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254 thoughts on “Spinal Fusion: Chiropractic and Subluxation

  1. jhawk says:

    @ Jann

    “Spinal manipulation for low back pain is performed by PTs and is a legit (if only moderately effective — again, if that) treatment”

    Is spinal maipulation performed by DO’s and MD’s legit as well?

    If so, what are they (PT, MD and DO) manipulating and what is the mechanism?

  2. DugganSC says:

    FWIW, there was a guest article on SBM in March from a former chiropracter here which seems to be indicating the same things as Jhawk and NMS-DC, namely that proper chiropractry does not involve classical subluxation, that the term should be struck from the current literature because it’s misleading, and that Chiropractors are one of your best choices for lower back pain, but should avoid anything involving the neck or joints other than the vertabrae of the lower spine.

    Either way, it sounds like I’m overdue to do much more research on my fiance’s chiropractor to determine whether he’s selling actual science or snake oil. The arguments on both sides have given me a lot of ammunition for shooting down the more spurious arguments.

  3. Scott says:

    @ DugganSC:

    Homola’s article agrees with Jann, not Jhawk or NMS-DC. In particular, he argues that chiropractors NEED TO get rid of the trash, not that it already HAS BEEN.

  4. Quill says:

    That SBM article by Sam Homola that DugganSC references also includes a good piece of advice in a comment by him which addresses the subject of some of the back and forth here:

    There are a few chiropractic schools that offer good instruction in the care of musculoskeletal problems. But I am not aware of any that have publicly renounced the vertebral subluxation theory. For this reason, I usually advise students who are interested in manipulation to go for a Doctor of Physical Therapy degree (DPT) rather than for a Doctor of Chiropractic degree (DC).

  5. nwtk2007 says:

    Scott, the term “medical community” does not equal “real doctors” now does it? And yes, chiropractors should stop lying to people about chiropractic being beneficial for so many things that it actually isn’t. So should some of the folks on this thread, to imply that a PT can do adequate spinal manipulation, examine or diagnose to any significant degree other than in their own opinion. At least in working with a few, I have yet to see it. Hell, I had to ask one yesterday to sign his report, for the second time. What a maroon.

  6. nybgrus says:

    Oh jhawk. You so funny.

    you have never palpated a transverse process, facet joint or anterior vertebral body?

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

    Looks like somebody just dodged the fact that he said anterior vertebral body. I actually pointed that out… you know, because you said anterior vertebral body, then quoted the response to it, and then addressed it at “Lx facet capsule.” I was making fun of you for stating anterior in the first place, and then for (intentionally or not) conflating your response with “Lx facet capsule,” and then for claiming you can hit bone:

    Lx facet capsule: place your thumb about one thumb width from the Lx sp and compress until you hit bone

    So who needs an anatomy lesson?

  7. nybgrus says:

    the term “medical community” does not equal “real doctors” now does it

    Why yes, yes it does. Unless you would also like to claim that the term “geologist community” should also include young and flat earthers.

  8. nwtk2007 says:

    Why no, it does not.

  9. jhawk says:

    @nybgrus

    “Looks like somebody just dodged the fact that he said anterior vertebral body. I actually pointed that out… you know, because you said anterior vertebral body, then quoted the response to it, and then addressed it at “Lx facet capsule.” I was making fun of you for stating anterior in the first place, and then for (intentionally or not) conflating your response with “Lx facet capsule,” and then for claiming you can hit bone:”

    I did not dodge anything. You sure do make a lot of assumptions. Incorrectly I might add. I was describing how to palpate the Lx facet joint (made up of an IAP which is bone, SAP which is bone and a facet capsule) to Marcus so he could potentially try it out on his LBP patients. This palpation of facet capsules (especially in the cx spine) is actually quite easy, which is the reason I chose to only describe this palpatory procedure. The ant. v. body palpation is a higher end palpation skillset and the facet joints must absolutley be palpated by the practicioner before you attempt the ant v. body. I will say that I shoud have not lumped ant v body in with tp and facet joint because it is not easy to do like the tp and facet joint.

    Ant v. body palpation: pt supine, doc at head of table with pt head in hands, palpate behind SCM and sink into ant tubercle of tp (oh my there is a palpable tp), once there slide thumb ant then medial, now you are on top of the longus colli, lighlty compress longus colli and guess whats there…. an anterior vertebral body. Please do not attempt this as I know you are not trained in this and will probably hurt someone.

  10. nybgrus says:

    The ant. v. body palpation is a higher end palpation skillset and the facet joints must absolutley be palpated by the practicioner before you attempt the ant v. body.

    Please do not attempt this as I know you are not trained in this and will probably hurt someone.

    I’d ask you please do not attempt this as it sounds very dangerous and useless.

  11. jhawk says:

    @ marcus welby again

    “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.”

    Objective findings to look for post treatment. You should know this stuff. Increase in ROM, improvement in orthopedic test, improvement in tissue texture, improvement in any number of patient specific provocative tests. Once again, relying on motion palp as the only objective finding is not reliable but the evidence that states this does have limitations as I posted earlier.

  12. jhawk says:

    @nybgrus

    “I’d ask you please do not attempt this as it sounds very dangerous and useless.”

    The reason I have palpated the ant v body is because the longus colli which lays partially on top of the ant v. body can be effected in whiplash injuries. It is a muscle and can therefore develop scar tissue, especially post MVA. Not so useless afterall.

  13. marcus welby says:

    jhawk: and those examinations post treatment which you enumerate are anything but subjective..Right? Since I know you will want the last word, I exit this discussion.

  14. Cowy1 says:

    @jhawk

    “Ant v. body palpation: pt supine, doc at head of table with pt head in hands, palpate behind SCM and sink into ant tubercle of tp (oh my there is a palpable tp), once there slide thumb ant then medial, now you are on top of the longus colli, lighlty compress longus colli and guess whats there…. an anterior vertebral body.”

    Except overlaying the SCM is the platysma and a bunch of fascia, underneath are a pile of vertical strap muscles plus more fascia before you get to the longus colli. To get at the ant v body you’d have to wiggle your magic fingers past all that stuff first. Improbable (at best) on a cachectic person and impossible on a bodybuilder like myself.

    Face it man, no way you’re getting at any ant v body without getting (literally) your fingers dirty; whatever you think you are palpating is just a figment of your imagination.

    “Objective findings to look for post treatment. You should know this stuff. Increase in ROM, improvement in orthopedic test, improvement in tissue texture, improvement in any number of patient specific provocative tests. Once again, relying on motion palp as the only objective finding is not reliable but the evidence that states this does have limitations as I posted earlier.”

    So your palpation is useless? And still a weak excuse for not studying the reproducibility of your assessments. Like Dr Welby said, get a bunch of chiros and blind them to 5 symptomatic and 5 asymptomatic pts. Have them evaluate each patient independently and see what kind of diagnoses they come up with; see if they can agree that pt x has a “subluxation” (or joint fixation or whatever the hell you want to call it) at T2 and pt y doesn’t have one at all.

  15. jhawk says:

    @Cowy1

    “Except overlaying the SCM is the platysma and a bunch of fascia, underneath are a pile of vertical strap muscles plus more fascia before you get to the longus colli. To get at the ant v body you’d have to wiggle your magic fingers past all that stuff first. Improbable (at best) on a cachectic person and impossible on a bodybuilder like myself. Face it man, no way you’re getting at any ant v body without getting (literally) your fingers dirty; whatever you think you are palpating is just a figment of your imagination.”

    Actually you are posterior to the platysma. By veritcal strap muscles I assume you mean the scalenes which attach to the tp’s of the cervical spine of which you are anterior to. Fascia yes but you do realize you can put the fascia in a relaxed position which allows for compression. Just becasue your palpation skill set is limited does not mean others can not palpate these structures. Oh and I have done this on a bodybuilder!

    “So your palpation is useless? And still a weak excuse for not studying the reproducibility of your assessments. ”

    Not sure how you came to this conclusion but I never said palpation is useless. I said the evidence for motion palpation lacks reproducibility. This is the whole reason I posted the article about these studies limitations.

  16. JPZ says:

    @nybgrus

    Sorry for the delay in reply. I need to correct your horrible derision of the words of the Imperial Guard and your affront to the Empire. It isn’t:

    “Move along, there are no droids here.”

    it is:

    “These aren’t the droids you’re looking for.”

    In a galaxy far, far away, you can end a sentence with a preposition. Remember [that]… always. LOL

  17. Cowy1 says:

    @jhawk

    Posterior to whatever man, you’re still claiming you can dig through a couple layers of fascia and muscle to palpate the anterior aspect of some vertebral body for reasons unknown. As that kind of digging is tantamount to assault it would be great if you had a really, really good reason to do it.

    “Lacks reproducibility”=useless. Sorry

  18. jhawk says:

    @cowy1

    “Posterior to whatever man, you’re still claiming you can dig through a couple layers of fascia and muscle to palpate the anterior aspect of some vertebral body for reasons unknown. As that kind of digging is tantamount to assault it would be great if you had a really, really good reason to do it”

    I already explained the reason for this type of palpation but here it is again in;

    The reason I have palpated the ant v body is because the longus colli which lays partially on top of the ant v. body can be effected in whiplash injuries. It is a muscle and can therefore develop scar tissue, especially post MVA. Also, there is no digging involved.

    “Lacks reproducibility”=useless. Sorry

    Yes I agree as a stand alone it (MP) is. Already stated this many times over.

  19. nybgrus says:

    @JPZ:

    My apologies sir, I stand corrected. I was also half in the bag when I wrote it. LOL.

    @jhawk:

    The reason I have palpated the ant v body is because the longus colli which lays partially on top of the ant v. body can be effected in whiplash injuries. It is a muscle and can therefore develop scar tissue, especially post MVA. Also, there is no digging involved.

    So you palpate a vertebral body because a muscle has scar tissue? And you don’t have to dig at all to get to the anterior aspect of the vertebral body?

