinking of their profession and reform it. But that is not the argument that has been presented here. Every chiro here has presented the notion that subluxation is not taught as the basis of chiro, that only fringe chiros practice anything but pure MSK related interventions, that chiropractic has lead to advancements in science and treatment of patients (which it has, but to a very minimal degree and that is not representative of the bulk, as Jann demonstrates), and that they are qualified to act as PCPs based on their training even though it is not only based in magical thinking but in toto is less than half of the training a comparable science based medical practitioner needs to act as a competent PCP.

    My question of what justification do you have for practicing in a manner inconsistent with your training and licensing could be easily answered by saying something to the effect of “I realized that my training and licensing were based in magical thinking and could not abide by it. Rather than leave my profession I want to reform it and practice in an evidence based manner.” I have not heard anything approximating that.

    Of course, once we get to that point then the question of how they can justify acting as PCP still remains (and I firmly believe cannot be addressed adequately) and exactly how to reform chiropractic is a burning question. As pmoran has pointed out, the evidence base for SMT is weak at best and the entirety of solid evidence base that chiropractic actually does have can be easily incorporated into something like PT. Of course, that leads to a turf war on their part since that would leave them without a job, but I honestly see no justification for a 4 year degree that is vastly over educated and over trained for such a narrow evidence base, but is simultaneously under educated and under trained to be a competent PCP.

    The changes needed would be drastic and, IMO, lead to some sort of merger between the two fields, creating something akin in status to a nurse practitioner in the form of a physio/manual therapist. But there is no way, once again IMO, that either field (alone or combined) could adequately act as a PCP.

    I hope that clarifies things for you JPZ and makes it more clear where my stance actually is. You’ve been quite diligent and fair in reading my extensive posts on the topic and I thank you for that and feel I owe you that clarification.

    But I won’t be addressing NMS-DC directly simply because I don’t have the time or desire to go down that rabbit hole again. That, and I genuinely would like to see other thoughts and perspectives on it besides my own counterpoint.

  12. marcus welby says:

    I keep coming back to point out that there is a vast difference between physical therapists, who have a smattering of magical thinking but are on the whole science based, and chiropractors, who are mostly magical thinking plus marketing. Physical therapists are extensively trained in rehabilitation techniques for gait training, regaining muscle strength and range of motion, adaptive aids prescription and training in use, understanding childhood musculoskeletal development (and learning that spinal manipulation of children has no place in healthcare, either for “maintenance of health” or treatment of enuresis, otitis media, headaches, autism, constipation, or any other complaint of infancy and childhood). Do not in any way compare PT with Chiropractic. One is science based, the other is not. Spinal manipulation is something which can be taught in one course in one semester in a PT school, and is a minor part of nearly nonexistent for most practicing PT’s. PT students also have extensive hospital experience, often some familiarity of the operating room from observation prior to their rehab efforts, and are some awareness of medical concepts and disease processes. The overlap of chiro and PT is minimal. PT in no way has an anti-MD bias, or anti-vax mindset.
    Another point that is missing here is the “doctor” appelation for chiropractors. Patients get confused as to what a chiropractor does and is trained to do. Chiropractors tend to respond by capitalizing on that: a sociologist I spoke with yesterday published a study about 3 or 4 years ago in Skeptical Inquirer. He made a number of calls to chiropractic offices in Tampa-St. Petersburg area and also in Tallahassee and asked a few questions of the person who answered the phone. Identified himself as someone with a medical condition such as high blood pressure. “Would chiropractic be advisable, etc.” Most of the time, the answer was yes. Sometimes the chiropractor would be consulted, sometimes not, sometimes the answer would be something like “unsure, come in and we can try it”… Some of my patients tell me they thought the doctor of chiropractic was a medical doctor. I am told many chiropractors have a jar of cotton balls and another of tongue blades prominently displayed to further this aura. The point is that chiropractors are blurring this line for their benefit, while PTs do not.

  13. JPZ says:

    @nybgrus

    Your concern is remarkably focused on the claim that a chiropracter can be a referring PCP. Set aside the woo, set aside the magical thinking, but this particular point seems to make you a bit bitter. And, I have noted before that the definitions of “medicine” or of “doctor” seem to enrage a number of folks here when challenged – as another example of folks growing bitter over a dispute of definitions. But, it is the responsibility of NMS-DC to make a competent point, to address your paranoia/anger about the referring PCP comment about PCPs.

  14. JPZ, if you all are going to argue about PCPs, I wish there would be a standard definition before. Is it Primary Care Provider, as my insurance companies have called it or Portal(of Entry) Care Provider, meaning someone who can refer to other physicians, not one who could bill for primary care such as pelvic exams, general diagnostic tests, etc.

    Personally, I might be amendable to saying that a chiropractor who recognizes a problem outside his field could refer to a specialist. Say, he suspects his patient has an auto-immune disease and he could refer to a Rheumatologist, instead of sending the patient to their primary physician to do so. I don’t think it’s wise for Chiropractors to act as Primary Care Physicians.

  15. Jann Bellamy says:

    @ DugganSC:

    It’s not clear to me from your description that your finacee’s chiropractor has rejected the “subluxation” just because he agrees that they (if they existed) don’t cause disease. My understanding is that there is still the notion among chiropractors that there is a diagnosable (through palpation and other means) “vertebral lesion,” “spinal lesion,” “joint dysfunction” (it may have other names) that can be treated with spinal manipulation or an “adjustment.” My further understanding is that there is no evidence that what they are finding has any clinical significance and therefore the connection between their treatments and claimed result of the treatment has not been established. Spinal manipulation is a legitimate physical therapy of moderate effectiveness for low back pain — pmoran went over the evidence in response to “The Cure.” (http://www.sciencebasedmedicine.org/index.php/16729/) Spinal “adjustment” is exclusively a chiropractic term — which they sometimes use synonymously (and confusingly) with “spinal manipulation” — the purpose of which I understand is the putative treatment of the putative “joint dysfunction,”
    a concept that is not recognized (as chiropractors describe it) in medicine or physical therapy. If I am incorrect I am sure the chiropractors who comment here will set me straight. (Sorry, couldn’t resist.)

    @ConspicuousCarl:
    “What exactly do they teach in chiropractic colleges when they aren’t teaching the subluxation stuff?”

    I don’t know. In the US, the Department of Education permits privately run accreditation firms to accredit post-high school education, with result being that chiropractic schools are vetted exclusively by chiropractors. So no one from outside the system knows — or can find out — much about what it taught. This is a problem with post-high school education in general in the US, as evidenced by the recent concerns over for-profit colleges covered in the news media.

    @lizditz

    Thanks for bringing this up. Sam Homola, DC, did a post on pediatric chiropractic a while back (http://www.sciencebasedmedicine.org/index.php/pediatric-chiropractic-care-scientifically-indefensible/) and I plan to do one too. It should not be legal for chiropractors to make these claims and the fact that the American Chiropractic Association (the largest industry trade group for chiropractors) and the Council on Chiropractic Education (the accrediting agency for chiropractic colleges) do absolutely nothing about this speaks volumes. In fact, they are wholly behind the concept that chiropractors should treat pediatric patients.

    @ JPZ

    “as another example of folks growing bitter over a dispute of definitions”

    These “definitions” have public health consequences. To the health care consumer, the term “primary care physician” means someone who can provide (as the name implies) “primary care,” i.e., according to MedLinePlus (Naitonal Library of Medicine http://www.nlm.nih.gov/medlineplus/ency/article/001939.htm):
    “A PCP is your main health care provider in non-emergency situations. Your PCP’s role is to:
    •Provide preventive care and teach healthy lifestyle choices
    •Identify and treat common medical conditions
    •Assess the urgency of your medical problems and direct you to the best place for that care
    •Make referrals to medical specialists when necessary”

    Chiropractors’ education and training is insufficient to qualify them as PCPs, and yet some (including the ACA) insist that the are indeed PCPs, thereby confusing and misleading the public. See also, “The DC as PCP?” (http://www.sciencebasedmedicine.org/index.php/the-dc-as-pcp/)

  16. Jann Bellamy says:

    @ micheleinmichigan:

    “Portal of entry” means that a patient can see the provider without a referral from another provider. It is not synonymous with primary care provider.

  17. nybgrus says:

    Jann – you posted this literally as I clicked the button to sign in and post myself.

    You have touched upon exactly what I wanted to say. First off, I apologize – I did say it before in “The Cure” thread but PCP is Primary Care Physician. That is also what the CCE accreditation document alludes to. It refers to “portal of care provider” instead of the specific term “primary care physician.” However, the subsections are identical to what “primary care physician” is, as outlined by Jann. In other words, according to the accreditation body, DCs are supposed to act as a portal of entry that is a primary care physician. They even take the moniker “doctor.”

    So JPZ, yes, that is one thing I am quite stuck on. Because it is a very serious point. Whenever I pause to think about it, I am gripped with a bit of anxiety at the notion that if I, as a PCP, were to miss something potentially serious that a person will suffer – pain, permanent injury, or death. The level of knowledge needed to minimize that is, literally, staggering. Trust me – I am expected to know it! My girlfriend jokes that in just 2 years I will be called “doctor” and the weight of that responsibility is profound on me. At least I know that I will have at least 3-6 more years of residency training under the supervision of someone already trained to get it right. Chiropractors don’t have that. They blithely think themselves capable of being portal of entry PCPs capable of making diagnosis with literally half the training that a an internal medicine specialist would have.

    The point I am trying to hammer in on there is that their basic fundamental training is around the concept of subluxation theory and that SMT is effective for a variety of MSK issues, including things like headache. The question is, what training do they have to distinguish a subarachnoid hemorrhage from a standard tension headache or cluster headache? I think I have demonstrated, and further with Jann in this article, that there is no way of determining who actually has that training and that the baseline minimum is not sufficient to conclude that any random DC has it. And as that old saying goes, to a carpenter everything looks like a nail.

    So it isn’t paranoia (it isn’t paranoia if they’re actually out to get you, right? ;-) and it isn’t anger, JPZ. It is a genuine concern for what it means for someone with inadequate training to fancy themselves adequately prepared to make accurate diagnosis and referrals. And it isn’t a “bitter dispute over definition.” As Jann rightly said, definitions are very important. I pointed that out when the term “subluxation” was used interchangeably between “vertebral subluxation complex” and “orthopedic subluxation” in order to get the best side of each term, despite the fact that they are not the same (and one is real and the other isn’t). The same here.

    So Michele, the question that still remains unanswered (well, as far as I am concerned it is, but I am open to evidence otherwise) is what in their training would allow a chiropractor to make that distinction that something is not MSK related and thus refer onwards? Obvious things like massive abdominal distention or jaundice, for example, sure. But what about things that mask as others? Or that have crossover and could be MSK or not?

    For example, chiros fancy themselves able to diagnose and treat MSK/neuro issues. That is the basis of their SMT. What if a patient presents with lower back pain and some tingling in their feet, along with some generalized weakness? Well, that could very well be MSK in origin. But it could also be metastic cancer with a paraneoplastic syndrome (Lambert-Eaton myasthenic syndrome). Or how about hesitancy in urination in an older man? Could be neurogenic bladder, which they might think is treatable by SMT. Could be BPH. Could be prostate cancer. Do chiros do a digital rectal exam to check?

    Of course I could go on and on, and I bet someone can find a way to nitpick my examples above. The point is that being a PCP is much more complicated than just deciding if something is or is not MSK related. And there is nothing that indicates that chiros have the training to catch those uncommon, but ever present and very important cases. So yeah, in theory the chiro could refer to a rheumatologist, Michele. But there is nothing in their guidelines, accreditation, or training that indicates uniformly that all chiros could or would do so. That is my central point there.

  18. nybgrus says:

    @Marcus Welby:

    I am not in any way trying to say that there is significant overlap between DC and PT. I stated quite clearly that PTs can incorporate the small amount of coincidentally evidence based technique of chiros very easily. I can’t comment on to how long or how much, which is why I left that open. I am trying to be as fair as I possibly can in my arguments, and even though I believe that everything useful of chiropractic can be easily absorbed into PT, I don’t have or know the evidence well enough to state that as a fact. And since that is not central to my argument, I have decided to be charitable and simply grant the DCs some leeway there. It doesn’t change the outcome of my thesis, nor does it give them significant wiggle room. And I hope it is clear now that it in no way denigrates PTs either.

  19. nybgrus says:

    oh, and by the way – I spent the whole day studying and am about to go to bed and after a half bottle of wine and some South Park, this is (sadly) my way of unwinding.

    I am happy to explain myself a bit as warranted and to those whom I respect, but as I said – when NMS-DC comes around again, I will resist the temptation to start another… spirited discussion.

  20. Scott says:

    Is it Primary Care Provider, as my insurance companies have called it or Portal(of Entry) Care Provider, meaning someone who can refer to other physicians, not one who could bill for primary care such as pelvic exams, general diagnostic tests, etc.

    I think it’s relevant here to note that chiropractors are unqualified for either of those tasks. Even just doing referrals requires a substantial amount of training (and diagnostic testing) in order to identify the appropriate specialty to which the patient should be referred. Without the proper training, all a chiropractor could do in terms of referrals would be to simply refer all patients directly to an actual primary care physician without even asking any questions. An activity for which it’s unlikely anyone would be willing to pay.

  21. Jann Bellamy @ “Portal of entry” means that a patient can see the provider without a referral from another provider. It is not synonymous with primary care provider.

    Okay, It seemed in the last discussion that folks were using PCP with different meanings. Which makes it hard to know what people were saying.

    So PCP=Primary Care Provider, POE( or other initials if that’s not standard)=Port of Entry – a Provider who can be seen without a referral and (I gather) a POE can not general make a referral to a specialist.

    If I’m wrong, please feel to clarify.

  22. @Scott- Not sure if your post called for my answer, but I really don’t have an idea on whether a Chiroprator is qualified to make a referral or not. My insurance allows self-referrals, so I would guess the qualifications would depend upon insurance company criteria. My solid opinion is that I do not think Chiroprators should be primary care providers, unless they are also an MD or DO (U.S. version).

  23. DugganSC says:

    @Jann:

    Thank you for your input, What may be muddying the issue is that I’m honestly not entirely certain to what degree this is chiropractry and to what degree she might be going to a legit physical therapist do does joint manipulations for items other than her back and she just refers to him as a chiropractor and the treatment as “adjustment” because he also works with the lower back. *wry grin* Sadly, I have some difficulty raising the subject due to having expressed strong opinions against chiropractors before I had evidence to back me up, so it may take some time to resolve this.

  24. ConspicuousCarl says:

    NMS-DC on 03 Nov 2011 at 10:39 pm

    @ConspicuousCarl:

    “Other courses” taught at chiropractic school (http://www.cmcc.ca/Document.Doc?id=861) Starts at page 53.

    Thanks, but I guess I didn’t really know the right way to ask what I was wondering. The course catalog has things like anatomy, and then other courses with the word chiropractic. I can guess pretty well what might be in the anatomy class, but what about the ones with the word “chiropractic” in the title?

    A perfect example would be “Chiropractic Practice: Principles and Professional Foundations”. What exactly are the founding principles, if not subluxations?

    Then they have “Chiropractic Skills I”, which I could assume to mean the physical practice, but what explanation, if any, is given for exactly why those practices are applied? Does it link back to the anatomy knowledge, or are anatomy and chiropractic merely presented side-by-side without the rejected subluxation theory to explain why one has anything to do with the other?

  25. nwtk2007 says:

    Yes, chiro’s are POE providers and should not be PCP’s. There is just too much which folks go to the doctor for that is outside their scope of practice. As to referrals, all providers are expected to make a referral to another provider when a condition requiring treatment outside their scope of practice or unknown is encountered.

    It is hard to imagine that there are people who are so poorly educated that they would go to a chiro for a cold or flu or some other purely “medical” condition. But then there are many who don’t know the difference between Tylenol and Motrin, etc, etc. With such ignorance within the general public, its easy to see how government has gotten into the charity business and created so many entitlement programs, basically, to care for those who are just too ignorant, what I call the 70/80′s, to be able to do much else.

  26. pmoran says:

    Personally, I might be amendable to saying that a chiropractor who recognizes a problem outside his field could refer to a specialist. Say, he suspects his patient has an auto-immune disease and he could refer to a Rheumatologist, instead of sending the patient to their primary physician to do so. I don’t think it’s wise for Chiropractors to act as Primary Care Physicians

    Michele, it is not wise to allow any fragmentation of primary medical care. A “family doctor” who knows you and your family well provides many benefits, including having all your medical information in the one place.

  27. Scott says:

    @ michelle:

    The point I was trying to make, and apparently didn’t make clearly, is that chiropractors can’t add any value via referrals, since they don’t have the training to do that properly. It would be much like self-referring, except there’s someone else wanting to be paid.

    It is hard to imagine that there are people who are so poorly educated that they would go to a chiro for a cold or flu or some other purely “medical” condition.

    Given that a substantial number of chiropractors explicitly claim they can cure/prevent such conditions, I can’t see why one would blame the PATIENTS for being “so poorly educated.”

  28. JPZ says:

    @Jann Bellamy

    “These “definitions” have public health consequences. To the health care consumer, the term “primary care physician” means someone who can provide (as the name implies) “primary care,”…”

    The “definitions” of these words changes depending on whom is speaking – even PCP can mean Primary Care Provider or Primary Care Physician in this same thread, and the distinction is significant. It comes down to this, if someone uses the term “doctor” or “PCP” in a manner you consider to be wrong, you need to have an objective and binding definition to point to as your reference point. MedlinePlus isn’t binding.

    For example, “Dietitian” is a legally-protected title with a specific definition. But, a “naturopathic doctor” gets to use the less-specific term “doctor.” “Drug” is specifically defined in FDA regulations, but many SBM commentators have disputed that official definition before in favor of their own definition.

    All I am saying is that a lot of people here get indignant over a perceived misuse of a word without their opinion being supported by an objective and binding definition. But, on a positive note, I am also seeing comments where people on this thread are sharing their definition of “PCP” and the role it plays in healthcare with a follow-up of whether chiropracters are trained to fulfill that role. That separates the poorly-defined word from the role and allows serious discussion of the core issues about the role.

    That said, I just had the thought that health insurance companies probably have terms like “Primary Care Provider” very carefully and clearly defined backed by enforcement through reimbursements. Maybe that is not binding across enough people to qualify as a common definition, but it does seem to have some weight.

  29. nwtk2007 says:

    @Scott.

    Ok Scott, fair enough. So who, then, do we blame for the ignorance of the differences between OTC medications. Are you suggesting that a huge number of patients aren’t “poorly educated”? Now, since most who fall into this class consider the ER their PCP and have for their entire lives, who could have educated them as to his important bit of information, or better yet, educated them as to the fact that they shouldn’t go to the ER for regular, non-emergency illnesses, etc, etc.

  30. JPZ says:

    @nwtk2007 and Scott

    This sounds like the politician trick where a concept like investing social security money in the stock market is defended by saying that the American people can be trusted with that kind of decision. If you challenge them, they will accuse you of saying the American public is stupid. Instead of pointing out how few people have set aside any money for retirement or some other logical point, I wish the comeback would be something like, “Wait a minute. I know a lot of stupid people. I imagine you know a lot of stupid people too? In fact, I think everyone in America could name a lot of stupid people. Tell me that doesn’t add up to a lot of stupid people in America.”

    LOL, just a little pre-election year humor I thought I would share. ;)

  31. nybgrus says:

    @scott:

    Exactly. They add no benefit to referall in how they can act as PCP/POE. They are just a middle man to take more money for something that is almost equivalent to self referring.

  32. @Scott- Okay. I see what you are saying now.

    @pmoran, no worries about me seeing any chiroprators, so the only fragmenting of care here is all the specialists and since the new computer records system they’ve gotten much better with communication.

    @Anyone, I think I may have worded my comments poorly and it came across as advocating for Chiroprators being able to refer to specialists. Firstly, I know I don’t have sufficient knowledge to advocate for such a thing. Secondly, I really am very unimpressed with the chiropractic field, So I understand and inclined to agree with the distrust

    So maybe my wording should have been, I can speculate that there might be some small chance of there being an argument for saying a Chiroprator could give referrals (but have no interest in making that argument myself) but there is no way in heck you can convince me that a Chiropractor should act as a PCP.

    Just as an addendum, one thing I was trying to address with my rheumatologist referral example, is that it seems pretty inevitable that a chiropractor will have patients with undiagnosed lupus, rheumatoid arthritis, osteoporosis or other illnesses with visible signs. If that CP recognizes those signs and wants to do right by their patient, what should they do? Certainly, at a minimum they should tell the patient to see their physician about it. IMO, from a patient’s perspective, since some of these conditions flare and then may have receded by the time the patient gets to their PCP, it would be nice if the CP wrote a note detailing his concerns. I think a note to the PCP would also be helpful as a nudge to the patient to really make an effort to make that PCP appt, since the CP made the effort to write the note.

    I was imagining the referral to specialist as a short-cut, but I know short cuts aren’t always advisable. I accept Scott and pmoran’s points in that matter.

    I was imaging the

  33. Grrr, editing errors, again.

  34. nwtk2007
    ” But then there are many who don’t know the difference between Tylenol and Motrin, etc, etc. With such ignorance within the general public, its easy to see how government has gotten into the charity business and created so many entitlement programs, basically, to care for those who are just too ignorant, what I call the 70/80′s, to be able to do much else.”

    nwtk2007, are you on crack? Sure some people don’t know the difference between Tylenol and Motrin and some people, apparently, don’t know the difference between a charity and a business. What does any of that have to do with the price of tea in China?

    Are you just throwing out a bunch of controversial political crap in the hopes of distracting from any debate on the value of Chiropractic care? Or are you just not able to focus?

  35. nwtk2007 says:

    Yes, crack, that’s it. Golly gee man, I was just responding to Scott there. Scott was implying that I was blaming the patients themselves for being so uneducated. In some small way he is right. However, I was just pointing out that the medical community might consider educating the public a bit more such that they, the public, might be better able to decide what they might need to do in the event of a health problem, instead of blaming chiropractors for doing what they do.

    So, in summary, DC’s should not be PCP’s, DC’s are well able to make referrals (much more so than the PT’s I have had the privilege of working with), they are portal of entry meaning that a person can go to one without a referral from an MD which does not mean PCP, and if you think chiro’s shouldn’t be portal of entry because they seem to you to mislead the public, then I suggest you, the medical community, start educating people better and demanding that your public schools do so as well.

    And finally, the public is to blame for a bit of their ignorance, I think, to redress the earlier point. No matter how bad the educational system might be, a person can get the education they need if the really want to. Not to mention the wealth of information at the very finger tips of all. As long as folks and their culture promotes ignorance as a good thing then they, the public, will continue to be victims of misinformation. Such is life in the US these days.

    Now, back to my crack.

  36. jhawk says:

    Chiropractic subluxation as taught by my school means a hypomobile joint and nothing else. It is synonymous with joint dysfunction, segmental dysfunction, intervertebral dysfunction, osteopathic lesion, joint fixation, joint blockage, etc. Just because schools use the term subluxation in their course catalog does not mean that these schools are teaching the historical and philosophical concept behind the term.

    “with an aggregate average of 13.5 appearances [in the catalogs] and many of those in technique classes…”

    It makes since that most of the appearances of the term subluxation were in technique courses as these are palpation courses designed to teach students how to palpate joint range of motion and if restricted then to mobilize or adjust/manipulate the said restriction.

  37. jhawk says:

    In regards to the CMCC study: I had not seen this study before. Thanks for posting.

    The study also found:
    “Similarly, strong negative responses (disagree or strongly disagree) were noted for ADHD/learning disabilities, arrhythmias/ECG abnormalities, autism, Crohn’s disease, eczema/psoriasis, infertility/amenorrhea, Parkinson’s disease, pneumonia, seizures, upper respiratory infection, urinary tract infection and vision problems”

    For the positive responses in the study (asthma, constipation, chronic pelvic pain, dysmenorrhea, infantile colic, and vertigo), I think the following quote from the limitations of the study sums it up quite nicely.

    “This study had several limitations. The clinicians could have misinterpreted the questions regarding each condition to mean whether or not chiropractic care was effective in treating the condition itself or the musculoskeletal symptoms associated with them. For example, conditions such as asthma and chronic pelvic pain have been associated with higher incidences of thoracic and lower back pain respectively.”

    Sorry for the double post.

  38. marcus welby says:

    Or “manipulable lesion”, which means, perhaps, anyone’s spine which includes vertebrae?

  39. jhawk says:

    @ marcus welby

    he said: “Or “manipulable lesion”, which means, perhaps, anyone’s spine which includes vertebrae?”

    The joint/spine must also include tenderness, range of motion abnormality or tissue textrue change before it becomes a manipulable lesion. If these are not present then yes it is just a spine.

  40. nybgrus says:

    and if you think chiro’s shouldn’t be portal of entry because they seem to you to mislead the public, then I suggest you, the medical community, start educating people better and demanding that your public schools do so as well.

    That’s the whole point of this blog. And IIRC (I was but a youngin’ back then) in the 80s the medical profession did try and educate the public on the quackery of chiro and the chiros fought back on a PR standpoint and said we were just concerned you guys were going to out business.

    But to your original comment:

    It is hard to imagine that there are people who are so poorly educated that they would go to a chiro for a cold or flu or some other purely “medical” condition.

    Its also hard to imagine someone taking homeopathy. Or going to a naturopath. Or believing that a foot massage can fix your liver problems. But it most certainly happens. However, the point is that this is, well, a non-point. There will always be the stupid, but really its just the ignorant. My girlfriend, for example, is incredibly intelligent. Yet she used to take echinacea for colds – the advertising was out there and she just didn’t have the time or compunction to look into further. Coupled with confirmation bias and anecdote and she was sold. After I told her it was BS, she did a PubMed search on her own and discovered I was right.

    When DCs (I assume Michele meant ChiroPracter or Chiropractic Physician when she said CP) call themselves “doctor” what do you expect? The average non-medical person gets sick, feels bad, what-have-you and they want to go see a “doctor.” So they call up a “doctor” of chiropractic and ask, “I have [XXX] symptoms, can you help me and see me?” And the “doctor’s” office tells them yes. A lot of people don’t do this – hence why DC usage was only at ~9% of the pop a decade ago and has declined since. But can you really blame those that do? I think not so much.

  41. nybgrus says:

    Chiropractic subluxation as taught by my school means a hypomobile joint and nothing else. It is synonymous with joint dysfunction, segmental dysfunction, intervertebral dysfunction, osteopathic lesion, joint fixation, joint blockage, etc. Just because schools use the term subluxation in their course catalog does not mean that these schools are teaching the historical and philosophical concept behind the term.

    That’s actually been one of my points. The term is used interchangeably whenever it suits. If your sole basis of practice is around an orthopedic subluxation of the spine then, (besides having almost no cases to work on since those are quite rare and acute) then why do you get to call youselves “doctor?” Well, because in the accreditation and education documents it is just subluxation and historically that meant vertebral subluxation complex as the basis of disease and that is the only historical point justifying DCs as being “doctors” – a point which has since been disproven.

    In other words, as in your case, the school may be teaching the real version of subluxation instead of the historical, but they extend its significance and use the term loosely to retain the historical status of doctor.

  42. NMS-DC says:

    Just checking in, Jann’s original post was detailed and, accordingly, I need time to address the points. Nybgrus was claming I’m going to prove it “wrong”; it’s just his interpretation of certain things and very different contextual perspective that I will bring up. We’re both looking at the same coin, the difference being I see both sides (I am critical of all fringe or “fundamentalist” chiropractic as well, like the readers at SBM) but I also am see the the established scientific side of chiropractic, focused on spinal and MSK disorders.

    @micheleinmichigan

    “Personally, I might be amendable to saying that a chiropractor who recognizes a problem outside his field could refer to a specialist. Say, he suspects his patient has an auto-immune disease and he could refer to a Rheumatologist, instead of sending the patient to their primary physician to do so.”

    This is how chiropractors are licensed in Canada and I think everywhere else in the world. My schooling made no bones about, primary contact, portal of entry, provider. Also, the CCEI (international chiropractic educational accrediting standards” states this very clearly:

    The purpose of his/her professional education is to prepare the chiropractor as a primary health care provider. As a PORTAL OF ENTRY to the health delivery system, the chiropractor must be well educated to diagnose, to care for the human body in health and disease and to consult with, or refer to, other health care providers when appropriate for the best interest of the patient

    I don’t think I am PCP in the sense that nybrygus does. Nor was I arguing that DCs are well trained and suited to be these broad range providers. I really don’t know why he was flipping out and harping on that point so much other than the PCP debate, as presented by him, is a uniquely American experience. It’s not in any other jurisdiction. I can see what Jann would want clarity on the PCP issue and I favour that being clarified as meaning primary contact, portal of entry, providers. And yes, direct referral access to a rheumatologist for a patient that I see who I diagnose with Ankylosing Spondylitis would be logical, and helpful to the patient. No need to to the DC->MD->specialist route when the DC->specialist route is more direct and cost-effective. But then again, maybe I see why some MDs don’t want to lose that middle man job and their “cut”. Is is really about the science with some of these MDs who are anti-chiro or is it because they stand to lose money potentially? It’s a fair question and I’m sure that some practitioners greed is what drives them.

  43. NMS-DC says:

    nybrygus

    Why do dentists and optometrists call themselves doctor? Orthopedic subluxations are actual partial dislocations which is a partially unstable joint. This is not what a spinal joint dysfunction/subluxation is, it’s a vertebral segment that not dislocated or unstable, it’s just not moving the way it’s supposed to. To you understand this concept at the least?

    NMS-DC

  44. NMS-DC says:

    @nybgrus (again)

    “Well, because in the accreditation and education documents it is just subluxation and historically that meant vertebral subluxation complex as the basis of disease and that is the only historical point justifying DCs as being “doctors” – a point which has since been disproven.”

    Historically it meant that, but that’s history. Contemporary (modern) chiropractic refers to as joint dysfunction/subluxation being a mechanical problems effecting the NMS system through. And, if you’re not moving well, you’re probably going to get some type of structural change down the road (i.e. OA) and have more disability, pain which leads to poorer overall health. It’s like a domino effect really.

    Also you state

    “In other words, as in your case, the school may be teaching the real version of subluxation instead of the historical, but they extend its significance and use the term loosely to retain the historical status of doctor.”

    The doctoral status comes from the 7-8 years of education. It comes with a specializing body of knowledge. Dentistry=teeth, optometry=eyes, chiropractic=spine. It’s not more complicated than that.

  45. jhawk says:

    nybgrus said: “If your sole basis of practice is around an orthopedic subluxation of the spine then, (besides having almost no cases to work on since those are quite rare and acute) then why do you get to call youselves “doctor?”

    An orthopedic subluxation is a partial dislocation and a chiropractic subluxation is a hypomobile joint. These terms are not interchangable. Also, chiropractic was not founded on the vertebral subluxation complex (VSC) it started with joint manipulation. The VSC was a theory (now debunked) of the mechanism of joint manipulation. Furthermore, this is not our sole basis of practice. Spinal manipulation is a tool used often in the chiropractic profession but there are other tools as well (myofascial release, stabalization exercises, postural exercises, Mckenzie methods, PNF, PIR, instrument assisted myofascial release, sensory motor stimulation, etc.)