    That’s it. Tomorrow I am telling my school of medicine that I get to make up whatever answers I want for my last exam. If chiros can do it and be “endorsed” by the WHO so can I!

  20. ConspicuousCarl says:

    So is the palpation supposed to reduce scar tissue, our prevent it?

  21. jhawk says:

    @conspicuousCarl

    Palpation only gets you to the site of pathology (scar tissue/adhesion) and then myofasical release (active or passive depending on the case) is performed to reduce the pathology.

  22. marcus welby says:

    jhawk: I would say to you that if you think you are actually accomplishing anything with your fingers or hands during “myofascial release” you are deluded. Massage and palpation are just that. Physical therapists also speak of myofascial release and it is imaginary.

  23. Blue Wode says:

    Good to read another great blog post from Jann Bellamy.

    NMS-DC wrote on 06 Nov 2011 at 1:58 am: “WHO produced an educational and safety guideline for training chiropractic doctors… 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.”

    I don’t think that NMS-DC should be quite so impressed by the WHO’s stance on chiropractic. For example, although its 2005 training and safety guideline says that the consequences of the chiropractic subluxation are ‘hypothesized’…

    Quote
    “It is hypothesized that significant neurophysiological consequences may occur as a result of mechanical spinal functional disturbances, described by chiropractors as subluxation and the vertebral subluxation complex (9, 10:169-170, 11).”

    …it also says, in a 2003 bulletin on lower back pain, that:

    Quote
    “People with low back pain often turn to medical consultations and drug therapies, but they also use a variety of alternative approaches. Regardless of the treatment, most cases of acute back pain improve. At the time, people in such cases may credit the improvement to the interventions some of which clearly are more popular and even seemingly more effective than others (e.g. chiropractic and other manipulative treatments in which the laying on of hands and the person-to-person interaction during the treatment may account for some of the salutary results).”

    and …

    “The spread of chiropractic and other manipulative treatments worldwide has won many adherents to this treatment , who perceive that it works better than others. This hypothesis was recently put to the test (25) and, although the respondents still favoured such approaches (chiropractic adjustment, osteopathic manipulation, and physical therapy), perhaps because of the time spent and the laying on of hands, meta-analysis cannot confirm the superiority of manipulative treatments (or, for that matter, of acupuncture and massage (26)) over other forms of therapy, or even time as a healer (25), which substantiates the contentions of WHO’s document (1). In most instances, manipulative treatments are more expensive than others (apart from surgery) and not more helpful to outcome (26).
    http://tinyurl.com/bpklv8c

    When you add the above to chiropractic’s quackery baggage and generally unfavourable risk/benefit profile, it’s easy to see why it’s increasingly not being recommended as a therapeutic intervention. One has to wonder how long its training establishments can survive.

  24. Jann Bellamy says:

    @jhawk

    Could you provide us with some references which:

    1. define the “manipulable lesion,” “joint dysfunction,” “subluxation” (as the terms are currently used) and list what other names chiropractors call it. I am hearing that they are the same thing but I could be wrong. If not, what is the difference?

    2. explain how to diagnose the manipulable lesion/joint dysfunction/etc.

    3. explain the clinical significance of the manipulable lesion/joint dysfunction/etc. — i.e., when you diagnose it, what does that mean re: the patient’s health?

    4. explain the therapies you use to treat the manipulable lesion/joint dysfunction/etc. and their putative effect on the manipulable lesion/joint dysfunction etc.

    If I am not up to date on current chiropractic (as some have suggested) I would like to see what current chiropractic is. Preferably, these references would be articles available on PubMed, but if that’s not possible I’ll take references to textbooks used in chiropractic schools, but please be specific about page numbers or chapters.

    Thanks.

  25. nwtk2007 says:

    Don’t do it jhawk. It would be like casting pearls to swine, or some such thing as that.

    The request that articles might be available on PubMed is the flag of insanity. Its all been hashed out over and over again. Much as the global warming skeptics and the creation scientists keep presenting the same arguments over and over again and must be dealt with using the same rebuttals over and over again, thus it would be for you. These guys have no intention of looking objectively at your position. Their bias is too thick. For them, it would just be a video game and you would be the target, whether they could or would make sense of your point of view or not.

  26. pmoran says:

    Jann: 1. define the “manipulable lesion,” “joint dysfunction,” “subluxation” (as the terms are currently used) and list what other names chiropractors call it. I am hearing that they are the same thing but I could be wrong. If not, what is the difference?

    There is little or no prospect of a helpful answer to this and some of your other questions, because these concepts derive solely from attempts to explain the clinical observations “I do this and (because of a presumed direct physiological impact) the patient gets better”.

    The “manipulable lesion” is the final acknowledgment of this fact, as more simplistic explanations for spinal manipulation’s “successes” such as bones being out of place and nerves being pressed upon have had to be abandoned, the word “subluxation” acquired too many adverse connotations, and “joint dysfunction” was rightly considered to be so vague as to not say anything very useful.

    The concept has no other basis, irrespective of what chiropractors try to make some of the laboratory research say.

    However, this is NOT a major problem for chiropractic —- so long as the original premise is true, mainly the (“because of —”) part of “I do this and (because of a presumed direct physiological impact) the patient gets better”.

    So understanding what the clinical evidence means has to be question number 1. And this is where the problem lies for chiropractors. The only area where there is a moderately tolerable combination of plausibility, anecdotal and clinical study evidence for activity (over placebo and other non-specific influences) is in acute low back pain.

    We are able to accept that SMT may benefit some patients with that even while not (yet) being able to describe “why?” in clear anatomical and physiological terms.

    As you move away from that specific clinical setting to consider other areas where some DCs claim clinical success for SMT the clinical evidence, plausibility and cost/risk/benefit considerations (even as a “mainly placebo” option) weaken dramatically.

    To be even-handed, this problem is not unique to chiropractic. Physiotherapy and sports medicine have similar weakly supported but popular treatments. TCM and homeopathy etc are similar attempts to work backwards into science from clinical observation, without being lucky enough to have such a culturally accepted role as SMT acquired in LBP, perhaps because of some patients being unusually responsive to SMT variants, as is so often displayed in the sitcoms.

  27. nybgrus says:

    Don’t do it jhawk. It would be like casting pearls to swine, or some such thing as that….. Much as the global warming skeptics and the creation scientists keep presenting the same arguments over and over again and must be dealt with using the same rebuttals over and over again, thus it would be for you.

    The lack of self awareness is downright staggering.

  28. nwtk2007 says:

    You are so right! I am laughing my ass off at exactly that. Peace out Mr Helper.

  29. JPZ says:

    @nwtk2007

    “Don’t do it jhawk. It would be like casting pearls to swine, or some such thing as that.

    The request that articles might be available on PubMed is the flag of insanity.”

    I hope this is some kind of joke or something. If I say the moon is made of green cheese, is it up to you to prove me wrong? What if I tried to prove the moon was made of green cheese, but I only referenced a book that is out of print and I don’t have a copy of anymore? If the concept of supporting your own assertions with verifiable sources of scientific information is foreign to you, why are you here? It would save you a lot of shouting at the rain if you adopted that concept or simply lurked to learn why it is so important.

  30. NMS-DC says:

    Wow! Another spirited discussion… which is great because we are here to debate and learn. There are obvious trolls on here with a lot of white noise which is drowning out some of the legitimate questions being raised.

    @Marcus et al.

    I think it’s great that we’re finally talking about subluxation and operationally defining it in terms what we all undertand: joint dysfunction or more broadly “manipulable lesion”. All manipulative therapy does indeed have a target “tissue”. I think this is a big step forward that we can talk about the spinal dysfunction, in mechanical terms at the very least for now.

    Ok, so a few important summaries

    1) SMT is has been found to be effective for not only acute, but for chronic back pain as well, and there is new research saying that “maintenance” SMT has been found to improve function in chronic LBP patients.

    2) Modern day chiropractors do not only use SMT (unimodal) but combine it with other conservative forms of therapy, such as massage and exercise. So it’s not only about passive modalities.

    3) Yes Marcus, SMT is at the core of chiropractic and will always will be. Every chiropractor agrees on this.

    4) I would surmise that subluxation is evolving, trading the vitalistic descriptors for scientific descriptors based on language all scientists share. So, by talking about the biomechanical and neurophysiological characteristics of joint dysfunction, it makes it easier to study with other professionals (such as biomechanists and neurophysiologists) because they can bring their expertise as well so we can all understand the biological effects of spinal manipulation and the biological effects of joint dysfunction

    5) I would ask that you read the papers I referenced to earlier in this thread,” Introducing the external link model for studying spine fixation and misalignment (http://www.ncbi.nlm.nih.gov/pubmed/17416279) There are 2 follow up papers. The take home point of them is that a joint that is fixated, or “stuck” or not moving well develops degenerative changes at the joint, the capsule and local tissues. This, of course, implies that joints biomechanically inefficient can lead to early onset of DJD, DDD at that specific fixated joint. Appreciating how the body will compensate however, one mechanical problem can result in a secondary or compensatory mechanical problem elsewhere and this process essentially repeats itself until mechanics are normalized.

    6) Objective change can be measured easily in many ways: ROM, pain pressure threholds (algometry) resisted muscle testing with a dynamometer. This is in addition to clinical orthopedic tests, soft tissue and joint palpation and valid, reliable outcome measures such as the Rolland-Morris Disability Index or the Low Back Disability Index. It’s not at all purely subjective as you insinuate. You could also use more global scales like the SF-12 or SF-36 for overall well being if you wanted to.

    @Jann

    These are good questions and I will try to answer them, but it’s a work week and I can only spend so much time replying to these very busy threads. But I do promise to get back to you shortly.

  31. NMS-DC says:

    @Blue Wode

    Your 2003 commentary by Erlich is outdated. I have provided 3 references, post 2007 that conclude that chiropractic care for LBP is cost-effective.