  46. NMS-DC says:

    @jhawk

    Exactly. The core of chiropractic is spinal/joint manipulation. It’s what EVERY chiropractor agrees upon, not the historical subluxation construct (i.e. monocausal for disease) which is perpetuated at this site and Jann’s post incorrectly assumes is still the dominant raison d’etre at EBM chiropractic schools. Also, he’s only looking at the USA. There is no such thing as “Life University” or “Sherman College of Straight Chiropractic” that is being taught outside the USA. Those schools are the subluxation-based schools that are continue to propagate the fundamentalist chiropractic, a minority which is looking more ridiculous as the days wear as the rest of the profession internationally, leaves that behind and it something that is taught in History class.

  47. nybgrus says:

    I don’t think I am PCP in the sense that nybrygus does

    First off, once again, this conversation is about the proffesion as a whole not your own personal experience. Secondly, as per the CCEI chiros are:

    Practice primary health care as a portal-of-entry provider for patients of all ages and
genders.
    
• Assess and document a patient’s health status, needs, concerns and conditions.
    
• Formulate the clinical diagnosis(es).
    
• Develop a goal-oriented case management plan that includes treatment, prognosis, risk,
lifestyle counseling, and any necessary referrals for identified diagnoses and health
problems.
    
• Follow best practices in the management of health concerns and coordinate care with
other health care providers as necessary.

    • Promote health, wellness and disease prevention by assessing health indicators and by
providing general and public health information directed at improving quality of life.
    
• Serve as competent, caring, patient-centered and ethical healthcare professionals and
maintain appropriate doctor/patient relationships.

    Now compare that with the MedlinePlus definition of what a primary care provider is (as Jann pointed out):

    A PCP is your main health care provider in non-emergency situations. Your PCP’s role is to:
    *Provide preventive care and teach healthy lifestyle choices
    *Identify and treat common medical conditions
    *Assess the urgency of your medical problems and direct you to the best place for that care
    *Make referrals to medical specialists when necessary

    Explain to me how that is materially different? You are tasked with doing the same thing as family practitioners, pediatricians, internists, OB/GYNs, and nurse practitioners/physicians assistants, without either the level of training nor the direct supervision of a physician. .

    No need to to the DC->MD->specialist route when the DC->specialist route is more direct and cost-effective. But then again, maybe I see why some MDs don’t want to lose that middle man job and their “cut”. Is is really about the science with some of these MDs who are anti-chiro or is it because they stand to lose money potentially? It’s a fair question and I’m sure that some practitioners greed is what drives them.

    Nice way to divert it. Of course it shouldn’t go DC->MD->specialist. It should just go MD->specialist. The point we are contending is that DCs don’t have adequate or sufficient science based training to go DC->specialist. It has nothing to do with losing money.

    Why do dentists and optometrists call themselves doctor?

    This is a fair point. The answer is because their specialties are actually science based and they would never treat or see someone who doesn’t have an ocular or dental complaint. DCs are not and would.

    Orthopedic subluxations are actual partial dislocations which is a partially unstable joint. This is not what a spinal joint dysfunction/subluxation is, it’s a vertebral segment that not dislocated or unstable, it’s just not moving the way it’s supposed to. To you understand this concept at the least?

    Yes, of course I do. And “hypomobile joints,” especially in the spine, has no good science or clinical evidence to support it as amenable to SMT. Ergo, the point still stands, no matter how much you try and quibble on the definitions.

    Historically it meant that, but that’s history. Contemporary (modern) chiropractic refers to as joint dysfunction/subluxation being a mechanical problems effecting the NMS system through.

    And, as Jann has just demonstrated, it also currently means that. You can keep claiming that “modern” chiropractic is this or that, but all you have is anecdote and your own thoughts on the matter – that is not an accurate reflection of the actual field and proffesion of chiropractic.

    And, if you’re not moving well, you’re probably going to get some type of structural change down the road (i.e. OA) and have more disability, pain which leads to poorer overall health. It’s like a domino effect really.

    Citation needed. You are making assumptions which are not adequately supported by the science (as pmoran has taken the time to point out) and inferring what must be the case regarding a lesion which has not been proven to exist (even your “hypomobile segmental joints” not just the vertebral subluxation complex).

    The doctoral status comes from the 7-8 years of education. It comes with a specializing body of knowledge. Dentistry=teeth, optometry=eyes, chiropractic=spine. It’s not more complicated than that.

    You are right. I will concede the point on a technicality. However, there are “doctors” of theology as well and as such are equivalent to doctors of unicornology and leprachaunology.

    However, the key difference is that “doctors” of chiropractic actually present themselves to be physicians. And before you go on saying how you don’t the point is we have demonstrated that the majority of your colleagues do as is the point of your schooling.

    Also, chiropractic was not founded on the vertebral subluxation complex (VSC) it started with joint manipulation.

    Really? Tell that to D.D. Palmer.

    You know, the founder of chiropractic?

    “A subluxated vertebra… is the cause of 95 percent of all diseases… The other five percent is caused by displaced joints other than those of the vertebral column.”

    Jann’s post incorrectly assumes is still the dominant raison d’etre at EBM chiropractic schools. Also, he’s only looking at the USA.

    [emphasis added]

    Really? That’s funny. ‘Cuz there is a whole section titled “A closer look at Canadian Memorial Chiropractic College” which then proceeds to talk about the Canadian chiros. And a section further down that discusses the Chiropractors Association of Australia which “actively promotes subluxation based chiropractic.” And “Chiropractic trade publications and so-called educational seminar promotion material often abound with advertisements of how practitioners can effectively sell the VSC [vertebral subluxation complex] to an ignorant public.”

    So in other words, we have Jann’s article – chock full of citations, references, and utilizing chiropractic’s own professional body stances, accreditation articles, specific schools, and research articles – demonstrating one thing and your anecdotes and unsubstantiated claims stating that’s wrong.

    And you apparently didn’t actually read the article either. You can’t win an evidence based argument without… you know, actual evidence.

  48. nybgrus says:

    ack! sorry for missing a tag. the first link is just to the medline plus article that Jann already linked to and the second is to the DD Palmer wiki page. Nothing particularly special

  49. NMS-DC says:

    @nybrygus

    It didn’t take you long to directly address me. Long winded rhetoric aside; DCs are trained in primarily NMS diagnosis and management. Portal of entry, primary contact for spinal disorders and other NMS cases.

    DCs do have sufficient science based training in NMS diagnosis and management, and to refer cases to other health care providers when appropriate. Chiropractors and their expertise in NMS are deemed acceptable by the World Health Organization, specifically it’s role in the creation of the Neck Pain Task Force. Sorry nybrgus, I’m going to side with the WHO regarding the DCs ability in managing NMS disorders. This includes referrals. DC->specialist referral is appropriate and valid, no matter what your personal opinion is.

    DCs primarily see spinal complaints. You can focus on on that 10% all you want. Like I said before, dentist=teeth, optometry=eyes, chiropractic=spine. No need to try and obfuscate it more than that.

    Actually yes, you need only to look at the CCEI, CCEUS, and WHO for education, training and safety in chiropractic. I’m not presenting anecdotes, I’m presenting documents in proper context, whereas Jann presents cherry picked articles with no context. Contemporary chiropractors adjusting subluxations= chiropractors manipulating joint dysfunction. DCs who talk about innate intelligence in subluxations subluxations causing visceral disease, preaching one cause one cure, encourage dependence and high volume/inappropriate care are practicing unethically, unscientifically, uncritically. These are the fundamentalist/straight/subluxation-based DCs (a la WCA). We both agree they are charlatans. That’s why they are freaked out by the new CCEI and CCEUS standards.

    Also, your arrogance is so much is that you, an MD student is telling me a DC the history of chiropractic. Wow. Palmer used spinal manipulation because he thought it would improve Lillards hearing. After it “worked” (it didn’t) he theorized that it was because of dysfunctional spinal joints (subluxation) was the “cause” and hence the 1895 quote you are citing. It was one theory, in 1895. Just like how MDs used leaches in 1895. Back then, that was best understanding that had at the time. Spinal manipulation is what chiropractic was founded on. The subluxation was merely a construct trying to explain “why” it worked. Stop revising history. You don’t know it.

    Your main argument now rests on semantics

    1) DCs are not PCP, even though I demonstrated that internationally they are portal of entry, primary contact (i.e. you don’t need a referral to see a chiropractor). DCs are not primary care physicians. We agreed. I never stated otherwise. You’re being incredibly redundant at this point.

    2) Chiropractors aren’t physicians, i.e. they’re not capable of diagnosis. Yeah we are, specificifically in spinal and NMS diagnosis.

    3) Comparing DCs who specialize in manipulative therapy on NMS (and you conceded that they are valid and appropriate for NMS) to theology and leprechanology? Absurd.

    Joint Dysfunction/fixation: animal models of studying effects of hypomobility on spinal biomechanics and local histological changes associated with joint fixation/dysfunction/subluxation.

    Introducing the external link model for studying spine fixation and misalignment: part 1–need, rationale, and applications.
    Introducing the external link model for studying spine fixation and misalignment: part 2, Biomechanical features.

    http://www.ncbi.nlm.nih.gov/pubmed/17416279
    http://www.ncbi.nlm.nih.gov/pubmed/17509437

    You, nybrygus, claim there is no such thing is joint dysfunction, i.e. hypomobile joints? So, DCs, PTs, sports MDs, and DVMs are all out to lunch? That’s your argument?

    The CAA is the WCA which is fringe. That study re: CMCC and Jann’s “take” is actually the same “take” of Edzard Ernst who used the study out of context and then made sweeping overgeneralizations about it. That is bad science (a favourite quote of yours). Cherry picking sources then leaving out context is bad science, its pseudoscience. And guess what? That’s what’s going on here ironically enough, by yourself and Jann!

    NMS-DC

  50. NMS-DC says:

    More joint fixation/immobilization as it relates to chiropractic medicine:

    Spinal motor neuronal degeneration after knee joint immobilization in the guinea pig.

    http://www.ncbi.nlm.nih.gov/pubmed/20605551

    Chiropractic sciences research, again. Whoops, where do those keep coming from? Read them and we can talk about it nybrgus. Try to keep up.

    NMS-DC

  51. NMS-DC says:

    @Marcus and nybrgus

    1) Nybgrus states “quite clearly that PTs can incorporate the small amount of coincidentally evidence based technique of chiros very easily.

    This assumes a) you assume that PTs can magically gain 116 years of experience of spinal manipulative techniques and develop proficiency at them equal to or greater than a DC, b) PTs would value SMT and manual therapy more than DCs c) uses manual therapy as their main treatment modality and d) have room to allot such time in their educational curricula, including clinical spinal manipulative biomechanics (class) and then psychomotor skills (technique class/lab).

    2) Marcus states that “Spinal manipulation is something which can be taught in one course in one semester in a PT school, and is a minor part of nearly nonexistent for most practicing PT’s. ”

    Marcus states that manual therapy is “minor part” and nearly non-existent component of PT while nybgrus asserts that already do and can take the “best” of spinal manipulation and manual therapies and chuck it in the PT curriculum! You two are hilarious. Marcus you do realize that Nybrgus does not support APTA Vision 2020, don’t you? That is, the desire for the PT profession to be DPTs and have direct access, just like DCs do. He also doesn’t think that DPTs should or could be able to refer to a medical specialist DPT ->specialist because DPTs aren’t GPs are aren’t good enough at what they do so they need a middleman GP to make the referral (and the $).

    You are aware, aren’t you, nybrgus and marcus that the WHO has recently (2005) suggested than a minimum of 2200 hrs for the use of controlled act of spinal manipulation as it relates to NMS diagnosis and treatment. Marcus suggests it can be done in one course and the WTO says 2200 hours of training. I’m not really surprised at this point to see how truly misinformed or ignorant you both are on recent developments regarding the chiropractic profession and research/safety of SMT. You guys are brilliantly proving my point. Keep it up!

    NMS-DC

  52. nybgrus says:

    It’s day before exam procrastination. But most of my stuff was copied and pasted, so it’s not like I spent a lot of time on it. Anyways:

    DCs are not PCP, even though I demonstrated that internationally they are portal of entry, primary contact (i.e. you don’t need a referral to see a chiropractor). DCs are not primary care physicians.

    Despite what all your professional bodies and accreditation documentation states, fine. Ill fully agree. People also don’t need a referral to see homeopaths, reiki masters, acupuncturists, reflexologist, bowenwork practitioners, etc etc.

    Chiropractors aren’t physicians, i.e. they’re not capable of diagnosis. Yeah we are, specificifically in spinal and NMS diagnosis

    And if that is all your profession claimed it could do and all it did, then we wouldnt be talking. BTW – homeopaths think they can diagnose all sorts of things too.

    Comparing DCs who specialize in manipulative therapy on NMS (and you conceded that they are valid and appropriate for NMS) to theology and leprechanology? Absurd.

    I conceded no such thing. I said to accept it for the sake of argument. I also stated that the evidence base is slim and the interventions are very few and very narrow.

    You, nybrygus, claim there is no such thing is joint dysfunction, i.e. hypomobile joints? So, DCs, PTs, sports MDs, and DVMs are all out to lunch? That’s your argument?

    No, that is not what I claimed. I claimed that there was no such thing as the chiropractic version of joint hypomobility. Anything that is a valid reference to joint dysfunction is already handled nicely by PTs, sports MDs, and DVMs. Which leaves the DCs out to lunch.

    I know – lets create an entire school and a 4 year post-grad degree so we can call someone doctor but their only scope of evidence based practice lies in treating specifically Staphylococcal and Streptococcal skin infections.

    That study re: CMCC and Jann’s “take” is actually the same “take” of Edzard Ernst who used the study out of context and then made sweeping overgeneralizations about it.

    Interesting. You are saying that people who actually look at the evidence from professional bodies are making sweeping generalizations. Well, you’re entitled to your opinion, but that doesn’t mean it is right. Ernst actually has some very solid evidence, support, and critiques. You’ve offered nothing compelling in return.

    That is bad science (a favourite quote of yours). Cherry picking sources then leaving out context is bad science, its pseudoscience. And guess what? That’s what’s going on here ironically enough, by yourself and Jann!

    Funny, because the references that you keep citing (oh my! where do they keep popping up from??) are what I would call bad science. It took me all of about 5 minutes to read through them to easily make that determination.

    The ELM part one article sums it up very nicely:

    A mimic of the chiropractic subluxation would permit a rigorous examination of the theoretical construct that provides a primary rationale for spinal manipulation and defines the profession in state and federal statutes. [1] , [2] and [3] The term subluxation is currently the focus of a heated debate in the chiropractic profession. Subluxation is a revered historical icon to many in the chiropractic profession and an anachronistic obstacle to others. [3] , [4] and [5] After a century of philosophical commentary and entrepreneurial explanation, many within the chiropractic profession are convinced that subluxation has progressed from theoretical construct to fact. However, there is still no validated criterion for identifying a subluxation.6

    The current debate over the relevance of subluxation, as well as its role in defining the chiropratic identity, enjoins examination of this foundational theoretical construct. [5] and [6] In this series of articles, we take a ‘proof of concept’ approach. The subluxation is operationally defined by 2 cardinal biomechanical features that are common to its many definitions, fixation (hypomobility) and malposition. [7] and [8] Consequently, fixation and malposition were induced experimentally using the ELM to produce a subluxation mimic. Because the ELM is a long-term survival model, with the rats studied for many months after experimental spine fixation, we believe that it may be used to study the putative chronic effects of subluxation as well as the effects of various therapeutic interventions.

    So they say that subluxation is controversial. Then they define it in a non-controversial way. Then they do an animal study to prove that their definition has some sort of basic sciences effect. Then they claim that can translate to the existing model of chiropractic. How many times must you bludgeon yourself with backwards science (conclusion first, then evidence for it)? Do you seriously not understand that you can’t define a pathology and then find evidence to support its existence? You must first discover a pathology, then do experimentation and study to determine what is causing it. If that turns out to be some sort of vertebral subluxation then that is all well and good. ALL the studies you cited are in animal models AND they are all taking the assumption that chiropractic is valid, subluxation exists, and then finding a way to define it such that some kind of evidence supports it existence. Meanwhile, there are no actual clinical studies demonstrating that any existing form of chiropractic intervention actually addresses the pathology via those mechanisms to produce a positive clinical outcome. It is all backwards science that is disjointed and strung together in a “just so” story to corroborate that already decided upon conclusion. That is bad science.

    I can also throw you dozens of articles that demonstrate the validity of homeopathy using the exact same type of science, techniques, clinical evidence, etc. Hell, even a Nobel laureate wrote an article that I can cite to prove to you that DNA can teleport and therefore homeopathy must be real. So yeah, unicornology and theology and homeopathy and chiropractic all are in the same ballpark. Chiropractic just accidentally got a few things right is all (well, so did theology).

    We asked you to cite articles as evidence. Just because you toss out a link doesn’t mean you are vindicated. The evidence actually has to hold up. And it doesn’t.

    Chiropractic sciences research, again. Whoops, where do those keep coming from? Read them and we can talk about it nybrgus. Try to keep up.

    So yeah, I read them. And I kept up. And they are almost entirely worthless and are indeed worthless in trying to advance your postulate about SMT and spine related pathology. More examples of bad science. I’m sorry that you can’t quite understand that.

  53. marcus welby says:

    Why do dentists and optometrists call themselves doctor? Orthopedic subluxations are actual partial dislocations which is a partially unstable joint. This is not what a spinal joint dysfunction/subluxation is, it’s a vertebral segment that not dislocated or unstable, it’s just not moving the way it’s supposed to. To you understand this concept at the least?

    The above is an imaginary concept which is taught in chiropractic schools and becomes the core focus of their practice. Whether you call this subluxation or manipulable lesion or some other name, it is primary to chiropractic and the legal definition of chiropractic in every state. Totally imaginary, however. No interobserver reliability in diagnosing such, no radiologic way to demonstrate, and the idea of a hypomobile segment being diagnosed by surface palpation and examination when the spinous processes are the only palpable portions of the spine and they are connected firmly by interspinous ligaments…this is magical thinking. Then, when each vertebral segment is only about 3 or 4 centimeters apart, to determine by palpable means which one is the cause of a patient’s pain is also ludicrous. Radiologists cannot examine xrays and tell which patient’s spine is painful and which is not. Then to say spinal manipulation is going to improve the range of motion of a hypomobile segment, rather than increase the motion of normally mobile or hypermobile segments 2 inches above and below the “hypomobile segment” , perhaps causing them to be symptomatic (spine surgeons generally operate to fuse vertebral segments which are felt on imaging to be pathologically hyPERmobile as a source of pain) this makes no sense whatsoever. The UCLA study of patients published by a joint chiropractor/MD group several years ago showed one third of patients treated by chiropractors with neck manipulation had significant worsening symptoms of pain for a number of days after their necks were twisted. And the Journal of Subluxation Research? Come on, the concept of a diagnosable subluxation or manipulable lesion however you wish to name the concept, is totally imaginary. The benefit of spinal manipulation is largely a result of a clinical encounter and is a placebo effect. In summary, chiropractic arose out of the observation that some people felt subjectively improved following a clinical experience with a member of the healing community. All the subluxation/hypomobile segment/manipulable lesion stuff is imaginary, yet is the core of chiropractic education, legally-defined practice, history, and belief. It cannot be demonstrated or reproduced by a second chiropractor, it cannot even be defined by the official chiropractic organizations. That has been the case for 116 years.

  54. nybgrus says:

    Marcus you do realize that Nybrgus does not support APTA Vision 2020, don’t you? That is, the desire for the PT profession to be DPTs and have direct access, just like DCs do. He also doesn’t think that DPTs should or could be able to refer to a medical specialist DPT ->specialist because DPTs aren’t GPs are aren’t good enough at what they do so they need a middleman GP to make the referral (and the $).

    I would insofar as they are under the direct supervision of a physician, just like nurse practitioners and physicians assistants are. There is a VAST difference there. But no, I would not support them being able to act entirely and totally on there own in a manner similar to DCs. Nor would I support that for NPs or PAs.

  55. NMS-DC says:

    @nybrgus

    Deconstructing you, once again:

    “People also don’t need a referral to see homeopaths, reiki masters, acupuncturists, reflexologist, bowenwork practitioners, etc etc.”

    Show me the World Health Organization endorsement of education and safety of these professions. Another red herring by you, and a bad one at that. Your argument on this regard is silly and tiresome. Furthermore we are talking about the PCP debate.

    So you are saying, that you never admitted that DCs were valid for MSK management? Do you forget our “spirited discussion” in the last thread. I can go get your quote if you want, but it would embarrass you. Your credibility is at stake here. Just move on from this point. It’s been done already and conceded.

    More gold from nybrgus:

    “I claimed that there was no such thing as the chiropractic version of joint hypomobility. Anything that is a valid reference to joint dysfunction is already handled nicely by PTs, sports MDs, and DVMs. Which leaves the DCs out to lunch.”

    Let’s see here. There is no such thing as the “chiropractic version” of joint hypomobility. So when we palpate a dysfunctional joint, it doesn’t count, but if a PT, sports MDs, DVMs do it counts? We’re all palpating the same thing: joint dysfunction. And if you admit that PTs, MDs and DVMs do it, you’re admitting that it exists… speaking from both sides of the mouth are we? Out to lunch? DCs do 94% of SMTs on (taking a deep breath) hypomobile joints! The only thing this is out to lunch is your argument. Weak. Again.

    And it keeps going

    “I know – lets create an entire school and a 4 year post-grad degree so we can call someone doctor but their only scope of evidence based practice lies in treating specifically Staphylococcal and Streptococcal skin infections.”

    Differential diagnosis of MSK and CT disorders ICD 9: http://www.health.gov.bc.ca/msp/infoprac/diagcodes/710_musculoskeletal.pdf

    Specific Spinal Disorders DDX
    http://worldspinecare.com/about-your-spine/spinal-disorders/

    It’s 4 years because there’s a lot to MSK. SMT isn’t the ONLY thing DCs to, it’s our expertise in it is what sets us apart from the other health professions.

    The greatest nonsense of all is you stating the research a) didn’t exist and b) wasn’t scientific and c) didn’t hold up. This is innovative and new research. The field is still emerging. But its there and its real. And BTW, that paper that doesn’t ‘hold’ up according to you (you did not read it) written by an MD and a PhD. It states that the immobilizing a knee joint, even briefly, leads to spinal motorneuronal degeneration, (i.e. joint dysfunction being bad for you) and that these neurodegenerative changes were reversible. Specifically the conclusion stated:

    “This study clearly showed histological and ultrastructural degenerative changes in the peripheral nerve fibers and the spinal motor neurons after various periods of the knee joint immobilization in the guinea pigs. Such degenerative changes were not associated with neuronal death and were reversible.”

    So, and MD and PhD, working at chiropractic institution, investigating the biological mechanisms of joint dysfunction demonstrates that said the joint dysfunction is associated with histological changes (soft tissue any articular structures) as well degenerative changes in the peripheral nerves and the spinal motor neurons innervating that specific joint and that it REVERSIBLE upon “release” of said joint hypomobility/dysfunction. This is a major premise as to WHY SMT works (on what, the manipulable lesion). This is what the contemporary science of joint dysfunction/subluxation is about. This is the chiropractic “angle” on joint dysfunction: it leads to altered neurological functioning.

    More proof that joints that don’t move well, have deleterious effects on the joints and local tissues themselves in terms of accruing damage, but also neurologically as the peripheral nerve and the spinal motor neuron innervating it start to degenerate. It’s functional because its reversible. Once it becomes structural (i.e. permanent structural change, OA) then its a whole different problem. Chiropractic is about correcting biomechanical problems while still in the functioning state, before structural degeneration becomes permanent. Based on this study, I think its apparent why that rationale is important.

    But just in case aren’t into this concept nybrgus: PREVENTION is more important (and proactive) than waiting for your approach, ignore and deny the “magical” joint dysfunction, then letting your patients joints to slowly degenerate away, because you don’t believe there’s a role for DCs, eventually the same patient will come back to in time with structural (OA or worse) changes in that joint and then, in your wisdom, and expert medical care will finally act and give them NSAIDs and/or pain killers. Bravo, nybrgus. You let personal ideology dictate your medical care as opposed to understanding the basic sciences involving joint dysfunction, spinal manipulation and then understanding the appropriate role of DCs in managing these cases.

    @Marcus:

    you think that biomechanical joint dysfunction doesn’t exist and you’re a PT? And you claim to be “evidence-based” yet you clearly outdated and I might add a relic in the current state of the literature regarding manual and manipulative therapy and joint biomechanics. You didn’t even know your own profession was adjusting necks! And you then suggested that one course would be sufficient in learning SMT while the WHO standards are 2200 hours? Patient safety is the primary concern behind this recommendation and proficiency in developing the necessary skills to competently perform SMT.

  56. NMS-DC says:

    @nybrygus

    Why under supervision of a GP? You guys are weak at MSK diagnosis:

    Musculoskeletal examination–an ignored aspect. Why are we still failing the patients?
    http://www.ncbi.nlm.nih.gov/pubmed/21165754

    “Musculoskeletal (MSK) complaints have high prevalence in primary care practice (12%-20% of visits), yet many trainees and physicians identify themselves as weak in MSK physical examination (PE) skills”.
    http://www.ncbi.nlm.nih.gov/pubmed/18925682

    Doctors likely to encounter children with musculoskeletal complaints have low confidence in their clinical skills.
    http://www.ncbi.nlm.nih.gov/pubmed/18823907

    More ‘cries from the joints’: assessment of the musculoskeletal system is poorly documented in routine paediatric clerking.
    http://www.ncbi.nlm.nih.gov/pubmed/15187245

    “The curricular review identified several weaknesses in the course: the apparent absence of a formalized needs assessment, course objectives that were not specific or measurable, poor development of clinical presentations, small group sessions that exceeded normal ‘small group’ sizes, and poor alignment between the course objectives, examination blueprint and the examination.” (ONE COURSE in MSK diagnosis.)
    http://www.ncbi.nlm.nih.gov/pubmed/21143996

    There is a need to improve competence of musculoskeletal system (MSS) examination in medical students and junior doctors.
    http://www.ncbi.nlm.nih.gov/pubmed/20525742

    “Medical schools in the United States have continued to demonstrate deficiencies in musculoskeletal education”
    http://www.ncbi.nlm.nih.gov/pubmed/21143996

    “The amount of time devoted to musculoskeletal medicine in the typical undergraduate curriculum is disproportionately low compared with the frequency of musculoskeletal complaints that occur in a general practice.”
    http://www.ncbi.nlm.nih.gov/pubmed/18829928 (solution a 6 week course in MSK!)

    Evidence of educational inadequacies in region-specific musculoskeletal medicine.
    http://www.ncbi.nlm.nih.gov/pubmed/21143996

    And on, and on, and on it goes. DCs have NOTHING to learn from MDs (GPs) regarding MSK. You’re the one’s who are deficient. PCP, nybrgus? The evidence suggests you’re going to be terrible at MSK diagnosis and management. That’s why I studied MSK for 8 years (4 years undergrad in BSc. Kinesiology/Human Kinetics and 4 years DC). Patients are better off seeing me, than you, for MSK management. And you denigrate and ignore this “little” area of medicine when even your own medical schools are admitting that your skills are deficient and management of these issues weak. Referrals? Yeah, DC to specialist, directly. I will skip your input. You have weak and deficient diagnostic skills in MSK and consequently MSK management.

    NMS-DC

  57. nybgrus says:

    this is getting downright funny.

    Show me the World Health Organization endorsement of education and safety of these professions. Another red herring by you, and a bad one at that. Your argument on this regard is silly and tiresome. Furthermore we are talking about the PCP debate.

    The UK NHS endorses homeopathy. Oh, and did you not notice that the whole point of this series was to demonstrate false legitimacy through legislation and licensure instead of actual evidence?

    Oh, and the WHO organization does not endorse it. They state “guidelines on basic training and safety in chiropractic.” The aim of the position is to “contribute to the enhancement of citizens’ health and well being” in light of the fact that “TC/CAM [use] is in the order of 50% in many high income countries.” In fact, the only mention of “endorsement” in the document at all is in the following sentence:

    “The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.

    2005 PDF

    So I fail to see how the WHO endorses the use of chiropractic. They are just trying to make it so you guys don’t harm people by attempting to reign you in. And lest you think otherwise, the WHO also has a document on the “technical aspects of the production and manufacture of homeopathic medicines that potentially have implications for their safety. This is of relevance for establishing national quality standards and specifications for homeopathic medicines, as well as for controlling their quality.” It also has the same exact reference of “endorsement” in that document and no further mention of endorsement.

    It also goes on to say that the World Health Association “also requests WHO to “continue providing technical guidance to support countries in ensuring the safety, efficacy and quality of traditional medicine.”

    So when you can cite actual evidence that isn’t exactly identical to the “evidence” for homeopathy, then you might earn a bit of respect from me. In other words there is your citation that proves that the WHO “endorses” the safety and education of those other “professions” in exactly the same manner. No red herring on this side of the table. So until you can cite anything better than homeopathic level evidence you’re the one whose reputation is at stake and is embarrassing himself (I’m assuming your male, forgive me if I am wrong).

    So when we palpate a dysfunctional joint, it doesn’t count, but if a PT, sports MDs, DVMs do it counts?

    Nope. Nobody palpates those lesions. Exactly as Marcus Welby stated. Easy as.

    And if you admit that PTs, MDs and DVMs do it, you’re admitting that it exists… speaking from both sides of the mouth are we?

    Nope. I’ve said it time and again – chiro has gotten accidentally lucky from time to time. Those bits of luck are already incorporated into the other fields mentioned. There really isn’t much else to learn, especially not “116 years of spinal knowledge.” That’s just laughable.

    SMT isn’t the ONLY thing DCs to, it’s our expertise in it is what sets us apart from the other health professions.

    Wait wait. First you say that all that OTHER stuff is hokum and that you guys are NMS/MSK specialists and that is all you can do. Now you say that ISN’T all that you do which is why you are set apart and have more privileges from others. Honestly, this is tiresomely easy. You can’t have your cake and eat it too, and that is exactly the point I have been making and you have been handily proving for me.

    The greatest nonsense of all is you stating the research a) didn’t exist and

    You’re right. If I did say it didn’t exist I was absolutely wrong. But as I said, research on homeopathy, reiki, reflexology etc etc all exist too. So mere existence isn’t interesting.

    b) wasn’t scientific and c) didn’t hold up

    Yep. That’s the money.

    And BTW, that paper that doesn’t ‘hold’ up according to you (you did not read it) written by an MD and a PhD.

    Appeal to authority. How quaint. Deepak Chopra has an MD and so does Andrew Weil. Ted Kaptchuk has a PhD. One of my clinical tutors this year said something I loved:

    “A duck with a PhD is still a duck.”

    It states that the immobilizing a knee joint, even briefly, leads to spinal motorneuronal degeneration, (i.e. joint dysfunction being bad for you) and that these neurodegenerative changes were reversible.

    Oh I read it. And I read the conclusion. And I agree with the conclusion. But to imply that that conclusion in any way applies to or lends credibility to chiropractic in any way is where you go off the rails. Especially considering that it was a knee immobilization – not a spinal immobilization. It’s really sad how you can’t fathom that the science doesn’t apply.

    This is a major premise as to WHY SMT works (on what, the manipulable lesion).

    Except that, as I pointed out, it was an immobilzation of a knee joint (wait, who didn’t read the article?) and you are relating that to spinal manipulation. I mean you quoted the fact that it was a KNEE and then used that to assert something about the SPINE. And you STILL miss the point that it was an EXPERIMENTAL hypomobilization and release. So even if it DID have to do with the spine, there is nothing there demonstrating that an in vivo hypomobilization would approximate it NOR that a chiropractic manipulation would RELEASE it.