    Yes, it is hypothesized that there are neurophysiological effects to joint dysfunction. There is evidence that this is so, see Henderson, Cramer et al. 2007, 2009 and He & Dishman 2010. There are other papers, but I suggest those three as a starting point.

    You write: “When you add the above to chiropractic’s quackery baggage and generally unfavourable risk/benefit profile, it’s easy to see why it’s increasingly not being recommended as a therapeutic intervention. One has to wonder how long its training establishments can survive.”

    Do you have a citation for this or is this purely conjecture on your behalf? The evidence disagrees with you yet again. Please refer to Cochrane reviews of SMT for LBP as well as the Spine 2011 issues regarding SMT and chronic LBP and maintenance SMT for LBP. Also please review the WHO Neck Pain Task Force which specifically states that manual thearpies (all performed by DCs such as SMT, mob and massage) as being effective as well as other modalities used by DCs such as exercise and education.

    If you’re going to chip in this conversation I suggest you brush up with current literature.

    Regards,
    NMS-DC

  32. rwk says:

    @Blue Wode
    I say old chum, glad to see we now have some typical British exaggeration in this Hatfield-McCoy feud

    When you add the above to chiropractic’s quackery baggage and generally unfavourable risk/benefit profile,

    “and generally unfavourable risk/benefit profile”

    Really?

    ” it’s easy to see why it’s increasingly not being recommended as a therapeutic intervention”

    Yeah, by the SBM -MDs..
    Whether you like it or not chap, That’s not the way things are going or else the SBM site wouldn’t be here.
    Can you show us your robust evidence for that last statement?

    Ta.

  33. NMS-DC says:

    @ all who reference Sam Homola

    I have requested twice already, (three times now) a debate with Dr. Homola regarding any topic regarding contemporary chiropractic. I ask that any moderator here please pass along my invitation so we can have a discussion.

    NMS-DC

  34. pmoran says:

    NMS-DC: I would surmise that subluxation is evolving, trading the vitalistic descriptors for scientific descriptors based on language all scientists share. So, by talking about the biomechanical and neurophysiological characteristics of joint dysfunction, it makes it easier to study with other professionals (such as biomechanists and neurophysiologists) because they can bring their expertise as well so we can all understand the biological effects of spinal manipulation and the biological effects of joint dysfunction.

    Sciency language is — well, just sciency language. It does not prove anything is so, or necessarily convey useful meaning.

    What do you mean by “the biological effects of spinal manipulation and the biological effects of joint dysfunction”? What biological effects does spinal manipulation produce?

    I, for one, am very familiar with the “current literature” you refer to and only the very biased to find in it any strong support for anything uniquely chiropractic. In fact you yourself now seem to be backing away from spinal manipulation as being the “core of chiropractic” so as to incorporate competing modalities into it. Why is that?

    The big stumbling block to communication here is not bias, which undoubtedly exists on both sides and sometimes for good reason, but that many chiropractors lack a solid grounding in the implications, strengths and weaknesses of various types of research. They lack any such tradition.

    It is SO easy to find support for pet beliefs in medicine. Our skepticism is not based upon any desire to persecute chiropractors (other than intolerably pretentious ones). It is based upon experience with the runaway medical beliefs of some of our own respected members and esteemed professors.

  35. jhawk says:

    @ marcus welby

    “jhawk: I would say to you that if you think you are actually accomplishing anything with your fingers or hands during “myofascial release” you are deluded. Massage and palpation are just that. Physical therapists also speak of myofascial release and it is imaginary.”

    When patients come in with achilles tendonopathy and their scar tissue is not only palpable but visual and the practicioner uses myofascial release which results in not only a palpable decrease in scar tissue but visual decrease in scar tissue (another objective finding), this is all imaginary? I think not.

    @ Jann Bellamy

    I will have to answer your questions at a later date as I also have a busy week.

    I am interested in your response to my previous posted question to you though:

    you said: “Spinal manipulation for low back pain is performed by PTs and is a legit (if only moderately effective — again, if that) treatment”

    Is spinal maipulation performed by DO’s and MD’s legit as well?

    If so, what are they (PT, MD and DO) manipulating and what is the mechanism of action of this manipulation?

    Thank you for getting this discussion back on topic.

  36. marcus welby says:

    Jhawk: your impression that the massage on the achilles tendon did any significant benefit beyond some very temporary warm feeling is totally imaginary. No scar tissue was affected in any significant way.

    And as to DOs and MDs doing some spinal manipulation, yes some do. I have bemoaned on this blog, in the past, the published evidence that about half of the vertebral artery dissection strokes due to neck cracking in Germany were caused by orthopedic surgeons. I would hope that information would encourage those German MDs who still use neck cracking as a treatment to abandon it entirely. There is no way to predict in advance which rare patient will suffer a stroke from this useless concept.

    To my knowledge, DOs, PTs, MDs who manipulate spines do not claim there is any core subluxation/manipulable lesion/dysfunctional segment nonsense behind their spinal manipulation. Just an ordinary variant or extension of massage therapy for a sore back. …It feels good for a little while. I accept that science. Warm bath feels good for a little while in this circumstance also.

  37. marcus welby says:

    JHawk: unless you meant achilles tendon stretch, which can be done slowly, sustained, by the patient alone at home. Seems to help some achilles tendonopathy over time. Often difficult to distinguish expected natural history of healing with time from effects of treatment, as in all of self-limited conditions with subjective outcomes. I don’t think slow, sustained passive stretch is what you were writing about. Direct effect of massage on scar tissue…..forget it. Temporary placebo beneficial feelings from the therapeutic encounter, often, perhaps.

  38. Blue Wode says:

    NMS-DC on 08 Nov 2011 at 9:35 pm wrote: “Your 2003 commentary by Erlich is outdated. I have provided 3 references, post 2007 that conclude that chiropractic care for LBP is cost-effective.”

    That is not the conclusion reached by the most recent Cochrane systematic review of Spinal manipulative therapy for chronic low-back pain (which was updated on 16th February 2011):

    Quote
    “High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. *Determining* cost-effectiveness of care has high priority.”

    http://tinyurl.com/dxocpd9

  39. Blue Wode says:

    NMS-DC on 08 Nov 2011 at 9:35 pm wrote: “You write: “When you add the above to chiropractic’s quackery baggage and generally unfavourable risk/benefit profile, it’s easy to see why it’s increasingly not being recommended as a therapeutic intervention. One has to wonder how long its training establishments can survive.” – Do you have a citation for this or is this purely conjecture on your behalf?”

    With regard to the generally unfavourable risk/benefit profile, it’s worth noting that guidelines tend not to take chiropractic pseudoscience into account. Indeed, the UK NICE guidelines for low back pain failed to consider that point, as Professor Edzard Ernst observed:

    Quote
    “So why were [these risks] not considered more seriously? The guideline gives the following reason: ‘The review focused on evidence relevant to the treatment of low back pain, hence cervical manipulation was outside our inclusion criteria’. It is true that serious complications occur mostly (not exclusively) after upper spinal manipulation. So the guideline authors felt that they could be excluded. This assumes that a patient with lower back pain will not receive manipulations of the upper spine. This is clearly not always the case. Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them. And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.”

    Ref. Ernst, E. Spinal manipulation for the early management of persistent non-specific low back pain–a critique of the recent NICE guidelines. Int J Clin Pract. 2009 Oct;63(10):1419-20

    http://tinyurl.com/6b6nkzg

  40. Blue Wode says:

    @ NMS-DC

    With regard to my statement that chiropractic is increasingly not being recommended as a therapeutic intervention, in 2010 it was revealed that Primary Care Organisations in the UK were refusing to fund NICE’s recommendations for spinal manipulation (and acupuncture) because of the controversy surrounding it.

    See http://tinyurl.com/5wjwes7

  41. Blue Wode says:

    @ NMS-DC

    With regard to chiropractic in the US, according to ‘The Future of Chiropractic Revisited—2005-2015’ there has been a 39% drop in chiropractic education student enrollment from 1969-2002 and, while the use of CAM in general has increased, the largest decrease occurred for chiropractic (9.9% to 7.4%).

    See http://www.altfutures.com/future-chiropractic-revisited-2005-2015

  42. Blue Wode says:

    @ NMS-DC

    With regard to the survival of chiropractic training establishments, at least one in the US closed this year:
    http://chirotalk.proboards.com/index.cgi?board=outlook&action=display&thread=5182

  43. Blue Wode says:

    NMS-DC on 08 Nov 2011 at 9:35 pm wrote: “Please review the WHO Neck Pain Task Force which specifically states that manual thearpies (all performed by DCs such as SMT, mob and massage) as being effective as well as other modalities used by DCs such as exercise and education.”

    With regard to chiropractic, what’s the point? Even if spinal manipulation were to be shown to be superior and more cost effective than other interventions, there is still the problem of safety and the chiropractic ‘bait and switch’ to overcome:
    http://www.dcscience.net/?p=1516

  44. Blue Wode says:

    @ NMS-DC

    IMO, the International Chiropractors Association (ICA) Best Practices documentation demonstrates most of what is wrong with chiropractic (ie, the ‘bait and switch):
    http://www.facebook.com/notes/richard-brown-bca-president/ica-best-practices-why-the-bca-cannot-join-the-aukc/153048378097052

  45. Blue Wode says:

    Rwk on 08 Nov 2011 at 9:36 pm wrote: “Can you show us your robust evidence for that last statement?”

    See my responses to NMS-DC above.

  46. Jann Bellamy says:

    @ jhawk

    “you said: ‘Spinal manipulation for low back pain is performed by PTs and is a legit (if only moderately effective — again, if that) treatment’

    Is spinal maipulation performed by DO’s and MD’s legit as well?

    If so, what are they (PT, MD and DO) manipulating and what is the mechanism of action of this manipulation?”

    I don’t know anything about spinal manipulation performed by DO’s and MD’s, so I cannot speak to that. I don’t know the proposed mechanism of action for spinal manipulation as performed by PTs. My statement was meant to reflect the fact that when PTs do spinal manipulation for low back pain, there is some moderate evidence that it is effective and that, as I understand it, the patients are not told they have “manipulable lesions” which are diagnosable and which are “adjusted,” resulting in some putative effect on the patient’s health. The latter is, as I understand it, something chiropractors claim but which is unsupported by any evidence. Hence, my request for evidence from you.

  47. jhawk says:

    @ marcus welby

    you said :”Jhawk: your impression that the massage on the achilles tendon did any significant benefit beyond some very temporary warm feeling is totally imaginary. No scar tissue was affected in any significant way. ” and ” Direct effect of massage on scar tissue…..forget it. Temporary placebo beneficial feelings from the therapeutic encounter, often, perhaps”

    So a sustainable visual decrease in the size of scar tissue is now a subjective placebo effect. You have lost it my friend.

    And some evidence to the contrary:
    http://www.ncbi.nlm.nih.gov/pubmed?term=myofascial%20release%20and%20adhesion

  48. nwtk2007 says:

    jwawk, I am telling you, you are wasting your breath on these guys. They are so adamant in their belief system and denial of other modes of treatment that it is like talking to Rush Limbutt, trying to convince him and his “conservative” coney’s that the world is indeed warming up, or that the world was not created in just a few days by some supreme power, etc, etc. You might as well be trying to convince a faith healer that he is not actually healing or try to convince the person healed that he has not been healed, even though the condition that has been healed is still present. It would be easier to convince a believer in the power of prayer that he/she is wasting his/her time and that nothing will come of it than to convince these guys that there is any significant benefit to anything a chiro does. Their biases are THAT strong.

  49. JPZ says:

    @nwtk2007

    *science-based facepalm*

  50. Quill says:

    @JPZ’s “science-based facepalm”:

    Indeed, indeed. Just doing a simple linguistic analysis of the non-responses from the chiro set reveals an astonishing lack of anything like a fundamental understanding of science even by a generously broad definition. I’m beginning to think that the unknown parts of chiropractic education must include induction in a “belief system” that is impermeable to critical thinking and examination of any kind of data outside its own “belief system.” I’d no idea chiros were so much like religious fundamentalists and faith healers but upon reflection it makes a lot of sense.

  51. Cowy1 says:

    @ jhawk

    You cite a cell-culture study as evidence for your ability to manipulate away scar tissue? Evidence fail.

  52. nwtk2007 says:

    You see jhawk, you can give them anything and everything to look at (as has been done in the past) and all they will do is sneer and insult. Very weak and insecure mindset with just a tad, a very large tad, of elitist conceit. They style themselves in their own minds as intellectuals and, admittedly, some are pretty bright. Some are even failed chiropractor want-to-be’s who now just live to somehow knock chiropractic around enough to, hopefully, get their student loans paid off or forgiven. Quill can even use big words like “impermeable” to try to demonstrate their superior knowledge. I feel so intimidated and always have on this site. But its fun to bandy about some of their ideas and “philosophies”. The video game goes both ways fella’s.

  53. Cowy1 says:

    @nwtk

    I do molecular biology research in addition to regular ole medical school (MS/MD type). While we have had some spectacular results with our work there is no way in the coldest depths of hell that I would say “hey, this works great in rats, let’s give it to all our patients” while on the wards because I would get my ass handed to me in a bucket. The fact that jhawk is dumb enough to cite a cell-culture (even further removed from translating to human medicine) study is indicative of both his poor education and inability to evaluate literature.

    Also, something even more telling, I’ve never actually seen a study done or cited by chiropractors that indicates chiropractic isn’t effective for something; it apparently always works. Real medicine doesn’t have near that kind of track record.

  54. nwtk2007 says:

    Now don’t go bragg’in. I got my Masters in Molecular Biology many years ago; research, published, taught. Been there and done that. In fact, tutored at the medical school, biochem mainly but also A and P, Path, etc. Now, now one is saying that Mr Hawk is correct and drawing good conclusions, but it has been my experience on this blog that laying out research relating to chiropractic is a waste of time due to the extreme bias on the medical side, when, in fact, much of chiropractic is medical, physical medical, but medical none the less. I have seen the bloggers here refute anecdotal evidence as being anecdotal, only to then bring their medical argument to bare with, none other than anecdotal stories and “evidence”, refusing to acknowledge their own short comings in their “analysis” of “medical” research. Not, of course by all, but always supported by the blog regulars. So, just say’in.

    Its an old argument in many medical circles, they that cannot see beyond their own pro-medical/anti-chiropractic positions.

  55. NMS-DC says:

    @BlueWode

    I asked for peer-reviewed scientific literature. Not blog posts or commentary on the ICA. You want evidence-based guidelines on chiropractic radiography?

    Diagnostic imaging practice guidelines for musculoskeletal complaints in adults–an evidence-based approach. Part 1. Lower extremity disorders. http://www.ncbi.nlm.nih.gov/pubmed/18082743

    Diagnostic imaging guideline for musculoskeletal complaints in adults-an evidence-based approach-part 2: upper extremity disorders. http://www.ncbi.nlm.nih.gov/pubmed/18308152

    Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. http://www.ncbi.nlm.nih.gov/pubmed/18308153

    More

    Do chiropractors adhere to guidelines for back radiographs? A study of chiropractic teaching clinics in Canada.
    http://www.ncbi.nlm.nih.gov/pubmed/18090093

    Adherence to radiography guidelines for low back pain: a survey of chiropractic schools worldwide.
    http://www.ncbi.nlm.nih.gov/pubmed/18722195

    Guess which schools weren’t willing to play ball with the EBM guidelines…. We know them already, I mentioned them earlier in this thread.

    BlueWode, seriously, you clearly lacking in your literature acumen. You need to really bring some good peer-reviewed evidence because otherwise you’re looking increasingly foolish and out of touch.

    NMS-DC

  56. NMS-DC says:

    @Jann

    “I don’t know anything about spinal manipulation performed by DO’s and MD’s, so I cannot speak to that. I don’t know the proposed mechanism of action for spinal manipulation as performed by PTs. My statement was meant to reflect the fact that when PTs do spinal manipulation for low back pain, there is some moderate evidence that it is effective and that, as I understand it, the patients are not told they have “manipulable lesions” which are diagnosable and which are “adjusted,” resulting in some putative effect on the patient’s health. The latter is, as I understand it, something chiropractors claim but which is unsupported by any evidence. Hence, my request for evidence from you.”

    Spinal manipulation performed by any health care practitioner has a common intent: improve function of the target tissue. That could be as simple of a) pain control b) improved range of motion c) improved neuromuscular reflexes or d) controversially, improved viscero-somatic function.

    LBP patients who present to PTs and get their backs adjusted/manipulated or getting it done done because the PT clearly feels there is a biomechanical problem at the spinal joints (spinal joint dysfunction aka subluxation). Diagnosable? To an extent, yes. To wit:

    Spinal palpation for lumbar segmental mobility and pain provocation: an interexaminer reliability study.

    Conclusion: Palpation methods that are used to provoke pain responses are more reliable than palpation methods in which the clinician purports to find segmental motion restriction. The prone instability test shows good reliability.

    http://www.ncbi.nlm.nih.gov/pubmed/18722203

    In fact, if you go to PubMed and type in “spinal dysfunction and chiropractic” you will get 84 hits. Spinal dysfunction being synonymous with subluxation. So, the debate has been reframed: does spinal dysfunction exist? Well, if DCs, MDs, PTs, DOs and DVMs all say it does, clinically, that kind of answers a basic question. Surely not all these professions are lying about this “magical” lesion. So what gives Jann et al? What do you really want to know?

  57. Cowy1 says:

    Bias? They guy thinks he can palpate the anterior aspect of a vertebral body to remove scar tissue and puts up a peripherally (at best) related cell-culture article to prove it and you think I’m biased? You need to lose your bias just cause he’s a chiro and call it what it is; incredibly dumb.

    The core of chiropractic, the subluxation or manipulable lesion or whatever, is a best a vitalistic fantasy and, at worst, a way to defraud patients. I shudder at the number of people I went to college with who are close to (or have recently) graduated chiropractic school and are involved in shady practice management schemes, two of the most prominent being Maximized Living and ChiroOne.

    The bloggers here do a nice job of not pandering to bs and if you don’t like it I guess you’ll have to take your ball and go home.

  58. NMS-DC says:

    @marcus

    Dr. Welby, you really need to brush up on your literature regarding the mechanical effects of loading the connective tissues. Fascinating stuff. I deal with soft tissue injuries all day long in practice. There is some great basic sciences research out there by Langevin and Frederickson on connective tissue function/degeneration/remodelling. Here are some abstracts to peruse. It’s not magical, you’re just not aware of this stuff. I will show you the way, good doctor.

    Fibroblast cytoskeletal remodeling contributes to connective tissue tension.
    http://www.ncbi.nlm.nih.gov/pubmed/20945345

    Tissue stretch induces nuclear remodeling in connective tissue fibroblasts.
    http://www.ncbi.nlm.nih.gov/pubmed/20237796

    Tissue stretch decreases soluble TGF-beta1 and type-1 procollagen in mouse subcutaneous connective tissue: evidence from ex vivo and in vivo models.
    http://www.ncbi.nlm.nih.gov/pubmed/17654495

    Mechanical loading of tissues, and the corresponding process of mechanotransduction is a very and important science for DCs and anyone who is doing manual body work for MSK injury rehab. Understanding the process of soft tissue remodelling is vital in our understanding of how we treat the soft tissues and how the biological mechanisms in play affect healing and recovery. It’s too bad that all the MDs here at SBM do not have sufficient knowledge of MSK because it like two specialists talking and not understanding each other. A physiatrist should be able to understand what we’re getting at here as they have specialized skills in NMS examination.