    I know science is hard, but come on – that is basic stuff NMS-DC.

    Chiropractic is about correcting biomechanical problems while still in the functioning state, before structural degeneration becomes permanent. Based on this study, I think its apparent why that rationale is important.

    It is a fine rationale. And the basic sciences behind it makes sense. But basic sciences usually DONT translate to clinical outcomes. So the study that you are so enamored with tells us NOTHING about whether such functional hypomobility actually exists in real life patients, whether there is a pathogenesis of disease based on that, whether chiropractic manipulation can alleviate that, and whether alleviation actually changes outcomes! That is how clinical medicine actually works.

    As I said – you are taking disjointed basic sciences stuff and trying to prove a conclusion by connecting the dots. Science doesn’t work that way. But pseudoscience sure does!

    because you don’t believe there’s a role for DCs, eventually the same patient will come back to in time with structural (OA or worse) changes in that joint and then,

    Want to shut me up? Want to actually prove your point instead of spouting pseudoscience for your pet theories? Find me a good, high powered, RCT that demonstrates that ANY chiropractic intervention actually prevents OA. Hell, find me a good case control study. You have none. All you can do is spout some basic science stuff and then assert that it must be able to prevent OA. THAT is why you are preaching pseudoscience.

    in your wisdom, and expert medical care will finally act and give them NSAIDs and/or pain killers. Bravo, nybrgus. You let personal ideology dictate your medical care as opposed to understanding the basic sciences involving joint dysfunction, spinal manipulation and then understanding the appropriate role of DCs in managing these cases.

    Talk about the pot calling the kettle black. You get to call my stance an ideology once you show me actual evidence that anything a chiro does will prevent disease. ANY disease. Show me any RCT. Show me ONE good case-control study. Until then you are pedding basic sciences as clinical medicine and THAT is pseudoscience.

    So now that I have destroyed your WHO argument and demonstrated the absolute fallacy of your guinea pig study, lets see what other stammering idiocy you can come up with.

  58. NMS-DC says:

    @nybrygus

    You destroyed my WHO argument, how? By conflating it with homeopathy? We are talking about chiropractic. You’re off the rails.

    1) WHO produced an educational and safety guideline for training chiropractic doctors. So that minimum standards in education are met before you can call yourself a chiropractor. You’re conflating this with the safe preparation of homeopathic potion. A document that talks about educational standards for a health care profession and a document that talks about safe production of (homeopathic) medication. Where are the WHO standards of education and training for homeopathy?

    2) There is a chiropractic doctor working at the WHO since 2008. Proof that the WHO “supports” and “endorses” contributions of chiropractic medicine to health care besides a) chiropractic being admitted to the WHO in 1997 and b) the development of training and safety guidelines in 2005. Recap 1997 -> entry to WHO –>2005 minimum safety and training guidelines for chiropractors–> 2008 DC hired by the WHO to work at the WHO in area of health policy

    http://sites.google.com/site/whoictm/participants/robinsonnicol

    Then you conflate, yet again by comparing the NHS to the WHO. I stated WHO. Apples and oranges, but you like to try and mix them up and confuse people with your arguments. But you seem mostly confused yourself. You’ll see later on in my response.

    More misinterpretations and wild assumptions by yourself:

    “Wait wait. First you say that all that OTHER stuff is hokum and that you guys are NMS/MSK specialists and that is all you can do. Now you say that ISN’T all that you do which is why you are set apart and have more privileges from others.”

    The other “stuff” we do? Diagnose MSK disorder. Exercise prescription/rehabilitation, nutritional/lifestyle counseling. Overall patient management for appropriate MSK care. Facilitating referrals. Co-managing cases with specialist and GPs. And then you flat out lie claiming I said we are “set apart and have more privileges”. You’re making this stuff up. Badly.

    The guinea pig knee paper you read and you agree with the conclusions. You state:

    “Oh I read it. And I read the conclusion. And I agree with the conclusion. But to imply that that conclusion in any way applies to or lends credibility to chiropractic in any way is where you go off the rails.”

    The conclusion states: Observation of the peripheral nerve (femoral nerve) also revealed demyelination alterations in some axons innervating the muscles of the knee joint. Interestingly, motor neuronal degenerative changes and demyelination were reversible after the knee joint immobilization was removed and knee joint activity was restored. These findings may assist in further development of models for spinal dysfunction such as the chiropractic subluxation complex.

    It lends credibility because it demonstrates that a joint (in this case a knee) that is in a biomechanical state of hypomobility/fixation/dysfunction/subluxation (the terms are synonymous) deleterious neurological effects as demonstrated by the demyelination of the peripheral nerve innervating the hypomobile joint and also spinal motorneuron degeneration that segmentally innervates it. It gives credence to the chiropractic theory that joint dysfunction affects your nervous system. If a hypomobile knee joint results in the aforementioned neurological changes, why wouldn’t the same concept apply to a spinal joint?

    What’s the fallacy of the guinea pig study? You first said it was “worthless” then said you “agreed with the conclusions”. But the conclusion clearly states “these findings may assist in further development of models for spinal dysfunction such as the chiropractic subluxation complex.

    So you basically just agreed with the conclusions of a paper, published in 2010, which is investigating chiropractic theory, that joint dysfunction results in impaired neurological functioning, which was found. To add to the irony, this paper, which won research paper of the year by the World Federation of Chiropractic, (because it demonstrated the biological mechanisms of joint dysfunction) was written by and medical doctor and a PhD in the Palmer research lab.

    To further emphasize my point of you are agreeing with me. I stated:

    “Chiropractic is about correcting biomechanical problems while still in the functioning state, before structural degeneration becomes permanent. Based on this study, I think its apparent why that rationale is important.
    It is a fine rationale. And the basic sciences behind it makes sense.” NMS-DC

    You replied

    “It is a fine rationale. And the basic sciences behind it makes sense.” So you have just agreed with the rationale of chiropractic (early intervention, prevention, addressing biomechanical issues while in the functional state) and then agreed that the basic sciences of this makes sense.

    You have just stated that you a) agree with the chiropractic rationale, b) that the basic sciences behind it makes sense. You previously stated, in our last discussion in the previous thread, that you found chiropractors “legitimate” for MSK disorders, and that they had “some effectiveness” in treating MSK disorders.

    So to summarize:

    1) you agree with chiropractic rationale towards MSK management
    2) you agree that the basic sciences behind it makes sense
    3) you agree that chiropractors are appropriately trained to diagnose and manage MSK conditions
    4) you agree that that DCs are legitimate as primary contact/portal of entry health care providers (for MSK)

    I knew you’d come around nybrgus. I guess you can teach an old dog new tricks after all. I know you got some studying to do. But it’s been enlightening debating you.

    NMS-DC

  59. NMS-DC says:

    @Marcus and nybrgus

    “Nobody palpates those lesions”

    I’m going to side with Hippocrates on instead of you two.

  60. pmoran says:

    The finding of neuronal changes with disuse atrophy is hardly surprising. Nor is it a clear endorsement of anything chiropractic.

    Which specific chiropractic medical claim does it support? Give me an example.

  61. NMS-DC says:

    @pmoran

    You said it was all placebo. Now, with joint fixaton/immobilization, producing deleterious neural consequences is “hardly surprising”. Gee, it only demonstrates that a joint subluxation/dysfunction does indeed produces impaired neurological functioning. And one this fixation is released, the neurodegenerative changes were reversible. The authors found this interesting. That is the premise behind chiropractic (functional) joint subluxation. And basic sciences research has discovered mechanisms of how this works. It’s not a smoking gun per se, but it’s a bullet in the chest to skeptics who didn’t think that ‘minor’ joint restrictions/fixations/dysfunction/subluxation had any real effect on the nervous system. So, does advance the premise that chiropractic has asserted.

    SBM still preaches the classical theory of “pinched nerve”, BOOP, subluxation=visceral disease. This traditional model has given way to a contemporary model that includes both direct and indirect effects on the function of the peripheral and central nervous system resulting from spinal and joint dysfunction/subluxation. And this paper validates that premise as it demonstrated degeneration in both peripheral nerves and spinal motor neurons as a result of joint fixation/immobilization. This is chiropractic 101. Solution: manipulate/mobilize those dysfunctional joints, massage those soft tissues around those sore joints. Give exercises to make them function better. Prevent bad body mechanics and educate patient on proper spinal hygiene Makes sense, no?

    I simply stated that joint dysfunction was a real thing and it was bad for you. This basic sciences paper was my evidence.It can explain, however, the importance of development spinal and joint disorders, and how getting those dysfunctional, hypomobile joints to move sooner than later is a good idea.

    And for you to suggest that paper is not a clear endorsement of anything chiropractic? The authors who are an MD and PhD said themselves in the conclusion that it the findings findings may assist in further development of models for spinal dysfunction such as the chiropractic subluxation complex.

    Checkmate Peter. This is contemporary joint dysfunction/subluxation research, peer-reviewed and indexed in PubMed. You guys said is was scientifically implausible. I just proved otherwise.

    You notice I never quote or bring anything related to JVSR here eh? It’s a garbage periodical and the scientists know it. That’s why it’s not indexed at PubMed. JVSR is a subluxation-based/fundamentalist chiro propaganda tool. No true academic or scientist takes it seriously and neither do contemporary chiropractors who are evidence-based.

    NMS-DC

  62. marcus welby says:

    @NMS-DC

    @Marcus:

    you think that biomechanical joint dysfunction doesn’t exist and you’re a PT? And you claim to be “evidence-based” yet you clearly outdated and I might add a relic in the current state of the literature regarding manual and manipulative therapy and joint biomechanics. You didn’t even know your own profession was adjusting necks! And you then suggested that one course would be sufficient in learning SMT while the WHO standards are 2200 hours? Patient safety is the primary concern behind this recommendation and proficiency in developing the necessary skills to competently perform SMT.

    You are all wrong again: orthopedic surgeon who worked in a world renowned spinal injury unit during spinal injury fellowship. Have strong feelings that way too much spine surgery is being done in the U.S. but that in no way validates chiropractic imaginary “spinal segment dysfunction/subluxation/manipulable lesion” nonsense. Have not operated on spine now in over 30 years but treat such and lecture medical students on back pain. Taught a full course on orthopedics to PT students during 3 day a week classes over 2 months for 7 years ending in ’91. Have personally interviewed patients who have had strokes from chiropractic neck cracking, some requiring craniotomy to correct, others confined to wheelchairs, and spoken with the surviving parents of a young woman who began seizing on the chiropractic table within moments of neck cracking for treatment of tailbone pain. She had undergone neck cracking about 150 times. When she eventually got to the ER after being taken there by her boyfriend, the docs there had difficulty figuring out what was wrong with her, since she could not communicate, so treatment was delayed. She lived less than 2 weeks. Her mother is still furious.

    Let us propose a little experiment for chiropractors to perform to convince us skeptics:

    Take 10 patients, half with back or neck pain or other symptoms considered treatable by chiropractic PCPs. Without knowledge of which patients have symptoms, ask 10 chiropractors to examine each of the 10 patients and diagnose where the spinal segment disfunction is located. Then compare the different diagnoses. I will guarantee the result will show the diagnosis is a fiction with no interobserver reproducibility and has no relation to symptoms of any sort. After 116 years, one would expect chiropractors to have done this study in spades. The last time I checked, in 2005, some Australian chiropractors had done a similar study and published in some chiropractic journal that there was no interobserver correspondence and the concept of subluxation should be questioned. Ya think?

  63. Can’t find my glasses, so could only read a portion of the comments, perhaps this has already been addressed. But someone brought up the example of dentists. I would point out that dentists AND optometrists do have patients that come to them with non-dental, non-eyesight complaints. Sinus pain is something that a dentist must consider when a patient comes to him with tooth pain. In my experience, on two occasions, I’ve had tooth pain that was ruled out as dental pain, the dentists suggested I go to my primary doctor for evaluation (damn sinuses) They did not give me a referral to an ENT. My sister has had two optometrist suggest she see her doctor about thyroid disease. They did not give her a referral to an endocrinologist.

    If Chiropractors see themselves as equivalent to Dentist or Optometrists, then it makes sense that they would follow similar process with patients. Send them to their primary physician for evaluation. That Dentist, Optometrist, Chiropractor IS only seeing a portion of the patient’s overall health history and complaints, of which the primary physician should have a much more in depth view.

  64. nybgrus says:

    NMS-DC your sad flailing is truly deplorable. Honestly I don’t even feel the urge to waste much more time on you. You are incoherent, rambling, and genuinely cannot understand science to save your life.

    I could, once again, destroy every single comment you have made. Unequivocally. But for a true believer that has no meaning.

    I’ll merely point out that the WHO liaises with the World Federation of Chiropractic on the same level as the World Federation of Acupuncture-Moxibustion Studies. I’ll further point out that acupuncture and moxibustion are bullshit, and leave it at that.

    So nit-pick, weasle, and do whatever you like. Either put up or shut up.

    I asked you a very simple thing which you completely ignored.

    Find me a good, high powered, RCT that demonstrates that ANY chiropractic intervention actually prevents OA. Hell, find me a good case control study.

    I’ll expand that – find me any such study that any chiropractic intervention actually prevents any disease. Show me any actual clinical correlate to any pathology. One, single, lonely robust study is all I ask for. No more homeopathy level garbage or acupuncture pseudobabble. Just ONE robust clinical study.

    That is the LAST thing I will ever address with you. Until you can answer that, and stop appealing to authority and bad science, I have nothing more to say to you.

    And you wonder why we scoffed at you when you first showed up around here.

  65. nybgrus says:

    NMS-DC your sad flailing is truly deplorable. Honestly I don’t even feel the urge to waste much more time on you. You are incoherent, rambling, and genuinely cannot understand science to save your life.

    I could, once again, destroy every single comment you have made. Unequivocally. But for a true believer that has no meaning.

    I’ll merely point out that the WHO liaises with the World Federation of Chiropractic on the same level as the World Federation of Acupuncture-Moxibustion Studies. I’ll further point out that acupuncture and moxibustion are bullshit, and leave it at that.

    So nit-pick, weasle, and do whatever you like. Either put up or shut up.

    I asked you a very simple thing which you completely ignored.

    Find me a good, high powered, RCT that demonstrates that ANY chiropractic intervention actually prevents OA. Hell, find me a good case control study.

    I’ll expand that – find me any such study that any chiropractic intervention actually prevents any disease. Show me any actual clinical correlate to any pathology. One, single, lonely robust study is all I ask for. No more homeopathy level garbage or acupuncture pseudobabble. Just ONE robust clinical study.

    That is the LAST thing I will ever address with you. Until you can answer that, and stop appealing to authority and bad science, I have nothing more to say to you.

    And you wonder why we scoffed at you when you first showed up around here. Honestly, its like debating a creationist. At least they admit they have an ideology.

  66. Jann Bellamy says:

    @ NMS-DC:
    “Jann’s post incorrectly assumes is still the dominant raison d’etre at EBM chiropractic schools”

    The post assumes nothing of the sort. I surveyed peer-reviewed chiropractic literature for the past three years, using PubMed, and found expression of concern from WITHIN chiropractic about the continued prevalence of the subluxation in chiropractic education and practice. I also found evidence, independent from their reviews, that the “detection” and “correction” of subluxations is still taught in chiropractic colleges. No one said that “it is the dominant raison d’etre.”

    I also found articles in peer-reviewed chiropractic literature which uncritically report the detection and correction of subluxations as a valid means treating asthma, vomiting, constipation, colic, GERD, etc., as well as bogus chiropractic subluxation diagnostic methods such as leg-length inequality and full-spine x-rays.