    @Jhawk, that was a good piece of literature, but read up on Langevin, she is the gold standard in this stuff. She also is studying the neuromechanical properties of acupuncture which, despite being poo-pooed here at SBM has a great program at the home of evidence-based medicine, McMaster University School of Medicine

    Contemporary Medical Acupuncture:

    http://fhs.mcmaster.ca/acupuncture/

    That’s a separate thread, but its more proof how an old natural healing art, like acupuncture can be explained in “western” medicine language i.e. science/neuroscience/neuroanatomy/neurophysiology. This is true with another old, natural healing art, spinal manipulation. SBM, it’s time you put up or shut up: does you belief system in chiropractic outweigh you willingness to understand or or you truly personally and philosophically opposed but hiding behind the “science” banner? Because I’m bringing you the science and most of you are just saying its worthless when I know you’re not reading it. Also, where is Dr. Homola? He’s like the polkaroo, never here when I’m here!

    Regards,
    NMS-DC

  59. nybgrus says:

    always entertaining.

    And Quill is spot on. There is a definite fundamentalism in the chiro attitude on top of a very poor understanding of science (at least as to how it translates on a clinical level).

    Notice that I asked for any actual clinical studies demonstrating that any specific chiropractic technique actually works for any specific pathology. What have we gotten in response? A lot of basic science studies, cell culture articles, and animal model studies. Nothing that has any bearing on what chiropractic actually is or how it relates to a clinical setting. Of course, to these chiros, that somehow is reasonable to extrapolate out, including NMS-DC telling me angrily that he he can prevent osteoarthritis if only my dogma didn’t prevent me from sending him patients.

    The only exception is some data for chronic lower back pain. Which is easily and adequately explained as a massage coupled with some placebo effects. When all you have is bench science level stuff and acupuncture/homeopathy level clinical evidence for one condition… you aren’t really making a good case for the utility of chiropractic.

    Hell, even if one was to grant that chiropractic is the most amazing thing to have ever happened for chronic low back pain… that’s all you have! Somehow the notion of a 4 year post graduate degree where the ONLY skill you have is to alleviate ONE condition seems… out of proportion.

    So no, nwtk2007 – it isn’t an ideological bias we have. It is that your side of the table can only bring the same worthless data. We can be consistently derisive because you are consistently failing to provide anything compelling. Just because you can throw a mountain of garbage at us, doesn’t make it impressive. It just means we a mountain to say is garbage. The fact that you consistently think your evidence is actually evidence for chiropractic is the ideological bias. All of the commentary and argumentation from your side of things is exactly like any other pseudoscientific or ideological denialist. Just change a few words and I may as well be debating a creationist, AGW denialist, anti-vaxxer, or theistic apologist. And that includes the fact that in each case, they will accuse us of being dogmatic. It isn’t dogma if it is correct. That would be like saying that my chemistry professor was dogmatic because he insisted that you must balance electrons in redox equations. No matter how many times I came up with an answer different than his, he would just never accept that he had a dogma. He just always insisted that those darned electrons had to be balanced. Boy, what an ideologue.

  60. NMS-DC says:

    @ntwk2007

    Yeah, there’s a lot of individuals here who masquerade behind the science, but only science they like and agree with. Science is like music, many different “genres”. These guys here, as a metaphor, like jazz and classical. We like rock and roll and blues. They say that that our rock/blues sucks and is “bad” but it’s just not their taste in music. Because they don’t like it, naturally, they don’t study it, and aren’t truly informed about it.

    I’m not a big fan of jazz, SBM but I know it’s a legitimate form of music and I won’t go around bashing it. You would be wise to offer DCs and other physical based health professions the same courtesy. We know you don’t like it, and definitely know you don’t understand it (because most of you truly don’t care to) but to say it’s all a house of cards in 2011? You have to lay off the kool-aid.

    And this nonsense about “true believers”. Belief is based on faith, like a religion. It does not change, it does not waver, it is static, it is dogmatic. That reflects SBMs position. Understanding is based on science, it changes based on the evidence, opinions are refined and evolve as the literature progresses. The chiropractic literature has progressed substantially the last 15 years (30 overall) and yet SBM maintains a dogmatic stance and calls the DCs willing to debate them here as “dogmatic and religious”. Truly ironic. And trolls like Quill and JPZ are white noise who have 0 medical background, so jhawk, nwork2007, don’t bother feeding the trolls. Jann, Dr. Bellamy at least try to ask pertinent questions at times. They’re worthy of our response and time.

    NMS-DC

  61. NMS-DC says:

    @nybrygus

    “telling me angrily”

    Another lie and misrepresentation on your part. Also, a straw man fallacy, tu coque, and appeal to authority all in one post.

    Also, another lie about level of SMT being = for homeopathy and acupuncture. But then again, you lost all credibility last week when I, in detail, showed SBM your lies, flawed logic and misrepresentation of other posters arguments. And you’re doing it again.

    Conflating yet again, now talking about electrons, theists, and so on. Red herrings. You never stick to the topic do you? Did you somehow miss the fact that SMT and manual therapies is also good for neck pain? So basically SMT is good for the mechanical spinal problems.

    Gee, given that 80% of adults will experience a debilitating case of neck/back pain then you can see why having DCs in the health care system is a good idea. After all dentists only deal with teeth. After all, it’s only your spine. More trivialization by you who is an elitist, cocky, arrogant and poorly informed STUDENT. You have no real world work experience. You are still a puppet on strings, nybrugus. Go jump through your hoops, get 5 years of clinical experience and then come back and talk to us. Real world practice is rewarding and humbling. Soon you will see not everything follows the textbook and you’re going to have a number of cases where your skills won’t be able to “cure” or “releave” their suffering. Then you fill truly find your way after getting humbled a bit and be a better doctor. But right now, your cockiness and extreme self-assuredness is a potential for a big downfall. It’s OK to be confident. But to misrepresent your opponents statement at every turn? Disgraceful.

    NMS-DC

  62. NMS-DC says:

    @BlueWode

    Supply and demand will always come into effect with respect to #s of DCs being graduated. The number dropping is not a bad thing in my opinion, it’s addition by substraction, clearing the dead wood out of the profession. I don’t think it’s a fluke either that it was a straight/subluxation-based school that closed down in the US this year.

    Your study re: the future of chiro is outdated (2005) and it’s again, US-centric. The rate of the Canadian population seeing DCs has raised to 15% presently (up from 10 percent a few years ago) with a regional high of 20% in Alberta. 50% or Canadians have sough chiropractic treatment at some point in their lives.

    There are also numerous chiropractic schools opening internationally, in public universities. The most recent ones in France, Brazil, South Korea, Switzerland, Spain, etc…

    DCs in Ontario, Canada are now involved in 10% of community family health teams. DCs are part of pilot projects of working in the ER in Toronto, handling the MSK cases that go to ER. DCs/PhDs are in every province now in at least one university. DCs are expanding their coverage in the US Military Department of Veterans Affairs. Do not delude yourself Blue Wode that the chiropractic profession is going downhill. It’s evolving and transforming from a fringe player in health care, to having one foot in the door at present time and the trend it towards integration. This decade will be the the tipping point. Of course, I was laughed off this board in 2006 when I claimed I was an EBM chiropractor. Now, there’ no denying that EBM movement within chiropractic. Research will continue to demonstrate that DCs have a specific expertise in MSK diagnosis and management, that DCs have a specific expertise in SMT and manual therapy as well as other conservative therapies for MSK management and that DCs in the health care system is is cost-effective and that patients are more satisfied with DC care for their spinal problems than any other practitioner.

    NMS-DC

  63. nybgrus says:

    Science is like music, many different “genres”. These guys here, as a metaphor, like jazz and classical. We like rock and roll and blues. They say that that our rock/blues sucks and is “bad” but it’s just not their taste in music

    And that is your most fundamental error. No, there are not “different genres” of science. There is one standard, and chiropractic fails to meet it. Period. This “different kinds of medicine” dichotomy is rank and utter buls***t. If you can’t understand why your analogy is unequivocally and wholly incorrect, then you’re done already. Figure that out first and then you have a chance.

    Another lie and misrepresentation on your part. Also, a straw man fallacy, tu coque, and appeal to authority all in one post.

    Really – cuz here you 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. 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.

    and then when I asked you for proof of that assertion you said:

    Chiropractic medicine does not cure or prevent diseases

    But clearly I’m the loon here.

    But then again, you lost all credibility last week when I, in detail, showed SBM your lies, flawed logic and misrepresentation of other posters arguments. And you’re doing it again.

    Seems to me I’ve lost nothing. You really are the Black Knight. And I’m not doing anything again. I’ve no need to destroy your silliness… again. I’ve made my point, and everyone here except for the chiros can see it quite clearly. But you keep telling yourself whatever you need to sleep well at night.

    Conflating yet again, now talking about electrons, theists, and so on. Red herrings.

    Do you even know what a red herring is? Or what the word “conflate” means? You are implying that my discussion about those topics is directly pertinent to the “evidence” presented for chiropractic. It’s called an “analogy.” I am likening the discussion to those other topics – i.e. drawing a paralell. Your mastery of the English language and its use in discourse leaves me quite underwhelmed.

    Did you somehow miss the fact that SMT and manual therapies is also good for neck pain?

    Actually I have yet to see any evidence that supports that claim and have, in fact, seen a few posted up here that directly refuted it. So no, I am really not missing anything at all.

    More trivialization by you who is an elitist, cocky, arrogant and poorly informed STUDENT. You have no real world work experience.

    So the guy who claims I appeal to authority, then tries to win an argument by denigrating my status as a student. And on top of that making assumptions that not only have no basis, but are also completely untrue. I worked for 4 years as an EMT, critical care tech, ortho tech, and surgical tech at a level 1 trauma facility. I’ve assisted in numerous procedures and interventions, done my fair share of chest compressions, scrubbed in and assisted in surgeries, and used to teach the splinting, wound care, and patient restraint classes for our quarterly hospital skills days.

    Do I have experience working as a doctor? No. But neither do you.

    Soon you will see not everything follows the textbook and you’re going to have a number of cases where your skills won’t be able to “cure” or “releave” their suffering. Then you fill truly find your way after getting humbled a bit and be a better doctor

    Ah yes, yet another religious style appeal. Wait till your life gets bad and your are on your death bed then you’ll find god! In this case though it is, wait till you get into the real world and see the suffering of patients and then you’ll think my woo looks better!

    Sorry mate, but I have seen real suffering. And I have also seen how to use caring and compassion to ease it. I’ve seen how those placebo effects come into play. And I know enough science to realize that is pretty much all you have to offer, wrapped up in a nice show with some lies and tenous bench science to try and lean on.

    It’s funny but the top entry on Prometheus’ “You might be a quack if….” post today is on Chiropractors. Sure seems to fit the bill nicely.

    But right now, your cockiness and extreme self-assuredness is a potential for a big downfall. It’s OK to be confident

    You can’t win with any actual science, so you have nothing but ad hominem to toss out. That’s fine – as I said, I’m not debating with you scientifically anymore because taking candy from a baby gets boring after a while. But at least stick to ad hominem you can back up. You don’t know me. At all. And you are confusing my strictness with rigor and adherence to reality with cockiness and self-assuredness. That couldn’t be farther from the truth. I know I am fallible and downright scared because I know that I will NEVER know enough to never make a mistake. And I know that those mistakes will harm people and probably cost someone their life at some point in my career. So unlike you guys who are content to say your patients seem happy leaving and that’s good enough for you, I need to actually do my best to find out what really works and how safe it is on a clinical level. I’ll make mistakes, but my characterization of chiropractic and the fact that I will never refer a patient to one (without drastic changes in what it means to be a DC) is not one of them. And I’d certainly never refer to you.

    But to misrepresent your opponents statement at every turn? Disgraceful.

    No misrepresentation here. But it must be getting through to you. As a theist or creationist learns their dogma is total BS and begins to move away from it, it is always met with rank and outward hostility. Nobody likes to be proven wrong, even on little things. But when it is your entire career, years of you life, and a decent chunk of change for your education that you then find out is built on nothing but vapors of science and mere whisps of reality, that is understandably gut wrenching and emotion provoking. I feel bad for you, but I’m not about to accept chiropractic as anything more than BS built on pre-scientific thought that has occasionally and accidentally gotten a couple of small things right.

  64. Quill says:

    Ah, NMS-DC. Your writing makes you seem overwrought especially with all those juvenile and irrelevant personal attacks. Wither your lofty senses? Your humility from so many years of “real-world practice”? You moralize like a jilted sophomore divinity student and wish so much suffering on a person you’ve never met, a random poster on a internet forum. Boggles the mind to think what you’d wish on people you actually know. Like patients?

    Probably should start at the beginning, though. So here:

    Science (noun): the intellectual and practical activity encompassing the systematic study of the structure and behavior of the physical and natural world through observation and experiment.

    Ought to contemplate that before you get around to answering all those questions from Jann that you repeatedly said you would. Sometime, of course, when you’re not so busy typing hundreds of words to other people who you claim have no credibility. (Maybe have a peek at your priorities, too?)

  65. pmoran says:

    NTK, are you trying to say that chiropractors are not biased in the way THEY interpret the research? That would be a miracle. You have far more invested in the issues than anyone here.

  66. JPZ says:

    Actually, I was quite interested to look at the cell culture-based studies about fibroblasts and different models of strain and stress. It seemed like a very interesting and serious attempt to ask whether certain cells respond to different models of stress/manipulation. I would also like to see the data from these studies applied to in vitro tissue models, animal models (if appropriate) and, ultimately, to take mechanistic data derived from these studies and test hypotheses in well-controlled clinical trials. Are there examples of these scientific links in the chiropractic field?

    @NMS-DC

    “And trolls like Quill and JPZ are white noise who have 0 medical background, so jhawk, nwork2007, don’t bother feeding the trolls. Jann, Dr. Bellamy at least try to ask pertinent questions at times.”

    Nice. 1) Ad hominem attack, and 2) I went to medical school too, i.e. deductive fallacy. And, since Jann is an attorney, you actually don’t believe it matters for people to have a medical background to be credible unless it serves you for an ad hominem attack. In fact, I lead GCP/ICH-compliant RCTs that do and have created new clinical standards and guidelines – I guess that isn’t “medicine” as much as it is forging new medical concepts out of the uncharted areas of basic health sciences (ok, ok – that one was me waxing a little too poetic). In just two sentences, you have shown yourself to be judgemental (of my background), inconsistent (in what standards you place on the background of people who can question you), and combative (via ad hominem attacks). I actually don’t know much of anything about chiropractery, and I freely admit it. As I have said in earlier parts of this thread, I am mostly listening and learning – well, less so when nwtk2007 started playing his/her “video game” with the comments on this thread (which I am a bit surprised that you and the other DCs didn’t ask him/her to stop as s/he was really undermining any productive discussion). And, while I am more than happy to listen and learn, how did you earn yourself credibility by being judgemental, inconsistent and combative? Again, this observation is totally divorced from any opinion or mention of chiropractery. This is about how you are presenting yourself as well as your personal opinions about other commentators.

  67. JPZ says:

    @Quill

    “You moralize like a jilted sophomore divinity student and wish so much suffering on a person you’ve never met…”

    ROTFL! A friend of mine was a divinity student, and he used to make the most hilarious observations along these lines. +5 funny.

  68. pmoran says:

    It’s not bias. There are key differences here that can be easily summarised.

    1. Chiropractors pay insufficient heed to the powerful illusions that can create an impression of treatment efficacy (over placebo) in daily medical practice and that also tend to leak through into clinical studies. Beliefs should be tempered with that knowledge.

    2. It is very difficult or impossible to create a credible laboratory model for some procedures and imputed medical outcomes. Conventional medical science is itself riddled with misuse of various animal and test tube models and that is not going to be better tolerated from chiropractic researchers.

    3. Weak evidence is tolerable only if the claims are proportionately cautious. Good science it littered with tentative statements and qualifications: “the evidence suggests” — “under these conditions”.

    We don’t see this from chiropractors. On the contrary, we see prejudgement of what the science is expected to show. That is a sure sign that there will be confirmation bias in the treatment of the evidence, and paranoia whenever it is held not to show what is desired.

  69. Blue Wode says:

    NMS-DC on 09 Nov 2011 at 11:38 pm wrote: “Your study re: the future of chiro is outdated (2005) and it’s again, US-centric. The rate of the Canadian population seeing DCs has raised to 15% presently (up from 10 percent a few years ago) with a regional high of 20% in Alberta. 50% or Canadians have sough chiropractic treatment at some point in their lives.”

    Fair enough, but I’d be more interested to know the current figures for the US (which has a significantly larger population).

    NMS-DC on 09 Nov 2011 at 11:38 pm wrote: “There are also numerous chiropractic schools opening internationally, in public universities. The most recent ones in France, Brazil, South Korea, Switzerland, Spain, etc… ”

    I would venture that those new schools owe their existence to lazy academics (shruggies) and duped legislators. On the subject of academic sloppiness, the following is lifted from a 2009 chiropractic paper:

    Quote
    “…perhaps the entire profession of chiropractic is a ‘bizarre fiction’ with no substantive grounding. If so, what is the basis for anyone being a chiropractic academic? In writing this paper the content preceding the point was shared with an academic colleague of the writer. The colleague is a learned man with qualifications in chiropractic and philosophy and suggested the writer should stop wasting time and simply accept that the subluxation exists.”

    More from the same paper:

    Quote
    “Inspired by a visit to Disneyland this paper explores the challenges associated with the need to teach something that may not exist.”

    Quote
    “…as long as we lack a technological means to generate quantitative evidence of the subluxation and its effects on human function, there is little option other than to rely on an intelligent use of language within a true context of philosophy to encapsulate the discipline’s beliefs.”

    Quote
    “…it matters not whether the subluxation is a tangible clinical entity with physical dimensions or a mental creation; what does matter is that the statements used to describe it are in themselves true.”

    [Ref. Ebrall, P. Towards Better Teaching about the Subluxation Complex, Chiropr J Aust 2009, 39: 165-70.]

    It’s worth noting that despite the concerns highlighted in that paper, its author, Phillip Ebrall, the former Head of Discipline, Chiropractic, Royal Melbourne Institute of Technology (RMIT), is now setting up a ‘Bachelor of Science’, chiropractic degree at the Central Queensland University (Mackay) due to commence 2012.

    NMS-DC on 09 Nov 2011 at 11:38 pm wrote: “DCs are expanding their coverage in the US Military Department of Veterans Affairs.”

    True, but you forgot to mention that access to chiropractic care in the Veterans Administration (VA) and Department of Defense (DoD) is by *medical consultation or referral only*.

    NMS-DC on 09 Nov 2011 at 11:38 pm wrote: “Do not delude yourself Blue Wode that the chiropractic profession is going downhill.”

    Are you sure that I’m the one who’s deluded? Apparently the future for ‘evidence based’ chiropractors in the US will mean following:

    Quote
    “Doctors of physical therapy (DPTs) are being positioned as the providers of musculoskeletal care, including diagnosis and manipulation. If DCs agree to be limited to caring for patients with musculoskeletal disorders, they can anticipate having the rug pulled out from under them by DPTs.”

    http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=55623

    To me, that points to a definite downhill trend.

  70. nybgrus says:

    The day these chiros stop citing bench science work and claiming that translates to actual clinical medicine… well, obviously that day won’t happen.

    NMS-DC just doesn’t seem to comprehend how incredibly weak his “evidence” is. I think he genuinely believes that one can actually take that kind of data and extrapolate it out to chiropractic. You can’t NMS-DC. And that’s not just chiro. NOBODY can claim clinical medical effects from the kind of evidence you are putting forth. No medical doctor would DREAM of doing so (as Cowy pointed out as well). It simply doesn’t work that way.

    http://saveyourself.ca/articles/fascia-contraction.php

    There’s on tiny example why.