    One assumption I did make is that chiropractors, like MDs, DOs, nurses, PTs and other health providers, read the peer-reviewed literature to keep up with the latest research in their field and they do so because it is relevant to their practices. From this I assumed that the aforementioned articles about chiropractic diagnostic methods and treatments are relevant to the current practice of chiropractic. If I am incorrect in this assumption, then why do they appear in peer-reviewed chiropractic journals?

  67. Quill says:

    So in other words, we have Jann’s article – chock full of citations, references, and utilizing chiropractic’s own professional body stances, accreditation articles, specific schools, and research articles – demonstrating one thing and [NMS-DC's] anecdotes and unsubstantiated claims stating that’s wrong.

    That seems to sum up things nicely. After reading this post and comments, as well as scanning the SBM archives to see more articles, links to references, and comments, I can say that I would never consider seeing a chiropractor for anything and will recommend to everyone I know that they avoid this small set of charlatans.

  68. jhawk says:

    @ nybgrus

    “I’ll expand that – find me any such study that any chiropractic intervention actually prevents any disease. Show me any actual clinical correlate to any pathology. One, single, lonely robust study is all I ask for. No more homeopathy level garbage or acupuncture pseudobabble. Just ONE robust clinical study. ”

    evidence for SMT of LBP:

    http://www.ncbi.nlm.nih.gov/pubmed/20889389 “Compared to family physician-directed UC, full CPG-based treatment including CSMT is associated with significantly greater improvement in condition-specific functioning.”

    http://www.ncbi.nlm.nih.gov/pubmed/21245790 “SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.” Also shows that manipulation is superior to sham manipulation/placebo.

    http://www.ncbi.nlm.nih.gov/pubmed/21407100 PT’s and MD’s have a higher disability recurrence when compared to chiro’s

    http://www.ncbi.nlm.nih.gov/pubmed/21334541

    As well as recommendations for SMT from the american college of physicians, american pain society, NICE guidelines and ahcpr guidelines.

  69. ConspicuousCarl says:

    Well I still don’t get what the heck makes them chiropractors. It’s great if they really do have enough knowledge to refer patients to other doctors when necessary (or even to apply non-chiropractic care themselves), but that’s a distraction from the core issue.

    When a chiropractor makes the traditional subluxation claim, and says he can cure a disease because a mis-aligned bone is interfering with healing signals and a manipulation will push it back into place, at least I know what he is claiming and how he thinks it works.

    But saying that “subluxation” just means a joint with poor mobility, or too much mobility, does not explain why the chiropractor thinks mashing on it will help. Maybe it does help, I don’t know. But surely the chiropractic college must be teaching students a reason why they think it helps. An answer might be something like “pressing the leg in direction [___] will relieve pressure on the cartilage and allow new tissue to build up”. I just made that up, and I have no idea if it makes medical sense, but it is a cause/effect statement which, if true, would at least explain the reason for doing it.

    Maybe one of our pro-chiropractic commentators can give me an example. Name a a uniquely-chiropractic treatment, and explain the mechanism by which it produces a specific benefit. I don’t mind if you have to use small words as if I am an idiot because I don’t know anything about it, but whatever response is provided should still be structured as a cause/effect explanation.

  70. jhawk says:

    @ marcus welby

    “Take 10 patients, half with back or neck pain or other symptoms considered treatable by chiropractic PCPs. Without knowledge of which patients have symptoms, ask 10 chiropractors to examine each of the 10 patients and diagnose where the spinal segment disfunction is located. Then compare the different diagnoses. I will guarantee the result will show the diagnosis is a fiction with no interobserver reproducibility and has no relation to symptoms of any sort.”

    This is actually one of the reasons why interobserver reliability has been shown to be equivocal, horrible study design on asymptomatic patients. Pain and tenderness at the sight of the restriction is a major diagnostic indicator of the restriction. Here is a very well written article on the limitations of these interobserver motion palpation reliability studies.

    Spinal Motion Palpation: A Review of Reliability Studies by Peter A.Huijbregts, DPT, OCS, FAAOMPT http://www.dynamicptmichigan.com/userfiles/file/Motion%20palpation.pdf

    A limitation not mentioned in this critique is that when using motion palpation to find joint restrictions you take the joint to end range (mobilize the joint). No wonder you can’t reliably find the restriction agian….you mobilized it already.

  71. Cowy1 says:

    @ jhawk

    Then why not do the correct study? Like marcus said, it would be simple enough and would be a lot more impressive than some marginally-relevant (at best) basic science.

  72. jhawk says:

    @ marcus welby again

    “and the idea of a hypomobile segment being diagnosed by surface palpation and examination when the spinous processes are the only palpable portions of the spine and they are connected firmly by interspinous ligaments…this is magical thinking. ”

    Spinous processes are the only palpable portion of the spine? Is this a joke? Let’s assume for a minute you are only talking about bony palpation and not forgetting the palpable spinal musculature and ligamentous structures. You have never palpated a transverse process, facet joint or anterior vertebral body? This really discredits your understanding of anatomy and palpation skill set.

  73. jhawk says:

    @cowy1

    As I said, welby’s proposed study would show equivocal results because the symptom is a mjor diagnostic indicator of joint restriction. The practicioner must be privy to this information.

  74. pmoran says:

    NMS-DCYou said it was all placebo. Now, with joint fixaton/immobilization, producing deleterious neural consequences is “hardly surprising”.

    What do you mean by “it”? You said this once before but I let it go.

    I know exactly what I said and I was referring to the meaning of the clinical evidence for spinal manipulation in medicine, namely that, to put it in more scientific terms, the null hypothesis (that it works as placebo) has not yet been entirely disproved. The point was the basic fragility of chiropractic’s core claims to legitimacy as a major science-based profession profession.

    I explained in detail why, while beiing prepared to go along with the view that it may help a subgroup of LBP patients. I have said this last at least twice here.

    The finding that a nerve to a muscle atrophies when that muscle is not used has no clear bearing on that. The medical problem to be overcome, if is possible, remains the immobile joint.

    Or are chiropractors using this study as evidence of more general or non-local neurological effects of joint immobilisation.? It clearly cannot support that.

  75. nybgrus says:

    This is actually one of the reasons why interobserver reliability has been shown to be equivocal, horrible study design on asymptomatic patients…..

    OK, so let me get this straight.

    First off, Marcus said that 5 would have symptoms/pathologies that would be considered treatable by chiropractic.

    Second off, interobserver reliability is a horrible study design? That is the very basis of scientific inquiry. If you, by definition, state that nobody else can observe what you are observing then you have removed yourself from the scientific process wholesale. And nobody here restricted you guys on how to determine which 5 had the actual pathology.

    But then you go ahead and answer that yourself:

    A limitation not mentioned in this critique is that when using motion palpation to find joint restrictions you take the joint to end range (mobilize the joint). No wonder you can’t reliably find the restriction agian….you mobilized it already.

    In other words, the only way to determine if a patient has a pathology…. is to treat the pathology. That is entirely equivalent to my saying that there can be no interobserver consistency in infectious disease, because the only way I could diagnose an ID is by treating it with antibiotics and by the time the next ID guy got to it it was already treated!

    That is so incredibly backwards and bad science I don’t even know where to begin. I mean seriously – think about what you are saying. You are justifying the existence of a treatment by saying that the only way to diagnose the pathology for which the treatment exists is to actually do the treatment.

    So how are you taught how to do this then? In medicine when I am taught to look for signs, I have trained physicians show me reproducible signs to look for. When a patient has an interesting finding, hordes of medical students descend on the hapless chap to first hand experience what an actual diagnostic finding looks/feels/sounds like.

    In chiropractic, you are saying that the only way to diagnose such a lesion is to actually manipulate it. And that because of that no two chiropractors will ever find the same lesion because the very detection of it fixes it. Also apparently, this lesion and manipulation are hard enough to detect and complex enough to treat that a 4 year post graduate degree is needed. Yet, by your definition, every chiropractic student will have to learn to assess completely de novo, with no objective frame of reference.

    And you wonder why we see this as all made up.

  76. nybgrus says:

    Sorry jhawk, I asked for a study that chiropractic prevented any disease, as NSM-DC has claimed. This is for a treatment.

    However, the articles are unimpressive to say the least. LBP is a relatively unique case that is amenable to acupuncture, which has been handily demonstrated to be pure placebo and nothing else. So you’ve done yourself no favors by citing LBP studies. Particularly these ones.

    The first article has an N=92. So the primary outcome achieving significance, in light of the Bayesian likelihood based on acupuncture and other placebo studies, is not impressive. It then further attempts to analyze nine more metrics and manages to find a couple that have significance. I’d suggest reading this to see why that is not an impressive way to do a study.

    The second article is from 1976 and discusses continued use of SMT to help LBP. Once again, not particularly impressive. If I told you that I had “treated” someone’s back pain by giving them a lifetime prescription of narcotics, would you not scoff at me? Of course the point about placebo effects still applies here.

    The third article is slightly more interesting, but once again the population defined is a particularly interesting one. Namely “non-specific” LBP. I’ve discussed the factors for chronicity and treatment of LBP in detail before and don’t have the time or desire to get into it much. Suffice it to say, even if I grant this one a bye, that still isn’t much.

    And the last one talks about costs associated and just concludes that it is cheaper to see a chiropractor. It comments that the patients were happy with their experience (well, at least the chiros were nice), and that the pain decreased from 6.2 to 1.9 – considering that 90% of LBP is mechanical in nature and resolves completely on its own over time, that hardly seems like a resounding evidence of effect for chiropractic. Perhaps you’d like to buy my special flu and cold tonic? Drink it every day and in 7-10 days your cold will get better! Don’t drink it and it will take at least a week before your symptoms resolve.

    And of course all of that on the backdrop of particular amenability of LBP to placebo effects and sham treatments.

    And that sort of study wasn’t what I asked for in the first place.

    And they weren’t particularly robust studies to boot.

    Perhaps I should also add “and no acupuncture level of evidence” to the “homeopathy level of evidence” to clearly make the distinction that I am looking for something other than placebo effects to explain the treatment.

    I won’t hold my breath though.

  77. nybgrus says:

    sorry that first article did not attempt nine more metrics. It was eleven. Well, actually at least eleven. I’m unsure of what “repeated-measures analyses, global adjusted mean improvement” is, but it sounds to me like trying to combine a couple of metrics to get another go at finding significance. I can’t be bothered to read the whole thing in detail to find out though, since its not important to the point.

    They also only found significance in 2 of the at least 11 metrics. However they used a term I particularly hate “nearly significant.” It is either significant or it is not. People fail to understand that a p-value of .00002 vs .045 does not mean that the former result is “more significant” than the latter result. Both reject the null hypothesis equally. You can’t somehow reject it “more.” Also, the p-value is an arbitrary cut-off to what has been deemed an acceptable Type I error. So saying a p-value of .08 is “nearly significant” means exactly nothing. The common misconception is that the closer to zero you can get your p-value the “more true” your claim must be, so if it is somewhat close to the standard alpha level, that means it must “almost” be true. That makes no sense, and many papers these days (not just chiro or CAM ones, to be fair – though they do tend to predominate) do this sort of thing.

    And of course, taken in a Bayesian context rather than a strictly frequentist framework, none of it is particularly interesting.

  78. marcus welby says:

    @jhawk
    Now this is getting interesting.
    Spinous processes are the only palpable portion of the spine? Is this a joke? Let’s assume for a minute you are only talking about bony palpation and not forgetting the palpable spinal musculature and ligamentous structures. You have never palpated a transverse process, facet joint or anterior vertebral body? This really discredits your understanding of anatomy and palpation skill set.

    So you think you can palpate the facet joint of a vertebra …..at least a full inch below the surface on a thin adult….truly magical. The transverse process is even further down. Yes, you can palpate muscles from the surface, this is true, and get some idea of tenderness and perhaps spasm. NO, you cannot palpate the articular processes or transverse processes unless you are doing spine surgery or dissecting a cadaver. Now, anterior vertebral body….all the way in the back of the abdomen, behind all of the internal organs…amazing. Some exceptions to my generalizations, of course, for instance, it IS possible to palpate the first two cervical vertebrae through the mouth and this may be of value in a fracture or infection involving that location. The coccyx can be palpated through the rectum. The palpation of the surface will not tell you which vertebrae or spinal unit is the source of the pain, of course, except in the case of tumor or fracture, when percussion tenderness may be localized to perhaps one of two vertebrae.

    Now, your explanation for lack of interobserver reliability….REALLY interesting. You seem to be saying the reason a second examining chiropractor cannot make the same diagnosis is that the first chiropractor, in the process of diagnosis (recognizing it is impossible in most instances to tell which vertebra is the source of a symptom…that would probably require, again in the absence of tumor, infection, or fracture….MRI or CAT scan, perhaps facet joint injections of local anesthetic, etc. ) the first chiropractor will have cured the hypomobile joint by manipulating it, so it is no longer hypomobile? Recognizing again, that orthopedists and neurosurgeons generally worry less about the hypomobile joints, as they tend to be restricted by scar or muscle spasm, and worry more about the hypermobile joints, but we won’t agree on this so lets move on. It sounds like you are saying that you treat the symptoms of pain in a general area…lumbar, thoracic, cervical, by manipulating the spine since you have been taught that is the thing to do, and many of these people seem to get better and pay the bill. No one else could now examine the patient or obtain an xray and tell that you have “adjusted” the subluxation, manipulable lesion, hypomobile segment, whatever, since the patient has been cured. Interesting concept.
    Now, some other occasion, please elaborate on the often-observed concept that infants, children, adults, in fact everyone, needs maintenance spinal manipulation for maintenance of spinal health. How does that concept merge with your “hypomobile segment” idea?

  79. NMS-DC says:

    @nybygus

    You can claim a that you “won” but any logical person reading the thread can see that you’re always deliberately trying to confuse and throwing in red herrings all the time. You never stick to the issue. And you never answer any of my questions.

    When did I, or anyone here claim to prevent organic/visceral disease? We’ve been talking MSK this whole time and you’re stuck (like a hypomobile joint) on the visceral/organ disease line of thinking. Get over it. Chiropractic medicine does not cure or prevent diseases. It’s primarily pain management at a minimum and the recent article in Spine stated that maintenance SMT, in chronic LBP cases, had better results than no treatment.

    Also, studies like you are suggesting aren’t practical or feasible as they would require 5-10-15 years duration to compare the intervention group to the control group. I don’t have any research articles saying that ensuring normal joint biomechanics would be a good idea, but I also don’t know of any good RCTs demonstrating the effectiveness of parachutes preventing death and major trauma related to gravitational challenge. Unless, of course, you want to volunteer to be in the control group…. http://www.bmj.com/content/327/7429/1459.full

    @pmoran

    You said the clinical effect of spinal manipulation was entirely due to placebo. This despite evidence I presented in previous threads clearly demonstrating a neurophysiological mechanism. I do concur that a positive clinical encounter between doctor and patient can result in additional benefits attributed to placebo, but why wouldn’t any doctor want to be empathetic and treat the patient with good beside manner? If being nice helps make them better, why not do it?

    Regarding the immobiization knee study, I don’t see the profession using it as a sacred cow. It’s just more information. Science-based chiropractors follow the rules of scientific inquiry and we want to know exactly WHY our patients get better, and know exactly HOW joint dysfunction results in pain, degeneration. If there are any additional effects of joint dysfunction, such as autonomic reflexes, that should be studied as well. How the locomotor system works and it’s relationship to health is of primary concern to chiropractors.

    If you really want to know where chiropractic research is headed specifically with joint dysfunction, then read up on the Research Chair at CMCC which is investigating spine instability, degeneration and joint dysfunction/subluxation. The main investigator, is a PhD in biomechanics, Dr. Sam Howarth and he is working with DC/PhDs trying to figure out what exactly is occurring biologically, with spine and joint pathomechanics.

    If you want to check out the research agenda for a better understanding of contemporary chiropractic research, feel free to visit this link http://www.cmcc.ca/Page.aspx?pid=357. I am involved in research myself (practice-based) and am always trying to stay on top of the literature as it relates to MSK, manual therapy, and conservative treatment of MSK disorders.