    So when you say you have evidence for chiropractic and you think that citing a heap of pubmed articles will do it, you fail to realize they have to be the RIGHT KIND OF DATA. Not just any old experiment will do. Not because the experiments are bad. But because they simply do not apply on a clinical level. You have exactly bupkiss.

  71. @nybgrus, we should forget Wakefield and his type. Perhaps ‘no GOOD medical doctor…’

  72. JPZ says:

    @nybgrus

    “The day these chiros stop citing bench science work and claiming that translates to actual clinical medicine…”

    I guess that is part of the rub with me about this discussion. I work in industry, and each scientific discovery has to justify further investment balanced by risk:benefit ratios. If I portray an in vitro result as leading to an incredible product claim without pointing out that the odds of getting that claim are 1:10 to 1:20, I would be discredited several times a year. That is more “managing expectations” than SBM, but I think the underlying principle applies – over-extrapolating data just gets you into trouble.

  73. nwtk2007 says:

    It is true that the “evidence” for the chiropractic subluxation is weak but chiropractic is not just subluxation based, just as medicine is not just drug/disease based. Chiropractors do all forms of physical medicine, some supported by evidence more than others. We also do functional capacity evaluations, disability ratings, physical performance testing, work conditioning, work hardening, etc, etc and we are very well trained for it, again, some of us better than others. The myopic view of chiropractors as all treating patients with a subluxation based form of care is just plain silly.

    It is amazing though, how well versed Blue Wode is on Chiropractic, as if he/she has some personal vendetta to wring out against the profession. He/she might be a bit happier if he/she got a life. Maybe go into the ministry or start selling shoes or something.

  74. we shouldN’T forget Wakefield. Damn, I could not type a correct post to save my life…

  75. NMS-DC says:

    nybrygus

    SBM claimed there was no biological plausibility to SMT and joint dysfunction. And I’ve shown the basic science behind these in spades. Interesting how not once, no one has called it psedoscience. Just “bad science” or backwards science. I guess it’s still progress.

    Also, you asked about clinical studies and they’ve been done in spades for the last 30+ years regarding effectiveness of SMT and manual therapy. So, we’ve covered that topic as well.

    You’re (again) misrepresenting my argument. You asked for evidence of basic sciences research by chiropractic scientists and I’ve provided it. Then you asked for biological plausibility of SMT and joint dysfunction. I provided it.
    So, at this point, what exactly are you looking for? I’ve already proven my main arguments that I began in Jann’s previous “The Cure” post

    1) DCs are well trained for MSK management and diagnosis
    2) There is evidence of effective and cost effectiveness for DC management of MSK
    3) There is basic science research into the biological mechanisms of SMT and joint dysfunction/subluxation.

    That’s all I claimed and it’s what I’ve proven. Your arguments which center around PCP issues, and “backwards science” wasn’t my argument at all so you’ve essentially been diverting us away from the my original post was about: Validity of chiropractic care for MSK and the fact that there is good basic sciences research being done by chiropractic scientists. I’ve established both those facts.

    NMS-DC

  76. JPZ says:

    @NMS-DC and everyone

    “Also, you asked about clinical studies and they’ve been done in spades for the last 30+ years regarding effectiveness of SMT and manual therapy. So, we’ve covered that topic as well.”

    I was going to ask NMS-DC about where s/he posted clinical trials in this thread, but I thought I should go through and scan the thread for them before I asked. Then I came across NMS-DC’s link to the Canadian Memorial Chiropractic College’s research pages (which I had never checked), so I thought I would give it a look (cue Halloween screams). I don’t know much about chiropractery, but I like to think I know a thing or two about good vs. bad science. I opened up the 2006-2009 research report (http://www.cmcc.ca/Document.Doc?id=57) and scanned briefly through it.

    There is a lot of what looked like valid research going on there, and many of the hypotheses sounded quite interesting. But, much of the research is on imaging, biomarkers, anatomical characterizations, in vitro models, animal models, devices (for back support, etc. – very nice and very practical research by Kim Ross), i.e. almost nothing on the actual techniques of chiropractic intervention (again, I know almost nothing about these techniques so I had to test the info based on whether I learned anything about chiropractic technique from the section).

    But, there is a researcher by the name of Howard Vernon who is trying to develop a sham control procedure for use in studies of chronic neck pain. Kudos to him, and, while I have no idea if he can do this or if it will work, it at least sounded like a serious attempt to improve experimental rigor.

    Next, I looked at the publications list just to get a feel for what gets published from all this work. Again, much of the research was on opinions, systematic reviews, teaching methods, case reports, and pilot studies – not really all that substantial from a scientific viewpoint. Then I came across this RCT:

    http://www.ncbi.nlm.nih.gov/pubmed/16341712

    Which does a side-by-side comparison of a DC and a PT method for lower back pain (yes, yes I know this kind of evidence has already been dismissed by commentators as “we already knew that”). It is not a bad study. The little birds will not fly down from the trees to sing to me as I read it like some Disney-esque nightmare, but its not bad (based on my limited understanding of… well, I said that a few times already).

    “So, at this point, what exactly are you looking for? I’ve already proven my main arguments that I began in Jann’s previous “The Cure” post.”

    Um, not really – at least not to me. I think the advice I gave you in “The Cure” could be summarized as – you aren’t answering the question you were asked, you are answering the question you want to answer. It took me 10 minutes to find out that CMCC does some decent quality science, has someone working on better experimental controls for chiropracteric clinical trials, and has published at least one decent study (there may be many more for all I know, I only gave the list a quick scan). You could have cut through all the discussion of subluxation, PCPs and whether you feel you are getting enough respect by presenting some concrete examples like this (I’m sure you know many more than I do) and saying that it is evidence of how things are changing in chiropractery from your perspective.

    I really have no motivation or interest in sticking up for your views, honestly. I am a scientist, and data carries the day in the end. Just stop insulting people.

  77. NMS-DC says:

    @JPZ

    CMCC does very good science as does UQTR, both Canadian, both scientific schools of chiropractic. You have to understand that is my whole perspective of being a DC is based on evidence-based chiropractic. My clinical education which can be seen here in its entirety (for courses and course descriptions).

    http://www.cmcc.ca/Document.Doc?id=861

    The faculty is from many disciplines and many MDs. The diagnosis and symptomatology courses, pathology courses, anatomy courses, neuroscience courses etc.. are all taught by either MDs, PhDs, MD/PhDs or DC/PhDs. That is what separates “contemporary” chiropractic schools from subluxation-based ones (they have no MDs and no PhDs on staff). The research base is solid and growing fast now, with a lot of cross appointments and many collaborations with universities in Canada and and around the world. Scholarly pursuit in modern chiropractic is real and it’s not pseudoscience. I think I’ve proven that time and time again, much to the dismay of certain SBM posters.

    Subluxation-based chiropractic is dying; because it’s premise is unsustainable and it refuses to adopt mainstream scientific research agenda which is the only way to move ahead in EBM. Blue Woode may be right in the US chiropractic may shrink, but it’s because it presents 2 models to the public and has 2 national associations (ICA, ACA) whereas the majority of the chiropractic, in countries outside the US have 1 national association and are committed to pursuing scientific chiropractic. Heck, even Palmer is doing some good research, RCTs and all:

    http://www.palmer.edu/Research/

    And this is supposed to one of the “straight”, quacky subluxation-based schools. Palmer is a decent research agenda even if they use traditional chiropractic language at times, but they still are talking about “spinal manipulation” and not “chiropractic adjustment” being synonymous which was one of my main arguments. Semantics like “adjustment” and “subluxation” are really just “spinal manipulation” and “joint dysfunction”. And they do go hand in hand (no pun intended) and Jann’s title of “Spinal Fusion: Chiropractic and Subluxation” is technically correct. But just not in the nutty way he thought.

    More research agendas from chiropractic schools:

    http://www.aecc.ac.uk/research/home.aspx
    http://www.nuhs.edu/research/current-research/
    http://www.nwhealth.edu/research/publications/

    And on, and on.

    Chiropractic science.

    NMS-DC

  78. pmoran says:

    SBM claimed there was no biological plausibility to SMT and joint dysfunction.

    Plausibility is pertains to specific medical claims, so that does not sound like anything that any SBM type would say. “No plausibility to joint dysfunction” does not even make sense.

    There is no basic implausibility to SMT as a treatment of acute LBP. There is a lot when it is advocated as a treatments for infantile colic and earache.

  79. nybgrus says:

    agreed. NMS-DC can’t even follow his own argumentation.

    We argued that chiropractic is still predominantly governed by the notion of subluxation as the origin of disease (and that indeed licensure of chiropractors included specific sections on exactly the disproven “version” of subluxation theory). That was demonstrated to be true.

    We argued that the use of the word subluxation was ambiguous, and in many cases intentionally so. That was demonstrated to be true.

    We argued that the existing education of and guidelines for practice of chiros was vague, and did not preclude the teaching of the disproven subluxation complex. That was demonstrated to be true.

    We argued that there have been no robust trials demonstrating the utility of any specific chirpractic technique for the alleviation, prevention, or cure of any disease or pathology. With the exception of weak data on par with that of acupuncture and massage for chronic LBP, that was demonstrated to be true. (Well, at least no chiro has been able to proffer such data).

    Now, nobody here, myself included said there is no basic plausibility to manual therapy for MSK disease. We said that there was no plausibility for the type of subluxation theory commonly taught in chiropractic schools as demonstrated by both myself and Jann. We further argued that basic clinical sciences provide the plausibility which we have already admitted but simply do not translate to actual clinical practice and outcomes.

    I have also argued that because of the ambiguity and heterogeneity of chiropractic education and licensing guidelines, coupled with the obvious inclusion of the disproven version of subluxation theory as required material in school and tested on the licensing exam that, as a whole, chiropractic cannot be trusted as a portal of entry or primary care physician. I have freely admitted before that a specific chiropractor may be able to function well enough in those roles. But based on the evidence, the default assumption when anyone presents with the letters “DC” after their name, the assumption must be they cannot.