  80. NMS-DC says:

    @cowy1

    The best study to date suggests spinal segments that are painful/tender, along with joint hypomobility are most likely to have acceptable levels of reliability. It also demonstrated that no palpation method, whether, static, motion palpation or other variants were superior to one or the other.

    Medical devices, such as the VibeDX, developed by a PhD engineer and DC/PhD in determining abnormal spinal kinematics and spine stiffness has demonstrated excellent reliability and validity. This was developed at the University of Alberta. The idea is that in the near future, this type of technology might replacement manual palpation for spinal dysfunction. The intervention would then be applied (SMT or manual techniques) and a retest with the device to see if spinal kinematics have changed at the intended levels of treatment. I’m looking forward to seeing if this pans out, but Dr. Kawchuck is no slouch and his reputation as a clinician and scientist is superb. I don’t think this technology is hokey, unlike the Subluxation Station (groan…)

    NMS-DC

  81. NMS-DC says:

    @nybrygus

    “you are saying that the only way to diagnose such a lesion is to actually manipulate it. And that because of that no two chiropractors will ever find the same lesion because the very detection of it fixes it. Also apparently, this lesion and manipulation are hard enough to detect and complex enough to treat that a 4 year post graduate degree is needed. Yet, by your definition, every chiropractic student will have to learn to assess completely de novo, with no objective frame of reference.”

    A 4 year degree in MSK medicine is needed because

    a) ensure patient safety as we are privileged to have direct access to patients
    b) provide good differential diagnostic skills in MSK, but also learn about non-msk pathology
    c) learn how to properly perform spinal manipulative techniques and ensure safety and effectiveness
    d) learn how to properly set up a good rehabilitation programme
    e) learn how to use and intepret lab diagnostics, imaging diagnostics as it relates to NMS diagnosis and ruling out serious pathology
    f) having a year dedicated towards clinical internship

    See my post above, nybrygus at how terrible MDs are at MSK diagnosis and management and why medical schools are trying now to correct this gap. You guys misdiagnose MSK all the time which leads to delays of appropriate therapy and overall a crappy prognosis. DCs are here to help.

    NMS-DC

  82. Jann Bellamy says:

    @ NMC-DC
    “When did I, or anyone here claim to prevent organic/visceral disease? We’ve been talking MSK this whole time and you’re stuck (like a hypomobile joint) on the visceral/organ disease line of thinking. Get over it. Chiropractic medicine does not cure or prevent diseases. ”

    No you didn’t claim that. What you claimed is that SBM posts demonstrated an outdated concept of chiropractic because of its emphasis on chiropractic’s belief in the vertebral subluxation. What this post is intended to do is demonstrate, by looking at chiropractic literature, that the continued presence of the subluxation in chiropractic practice and education is a cause of concern to at least a few chiropractors themselves and for good reason, as peer-reviewed chiropractic literature continues to present it as a clinically relevant condition capable of diagnosis and treatment for both MSK and non-MSK conditions and it continues to be taught as such in chiropractic colleges. If you agree that the subluxation does not exist, then it would be helpful to make those concerns known to the U.S. Council on Chiropractic Education, which continues to accredit chiropractic colleges which teach the “subluxation” and to authors of articles in the peer-reviewed chiropractic literature, who continue to write articles based on its “detection” and “correction.” Perhaps you could write a letter in response to such articles and call them out on it. Perhaps you could also complain to the Canadian Memorial Chiropractic College about allowing chiropractic students to be trained by practicing chiropractors who still believe in the “subluxation.” Except for a very few academics and practicing chiropractors, it seems the rest of chiropractic is willing to go along with this subterfuge. I would be reluctant to criticize medical management of MSK issues when just about all of chiropractic seems willing to go along with the practice of detecting and treating a condition that doesn’t exist.

  83. NMS-DC says:

    @Jann

    To avoid confusion:

    chiropractic adjustment of spinal subluxation = spinal manipulation of spinal joint dysfunction.

    That’s pretty clear. A subluxation, i.e. joint dysfunction is a real biomechanical, functional problem with joints.

    Now, let’s get even clearer: if a chiropractor is using terms like innate intelligence, doesn’t diagnose, detects/corrects subluxation you’re talking about a subluxation-based chiropractor. It used to called straight, also called fundamentalist because they refuse to stray from the 1895 concept of chiropractic (i.e. joint dysfunction is the cause of all disease). They are unimodal, the only thing they do, is manipulate. That’s it. Their practices are high volume, see 100+ patients a day because they spend like 2 minutes doing full spine adjustments. That’s bad care and that’s bad practice. The ONLY diagnosis they make is VSC, there is no differential diagnosis.

    In fact, the subluxation-based DCs are furious right now because the CCE is taking steps to ensure that modern chiropractic education isn’t about “detecting and correcting subluxation” because modern chiropractic is much broader than that (see http://www.thechiropracticjournal.com/news4.php?M=november&Y=2011)

    No schools in Canada are subluxation-based. There are some in the US, and I might be wrong, but if I remember correctly, Life, Parker, Sherman, Cleveland and maybe Logan schools are the ones that are philosophy heavy (dogma heavy really) and science-short.

    The CMCC paper you referred to is not at all the way you presented it and even in the conclusion it stated the obvious limitations::

    “This study had several limitations. The clinicians could have misinterpreted the questions regarding each condition to mean whether or not chiropractic care was effective in treating the condition itself or the musculoskeletal symptoms associated with them. For example, conditions such as asthma and chronic pelvic pain have been associated with higher incidences of thoracic and lower back pain respectively.Moreover, several clinicians did suggest that those individuals exhibiting any of the above listed conditions may have co-morbidities or dysfunction in their musculoskeletal systems, making chiropractic treatment both practical and beneficial. Although clarifications were made about the question to those who asked, it cannot be assumed that all respondents were accurate in their interpretation of each question in the survey. Future studies ought to take greater care in differentiating whether a respondent believes that chiropractic care can effectively manage a condition listed, the musculoskeletal effects associated with it or a combination of the two.”

    I know these clinicians, I know the school (alma mater) and I graduated there in 2006. They don’t teach the VSC as a stand-alone concept, the diagnosis of VSC is not allowed in clinic nor is it even a choice on any exam I ever had there. We learned about the term subluxation as being synonymous with joint dysfunction but descriptively we would call the stiff spinal segment a restriction/fixation/dysfunction as part of our physical examination findings, not as a stand alone diagnosis.

    I understand in the US, state laws, scopes of practice and reimbursement are TIED to a the VSC. That sounds crazy to me, but in the early 1900s I guess that was the strategy to avoid incarceration for practicing medicine. I am not aware of any other jurisdiction in the world where the laws and scopes are like this. I went through all the Canadian provincial chiropractic acts and not one mentioned subluxation as a scope of practice. So, if you want to reform American laws, I would suggest you take a look at your neighbour to the North and look at how DCs are regulated up here. Quite different. I can’t call myself a physician, not would I want to, I’m not an MD. But I am a DC, and like a DDS, DO and other doctored health professions, I have a duty to diagnose, but again, it’s limited to NMS. But that’s my training! So, there is no conflict and I don’t practice in a way that is not congruent with Canadian laws. I tried to explain this to nybrygus but you can’t teach anything to someone who knows it all.

    The majority of American chiropractic is not subluxation-based, Jann. Villanueva-Russell (2011) demonstrated that 73% of current practicing chiropractors see themselves as “back” doctors. You really do need to stop saying the minority is the majority and vice-versa. It’s a disservice to the work you do.

    That minority who only adjusts, only uses the traditional terminology and interpretations, disavows anything other than chiropractic adjustments, and only makes one diagnosis are the charlatans that are being phased out with each revision of the CCE-US. Subluxation based chiropractic is not a majority anywhere in the world, and that’s reflected in the membership of the World Chiropractic Alliance, the subluxation-based DCs association of choice.

    NMS-DC

  84. NMS-DC says:

    @jann

    My comment is awaiting moderation, it was a lengthy reply. In the meantime, here is a synopsis of the the most recent CCRF (http://files.chiropracticcanada.ca/2011/researchbulletin/canadianchiropracticresearchbulletinno.19.pdf)

    Modern chiropractors (maybe I should qualify, Canadian?) like myself are committed explaining the biological effects of chiropractic manipulation, spinal biomechanics and neurophysiology, MSK-related research, epidemiology concerning the effects of MSK disorders, etc.

    Don’t let the dogma and religious tenets of subluxation/innate intelligence (untestable) detract from legitimate scientific investigation of subluxation, the biomechanical joint dysfunction.

    Cheers,
    NMS-DC

  85. Cowy1 says:

    @NMS-DC

    I was going to write a reply but Marcus and nygbrus beat me to it with their posts at 6:13pm and 3:57pm, respectively. In short, if chiropractors are unwilling to assess interobserver reproducibility of their ability to palpate “segmental joint dysfunction” (cough, subluxation cough) because they need to treat in order to determine where the “lesion” was then that is pretty weak sauce.

    I have yet to meet a chiropractor (n~12) that doesn’t believe in subluxation as a cause of organic “dis-ease”; whether as the “one true cause” of all human ailments or as a component of a patient’s pneumonia. And I live in Chicago, home to the supposed “research arm” of the profession at NUHS. Jan is correct; chiros that do MSK only are the rare exception.

  86. nybgrus says:

    hmmm… lets see. Bad science. Followed by mumbo jumbo. Then some more bad science. Then clinical extrapolations of basic science followed by special pleading. My goodness me, how on earth have you just not convinced me. Oh, and of course:

    Chiropractic medicine does not cure or prevent diseases

    Really? wow…. I could have sworn somebody said:

    But just in case aren’t into this concept nybrgus: PREVENTION is more important (and proactive) than waiting for your approach, ignore and deny the “magical” joint dysfunction, then letting your patients joints to slowly degenerate away, because you don’t believe there’s a role for DCs, eventually the same patient will come back to in time with structural (OA or worse) changes in that joint and then, in your wisdom, and expert medical care will finally act and give them NSAIDs and/or pain killers.

    See. I can play the game too.

    Also:

    It’s primarily pain management at a minimum and the recent article in Spine stated that maintenance SMT, in chronic LBP cases, had better results than no treatment.

    Actually, pretty much all articles compare [BS placebo intervention aka SMT] to “standard of care.” I’ve explained why the effects are seen. So how pmoran. And Marcus is also handily destroying both you and jhawk.

    You can claim a that you “won” but any logical person reading the thread can see that you’re always deliberately trying to confuse and throwing in red herrings all the time.

    I’ll leave that to the logical people to decide. But it is abundantly obvious that you are not in such a position to render opinion on your own statement.

    Well, I just finished my first day of exams, so I’m going to have a jug of beer with my anatomist friend and have a laugh at how chiros can apparently palpate the anterior vertebral bodies and facet joints of vertebra.

  87. NMS-DC says:

    Sorry Cowy1, like Harriet said, anecdotes here mean nothing. Evidence, please. I already provided mine.

    Studies have been done, such as the following: A review of intraexaminer and interexaminer reliability of static spinal palpation: a literature synthesis. (http://www.ncbi.nlm.nih.gov/pubmed/19539121)

    Conclusion: Reported indices of agreement were generally low. More of the pain palpation studies reported acceptable kappa levels, although no one method of palpation could be deemed clearly superior.

    Palpation for abnormal joint mechanics, if found (i.e. increased stiffness) and it’s painful and it’s appropriate (no contraindication for SMT) then, with consent, I’ll adjust (along with performing soft tissue massage and supporting it with exercise and modalities as appropriate. Sometimes I’ll mobilize. Other times I won’t lay a hand on them. It depends on each case. As a clinician I have to discern what is going to be the best treament and have good outcome measures (which I do).

    Anyways, given it’s Sunday and a busy work week, I likely won’t be able to peruse this thread until later in the week. Hope all at SBM has a good and productive week, and retirees, enjoy you’re lucky!!

    NMS-DC

  88. NMS-DC says:

    @nybrgus:

    According the fixation model as presented by Cramer et al (2007) DJD was occuring within 3 weeks. If left like that for 3 years, I’m guessing it would be worse. I don’t know. I’m just using logic. But why would you want to let the joint, the shows pathological changes after 3 weeks, just rot away more time, especially if there’s pain? I guess that’s where the chiropractic and medical professions differ on the subject. That’s fine. It’s just professional disagreement.

    I’m not aware of any manipulative text, whether it be chiropractic, osteopathic or manual medicine in Europe, that states we can palpate anterior vertebral bodies of the cervical spine. The facet joints of the cervical spine are pretty easy to feel. It gets harder as you move distally down the spine where your hands can’t directly contact (or its hard to) the articular structures (besides spinous process) in the lumbar spine. But you can assess generalized stiffness of each vertebrae using shear tests as described by Professor Stu McGill, a biomechanics expert in spinal stability. His work is great. You should be aware of it when counseling your LBP patients in the future nybrygus.

    Also, you, Marcus, Pmoran have presented your personal opinion, (anecdotes) of why SMT is placebo, and this is worthless here at SBM. I presented papers on neurophysiological effects of SMT which disputes your personal opinion. Now, find me a study which states that the effects of spinal manipulation are purely placebo. No study, no dice. Enjoy your beer.

    NMS-DC

  89. rwk says:

    @Cowy1
    I have yet to meet a chiropractor (n~12) that doesn’t believe in subluxation as a cause of organic “dis-ease”; whether as the “one true cause” of all human ailments or as a component of a patient’s pneumonia. And I live in Chicago,

    Please tell us who these 12 chiropractors are so I can scold them. I’m serious and I will. If they’re from NUHS
    I’ll let the president know. That is unless your making this up.

  90. pmoran says:

    NMS-DC@pmoran
    You said the clinical effect of spinal manipulation was entirely due to placebo.

    I said that the evidence for the use of spinal manipulation even for bad backs is not entirely exclusive of that possibility, which is not the same thing. That evidence is also compatible with SMT having either a small effect overall, or a greater effect for a few that is diluted by many that are either not helped or made worse.

    This is why I never ever said, nor would I ever say, that the effects of SMT on back problems is “entirely due to placebo”. Go check, if you wish.

    Now in this last post of yours you even accuse me of having ” – presented your personal opinion, (anecdotes) of why SMT is placebo, and this is worthless here at SBM.

    You have already forgotten that that the basis for the opinion I expressed was systemic reviews of the RCTs investigating SMT, melded with much that we have had to learn (to our our discomfort ) about the uncertain reliability of such studies.

    I have tried to be patient but in order to be civil with you I have had to ignore your ridiculously inappropriate triumphalism. That merely reveals how little you understand your own position. You have not even tried to respond to my challenge to specify what precise chiropractic claim or claims you are talking about. That would at least have a provided a clear context for whatever it is you are waffling on about.

    The assertion that doctors favour leaving joints immobile is also ridiculous as well as insulting. Actually doctors have infinitely more experience than chiropractors about the effects of immobile joints, in fracture treatment, intentional arthodesis and spinal fusions, various diseases, spinal and other joint trauma trauma and degenerative diseases, in most of which contexts early mobilisation is a key part of treatment and chiopractic’s “special effects” are just not seen.

    What one earth do you think you can teach us about this? Be precise for once.

  91. jhawk says:

    @ marcus welby

    “So you think you can palpate the facet joint of a vertebra …..at least a full inch below the surface on a thin adult….truly magical. The transverse process is even further down. Yes, you can palpate muscles from the surface, this is true, and get some idea of tenderness and perhaps spasm. NO, you cannot palpate the articular processes or transverse processes unless you are doing spine surgery or dissecting a cadaver. Now, anterior vertebral body….all the way in the back of the abdomen, behind all of the internal organs…amazing. Some exceptions to my generalizations, of course, for instance, it IS possible to palpate the first two cervical vertebrae through the mouth and this may be of value in a fracture or infection involving that location. The coccyx can be palpated through the rectum. The palpation of the surface will not tell you which vertebrae or spinal unit is the source of the pain, of course, except in the case of tumor or fracture, when percussion tenderness may be localized to perhaps one of two vertebrae”

    Lx facet capsule: place your thumb about one thumb width from the Lx sp and compress until you hit bone (yes about 1 1/2 inches). Not magical at all really. Try this on your next LBP pt as it might be the source of their pain!

    “Now, your explanation for lack of interobserver reliability….REALLY interesting. You seem to be saying the reason a second examining chiropractor cannot make the same diagnosis is that the first chiropractor, in the process of diagnosis (recognizing it is impossible in most instances to tell which vertebra is the source of a symptom…that would probably require, again in the absence of tumor, infection, or fracture….MRI or CAT scan, perhaps facet joint injections of local anesthetic, etc. ) the first chiropractor will have cured the hypomobile joint by manipulating it, so it is no longer hypomobile?”

    I did say this but it was not intended to be a large part of my argument, only an after thought really. My main arguments are established in the article I posted above about the validity of the studies examining inter-observer reliability as it relates to motion palpation.

    “Now, some other occasion, please elaborate on the often-observed concept that infants, children, adults, in fact everyone, needs maintenance spinal manipulation for maintenance of spinal health. How does that concept merge with your “hypomobile segment” idea?”

    I do not agree or practice with the concept that everyone needs spinal manipulation. In my practice I only see patients that are in pain. I probably use spinal manipulation on about 30% of my patients and only for a limited amount of time.

  92. jhawk says:

    @nybgrus

    “Second off, interobserver reliability is a horrible study design? That is the very basis of scientific inquiry. If you, by definition, state that nobody else can observe what you are observing then you have removed yourself from the scientific process wholesale. And nobody here restricted you guys on how to determine which 5 had the actual pathology. ”

    Taken out of context this is what I said. The studies of interobserver reliability for motion palpation say motion palp is equivocal and I posted an article that addresses the limitaions of these studies.

    “So how are you taught how to do this then? In medicine when I am taught to look for signs, I have trained physicians show me reproducible signs to look for. When a patient has an interesting finding, hordes of medical students descend on the hapless chap to first hand experience what an actual diagnostic finding looks/feels/sounds like”

    I listed these previously. pt must have pain/tenderness, range of motion abnormality and tissue texture change. This is actually part of my point, a lot of these motion palp reliability studies are on asymptomatic patients. Of course you can not reliably find a significant joint restriction on an asymptomatic patient.

    “In chiropractic, you are saying that the only way to diagnose such a lesion is to actually manipulate it. And that because of that no two chiropractors will ever find the same lesion because the very detection of it fixes it. Also apparently, this lesion and manipulation are hard enough to detect and complex enough to treat that a 4 year post graduate degree is needed. Yet, by your definition, every chiropractic student will have to learn to assess completely de novo, with no objective frame of reference”

    No I did not say this. But this could be a confounding variable in some of the studies. There are grades of restriction. Once again the practioner must not use motion palp (MP) as the only diagnostic indicator of joint restriction.

  93. nybgrus says:

    the pseudobabble is spewing forth with such vigor I can’t possibly keep up. But after some beers and some laughs (and discovering I was, apparently, one of the few that got a particuarly tough and divisive question on the exam correct today) I’ll give it a go for S’s and G’s. This has long left the realm of any sort of scientific discourse, since the chiros here absolutely refuse to even try.

    So to recap, NMS-DC cites a study confirming that the application of chiropractic is willy nilly “as you wish” BS by demonstrating that nobody could agree on a common pathology. They just massaged people and spoke sweetly to them and after some nice placebo effects and a little natural progression justified “116 years of spinal expertise.” He justifies this by stating that as long as nothing actually actually contraindicates SMT, hey, why the hell not? Of course, since he is a clinician, damned be the science and he can magically discern what is going to be the best treatment based on his experience. Maybe you and Jay Gordon should have a chat?

    Then, as if that wasn’t good enough, he comes back and cites the guinea pig article again. Once again, utterly failing to realize that basic sciences research (which in this specific case was so utterly unimpressive that if I were on an IRB I wouldn’t agree to let the poor guinea pigs be harmed for such an inanely mundane hypothesis) does not directly translate to clinical experiences or outcomes. Apparently, since disuse of a muscle group leads to atrophy of the corresponding spinal nerves, that magically means that mobilizing the spine of those same segments has some sort of bearing on the discussion. Never mind that not one single chiropractic maneuver has ever been demonstrated to actually “mobilize a spinal segment.” Nor that he just cited an article demonstrating that such a pathology can never actually be documented outside of the head of an individual chiropractor. It’s there and they can feel it and fix it damn it!

    Oh, and of course, that related to osteoarthritis because, well, obviously OA is a neurological disease. (for those reading who are not medically trained, OA is not a neurological disease). There’s that logic he uses for ya. Because, you know, pretty much every single basic sciences animal model can easily be logically extrapolated to clinical scenarios in humans on systems and joints that have nothing to do with the animal model in question. That’s just, well, logical.

    Then of course is the wonderful dig at actual medicine. That we just look at hapless patients and say, “Suffer!” with glee as we throw boxes of narcotics at them and laugh maniacally as they “rot away” into that neurodegenerative state of osteoarthritis.

    He then answers for jhawk, who states he could palpate anterior vertebral bodies. “Of course chiros can’t! That’s silly,” says NMS-DC. Wait, where was that uniformity in training that the WHO endorses?

    Ah, but of course, NMS-DC can manage to actually palpate the articular surfaces of the vertebra (you know, the ones in addition to the spinous processes, because those are totally articular surfaces {once again, for those not medically trained, spinous processes are not an articular surface}).

    And then the scene closes with a claim that the opinions of two trained physicians, each backed by a body of evidence is “personal opinion” whilst his own, backed by…. um… stuff… is evidence.

    And believe me, I did enjoy my beer. Especially whilst discussing how on earth disuse atrophy of a myotomal motor neuron in any way relates to SMT. Good times were had.

  94. nybgrus says:

    as for jhawk, I honestly feel a bit bad.

    You genuinely strike me as a nice fellow – and I really mean that. But you also seem way in over your head.

    Let me demonstrate:

    Lx facet capsule: place your thumb about one thumb width from the Lx sp and compress until you hit bone (yes about 1 1/2 inches). Not magical at all really. Try this on your next LBP pt as it might be the source of their pain!

    First and painfully foremost, are you comfortable with the definition of “anterior?” The anterior vertebral body is the bit that directly abuts the retroperitoneum. Directly in front of it would be some fascia, then a bit of muscle, then some intestine, and well, really, the entire abdominal cavity. Just a tetch more than 1.5 inches.

    But alright. Lets take the brief assumption that it was just a mixup that continued after a couple of posts ridiculing the utter inanity of palpating an anterior vertebral body by someone with a 4 year post graduate education calling himself doctor. Lets assume the intended meaning was posterior vertebral body. You know, the bit that is actually closest to the surface of the back (i.e. feasibly within 1.5 inches of the skin surface, assuming you aren’t… hefty).

    You are now asserting that you can directly hit bone by pressing hard enough. Well, lets see – you say “muscle” so clearly you aren’t referring to going in between the spinous processes and separating the interspinous ligaments and the interspinalis muscles. That’s a good start. So you are coming at a slightly lateral approach, through the spinalis, rotatores, and multifidis. Maybe the iliocostalis and longissimus, depending on how lateral your approach is. And that is just the intrinsic muscles. That doesn’t take into account the superficial muscles. So suffice it to say, jhawk is separating out a pretty hefty portion of muscle fibers to dig 1.5 inches down into someone’s back so he can palpate a hypomobile joint that cannot be verified as existing by any means known to man prior to digging in, and cannot be subsequently verified by any other man since by discovering its existence he has simultaneously cured it as well!

    Phew! Good things these chiros are a completely trustworthy folk, else I might be suspicious that they’re making the whole thing up!

    I did say this but it was not intended to be a large part of my argument, only an after thought really.

    Never mind that bit. The whole “we make this shit up as we go along” part is really just a minor aspect of it.

    There are no droids here.

    My main arguments are established in the article I posted above about the validity of the studies examining inter-observer reliability as it relates to motion palpation.

    You know, the one that says there is no reliability and that’s OK!. We don’t need no stinkin’ interobserver reliability! That’s for squares, daddio! Yeah!

    Thankfully, the evidence base of chiro is that SMT works for NMS/MSK issues and that is what they are specialized in, and that is a serious need of the people… man.

    I probably use spinal manipulation on about 30% of my patients and only for a limited amount of time.

    Oh, well, 30% of the people anyways. Sometimes. You know. When I feel they can pay me for… err.. I mean, when they need it. Otherwise, I just stare at them and ask for money.

    But of course, I’m just being mean because I have been…

    Taken out of context this is what I said.

    Because in context:

    The studies of interobserver reliability for motion palpation say motion palp is equivocal and I posted an article that addresses the limitaions of these studies.

    Yeah! We don’t need that interobserver reliability to chain us down, man! Be free!

    So how about that hypothetical that Marcus proposed? You know where he said:

    Take 10 patients, half with back or neck pain or other symptoms considered treatable by chiropractic PCPs. Without knowledge of which patients have symptoms, ask 10 chiropractors to examine each of the 10 patients and diagnose where the spinal segment disfunction is located

    Well:

    Of course you can not reliably find a significant joint restriction on an asymptomatic patient.

    Woah. Did a chiropractor just not even remotely address the point? Nah… couldn’t be.

    There are no droids here.

    So how does a chiropractor determine a lesion to exist? Xray? Naw, that can’t work this shit is subtle. MRI? Nah, we don’t need those. So how then? By digging 1.5 inches into muscle and assessing hypomobility of course!

    Once again the practioner must not use motion palp (MP) as the only diagnostic indicator of joint restriction.

    Oh.

    Move along, there are no droids here.

  95. Jann Bellamy says:

    @ NMC-DC

    “You really do need to stop saying the minority is the majority and vice-versa. It’s a disservice to the work you do.”

    I’m not saying it — all I am doing is quoting your own literature. You’ll have to take it up with the authors who wrote these chiropractic journal articles.

    “Villanueva-Russell (2011) demonstrated that 73% of current practicing chiropractors see themselves as “back” doctors.”

    That doesn’t mean they aren’t “detecting” and “correcting” subluxations. The notion that subluxations/joint dysfunctions/manipulable lesions — whatever you want to call them — exist, are diagnosable, can be “adjusted” and that this process is beneficial, is just as much nonsense when applied to MSK conditions as non-MSK conditions. It seems all chiropractors have done is repackage the old VSC into a new “manipulable lesion” — the diagnosis of which is just as shaky as diagnosing the “VSC” and the effects of which are just as questionable. I know, I know about spinal manipulation and its moderate (if that) effectiveness for low back pain — but that is not what we are discussing here. We are discussing the notion that there is some sort of “spinal dysfunction” that chiropractors can detect — but no one else can — and that it can be adjusted, setting off some speculative cascade of effects. Spinal manipulation for low back pain is performed by PTs and is a legit (if only moderately effective — again, if that) treatment. The whole “manipulable lesion” idea that chiropractors put forth is no more defensible than the VSC. You can cite research all day long that chiropractors and PhDs are trying to determine what happens — but until you can show that a “manipulable lesion” can be accurately detected, is clinically significant, and that the “adjustment” is beneficial to the patient then you shouldn’t be doing it at all, for any condition.

  96. marcus welby says:

    I say this to Jhawk and NMS-DC: thank you for being somewhat candid in your attempted defense of chiropractic. I think I am beginning to get it. From the medical side it would appear that the spinal manipulation thing is a core concept in chiropractic as it has been for 116 years. The other nutraceutical dispensing and holistic health advice, along with caution to your patients regarding vaccine dangers and the excess of prescription drugs, is added on now as an overlay to the fundamental spinal manipulation thing. In so many words, you are admitting there is no subluxation, and what has been previously labelled as such is now being called something else, a dysfunctional spinal segment or manipulable lesion or some such, to distance yourself from the toxic subluxation, which is still in the official legal definition of chiropractic in every state. And in so many words, you are admitting there is really no science to the dysfunctional spinal segment/manipulable lesion thing either, that you manipulate the spine of a patient after examining them, and you, in your mind, “feel” the disfunctional segment loosen up, so to speak, and become healthier and not as hypomobile. This must be a good thing, in your mind and according to your training and experience, because many patients pay their bill, return for more, and many seem to report subjective improvement after the manipulation. Not to worry that no one else can now examine the patient following treatment and detect any objective change, since you are sure you have cured them, simultaneously with the act of diagnosing the location of the spinal segment disorder. Chiropractic academics have been searching for some science to attach to this spinal manipulation for what is in essence treatment of usually self-limited mechanical discomfort, often with considerable psychogenic and stress-related additional baggage (think workers comp or auto accident, slip and fall with lawsuit pending) and it is no surprise there is precious little to show for their research efforts.

  97. nwtk2007 says:

    Oh come now, Dr Welby, you know as well as I that there is just a tad bit of evidence and science to the “subluxation” and the benefits of “it’s” removal. On this very web site I and others have made reference to a bit of the research and have had much of it shot down with narry a look. Admittedly by some, who just dismiss it out and out because its chiropractic.

    Having read your last post, I’d say that you sound much like an insurance adjustor who gets bonuses based upon denial of claims. What a sorry lot they are. Lord knows I wouldn’t want to be dependent upon my back for my and my families sustenance, get injured and have to deal with the likes of one of them.

    And, of course, totally unrelated to the subject here, is their responsibility for the high costs of health care in the states. What a corruption of all that’s holy!

  98. Scott says:

    I was unable to check on things over the weekend, so this is a bit back in the thread, but it can’t go unaddressed.

    Scott was implying that I was blaming the patients themselves for being so uneducated. In some small way he is right. However, I was just pointing out that the medical community might consider educating the public a bit more such that they, the public, might be better able to decide what they might need to do in the event of a health problem, instead of blaming chiropractors for doing what they do.

    I was not IMPLYING that you were blaming the patients for being so uneducated, nor can you credibly claim that that’s only correct “in some small way.” What you said was

    It is hard to imagine that there are people who are so poorly educated that they would go to a chiro for a cold or flu or some other purely “medical” condition.

    which is exceedingly explicit.

    It’s even more telling that your recommended solution is that REAL doctors need to educate people so that they can tell when chiropractors are lying to them. A far more appropriate approach would be for the chiropractors to stop lying.

  99. jhawk says:

    @nybgrus

    I said: “Lx facet capsule: place your thumb about one thumb width from the Lx sp and compress until you hit bone (yes about 1 1/2 inches). Not magical at all really. Try this on your next LBP pt as it might be the source of their pain!”

    you said: “First and painfully foremost, are you comfortable with the definition of “anterior?” The anterior vertebral body is the bit that directly abuts the retroperitoneum. Directly in front of it would be some fascia, then a bit of muscle, then some intestine, and well, really, the entire abdominal cavity. Just a tetch more than 1.5 inches”

    See where I said Lx facet capsule. Well that is not synonomous with ant. vertebral body. Looks like somebody needs an anatomy lesson!

    “You know, the one that says there is no reliability and that’s OK!. We don’t need no stinkin’ interobserver reliability! That’s for squares, daddio! Yeah!”

    Did you read the article? It does not say this. It only calls into quesiton the validity of these MP reliability studies. Here you go again, misrepresenting others words.

  100. jhawk says:

    @ marcus welby

    “Not to worry that no one else can now examine the patient following treatment and detect any objective change, since you are sure you have cured them, simultaneously with the act of diagnosing the location of the spinal segment disorder”

    You also are taking my words out of context. Motion palp could improve minor joint restrictions in some people which could be a limitation to the MP reliability studies. That is all nothing more. This does not extrapolate to every person as you are trying to skew my words and say it does.

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