    I have further argued that the actual evidence base for chiropractic is very narrow and slim at best – hardly anything to base an entire 4 year post-graduate degree on. That has not been demonstrated false.

    I have further argued that chiropractic in general engages in bas science because there is a consistent push to use bench science data as evidence for existing treatments and therapies. In other words, you are taking something that is already in clinical practice, which has no established evidence base for efficacy, safety, or even that it is treating an established pathology and then using bench science not as a mere demonstration of plausibility</i< but as evidence for the efficacy and validity of said clinical practice. In short it is taking a conclusion and finding evidence to support it – the very definition of bad science.

    So that in no way demonstrates:

    1) DCs are well trained for MSK management and diagnosis
    2) There is evidence of effective and cost effectiveness for DC management of MSK
    3) There is basic science research into the biological mechanisms of SMT and joint dysfunction/subluxation.

    any of that.

    Perhaps with a reboot of the conversation, something more productive can come about. I don’t have the time to go over the links that JPZ commented on, but based on our history I’ll take his analysis as tentatively accurate. In which case I am happy to laud that apparently small cadre of chiros who are actually doing a bit of real science to try and demonstrate actual utility. However, I must point out that such utility is still not demonstrated. If you have more along those lines to contribute then please do NMS-DC. But continuing to be vague about terminology, claim that of course chiropractors don’t believe in subluxation theory in the face of staggering evidence otherwise, cite bench science as evidence for clincal therapy, and use appeals to authority like the WHO guidelines as evidence is not a winning tack.

  80. nybgrus says:

    @michele:

    Well, Wakefield was outright fraud motivated by money. But I do see your point. Yes, no good medical doctor would. We see examples like Chopra, Weil, Ornish, and Oz (the four horsemen of the CAMopalypse?) that demonstrate that handily.

  81. JPZ says:

    @nybgrus

    “I don’t have the time to go over the links that JPZ commented on, but based on our history I’ll take his analysis as tentatively accurate.”

    As I said, I may be the least competent evaluator of chiropractery here. And one can easily dismiss minutia like an investigator at CMCC who looks at IL-2 release from cells harvested after a chiropractic procedure. As someone trained in immunology, I can say that IL-2 release assays cannot be interpreted as a benefit or a harm. I mentioned what I saw, and since that was a 2006-2009 report and this is nearly 2012 – it might be useless or proven, I don’t know. But, in terms of apparent intent, I like the three lines of research I mentioned. But, for humor’s sake, I think that reading a 3 year report on research from an institution is like looking at the cheerleader line at a (American) football game and judging the teams performance in the last three years based on their physical excitement about their team. Many apologies if I insulted any trustees here (but I am going to guess that a few of you winked, shame on you for being within 1 SD of the norm). I’ve done a few “research updates” for these reports, so I may have become cynical.

  82. nybgrus says:

    As I said JPZ – I take it tentatively and am happy to extend credit where it may be due. It really doesn’t fundamentally change anything about my argument.

    But if you say the science they were trying to do seemed legit and was looking at generating some kind of study model that could lead to a clinically useful outcome, then I am happy to take that at face value for now (since it comes from you). I’ll laud them for the effort, though as I pointed out it is extremely preliminary to base an entire field on. A field, btw, which has existed for 116 years and is only now attempting to actually prove the validity of its methods and therapies. Remind anyone of anything else? Acupuncture perhaps? Just sayin’

  83. nybgrus LOL, CAMopalypse.

  84. pmoran says:

    JPZ: http://www.ncbi.nlm.nih.gov/pubmed/16341712

    Which does a side-by-side comparison of a DC and a PT method for lower back pain (yes, yes I know this kind of evidence has already been dismissed by commentators as “we already knew that”). It is not a bad study. The little birds will not fly down from the trees to sing to me as I read it like some Disney-esque nightmare, but its not bad (based on my limited understanding of… well, I said that a few times already).

    Actually, JPZ, this is an inherently weak study and the results are not clearly indicative of anything. http://www.ncbi.nlm.nih.gov/pubmed/16341712

    NMS-DC can regard it as “good research” because it appears to support one form of spinal manipulatiive therapy (are flexion-distraction methods even common in chiropractic? — I have not heard DCs refer to them much – is this a variant of the usual HVLA?).

    However, being an unblinded non-sham study performed at a chiropractic institution it is not strong evidence of treatment efficacy. Placebo responses and reporting biases are possible, multiple outcomes were looked at, and the results are also not intelligibly consistent within the subgroups analysed.

    Of course, how you view this study depends upon what hypothesis you think it is testing. The SBM approach will be to always dismiss such studies as too weak to mean much, because intrinsic efficacy is mainly what matter to us/them. If, however, you are asking “which approach will produce the more satisfied clientele?” then that hypothesis IS supported at least under the conditions that applied to this study. If you are asking “will either approach get patients back to work quicker?” then even the results of this study don’t seem to support that, as there was no difference between the groups in measures of back function.

    Note how the implications of this single study vary greatly depending on the claim that is being tested (why I have been trying to get the DCs to be much more precise with those)?

    It is vital that chiropractors understand all this as they plan their future, as the whole future of their profession hangs, in part, on what precisely their methods do. As health purse strings tighten further and further it will obviously be the weaker, more disposible modalities that will be dropped off first.

    I think NMS-DC is semi-delusional in his optimism regarding the future for DCs, unless, by some miracle, chiropractors drop chiropractic ideology totally and are then able to compete successfully with physical therapists. There are other options, but they pose nearly as many difficulties.

  85. Scott says:

    Here’s something I’ve wondered about. Suppose one presumes that chiropractors abandon the subluxation concept entirely. What else do they bring to the table that is unique or specific to chiropractic?

    If the answer is “nothing,” what would be the rationale for the continued existence of the profession? The “reformed” chiropractors themselves would presumably wish to continue using the degrees they have, but why should any new chiropractors be trained?

  86. nybgrus says:

    @Scott:

    Exactly what I have been arguing as well. Pmoran has taken time that I have not had to read and explain the inherent problems with each bit of “evidence based practice” that has come forth. However, my general null hypothesis, that the armementarium of chiropractic that does actually have clinical efficacy worth adopting is very narrow has yet to be rejected.

  87. jhawk says:

    @Jann Bellamy

    you said: “1. define the “manipulable lesion,” “joint dysfunction,” “subluxation” (as the terms are currently used) and list what other names chiropractors call it. I am hearing that they are the same thing but I could be wrong. If not, what is the difference?”

    The ACA defines subluxation as a motion segment, in which alignment, movement integrity, and/or physiological function are altered although contact between joint surfaces remains intact. There are many terms that are synonomous with subluxation such as manipulable lesion, joint dysfunction, joint restriction, joint fixation, intervertebral dysfunction, somatic dysfunction, joint blockage, segmental dyskinesia, vertebral subluxation complex, osteopathic lesion. They are all the same thing.
    ACA website: http://www.acatoday.org/level2_css.cfm?T1ID=10&T2ID=117

    you said “2. explain how to diagnose the manipulable lesion/joint dysfunction/etc.”

    You must have pain/tenderness, asymmetry, range of motion abnormality (global or local) and/or tissue texture change. Book: Rehabilitation of the Spine 2nd edition. Craig Liebenson, pg. 488-489. Well respected and required text in the chiropractic school with contibutions from many areas of manual medicine (PT, DC, MD, PhD) and including but not limited to Pavel Kolar, Vladimir Janda, Stuart Mcgill and Karel Lewit.

    you said: “3. explain the clinical significance of the manipulable lesion/joint dysfunction/etc. — i.e., when you diagnose it, what does that mean re: the patient’s health?”

    It means the patient is in pain and has decreased ROM which effects their activities of daily living.

    4. explain the therapies you use to treat the manipulable lesion/joint dysfunction/etc. and their putative effect on the manipulable lesion/joint dysfunction etc.

    Manipulation/adjustment/mobilization to restore motion, decrease pain and increase activities of daily living.
    It is thought to work by: releasing entrapped synovial folds or plica (meniscoid entrapment), relaxing muscles and breaking up articular adhesions. This info is from the book I mentioned above on pg 488.

    I hope this helps.

  88. Cowy1 says:

    Wonder if that book describes the best way to manipulate the anterior aspect of T2 without picking up a scalpel.

  89. jhawk says:

    @cowy1

    “Bias? They guy thinks he can palpate the anterior aspect of a vertebral body to remove scar tissue and puts up a peripherally (at best) related cell-culture article to prove it and you think I’m biased? You need to lose your bias just cause he’s a chiro and call it what it is; incredibly dumb. ”

    Another misinterpretation and misrepresentation of what I said. First of all, I am not removing scar tissue from the v. body. I am removing it from a muscle that lays on top of the v. body (longus colli). Your argument that 2 muscles (platysma, scalenes) and fascia would stop this palpation is ridiculous. How about the upper posterior rib cage which has fascia and 4 muscles (trap, rhomboids, serratus post. sup, erector spinae) in the way before you can palpate the ribs. Can you not palpate the posterior rib cage?

    The cell culture study was posted to Marcus as he was implying that myofascial release (MR) does not have a histological response to scar tissue. This study mimics MR in vitro and shows a cellular response. Nothing else. Obviously this is not generalizable to the rest of the population but it is interesting and will hopefully lead to future research.

  90. jhawk says:

    @cowy1 and marcus welby

    I think this study is what you were asking for in a previous post. http://www.ncbi.nlm.nih.gov/pubmed/3343953

  91. jhawk says:

    @ Cowy1

    “Wonder if that book describes the best way to manipulate the anterior aspect of T2 without picking up a scalpel.”

    Nope. The frist rib is in the way.

  92. Cowy1 says:

    @jhawk

    Maybe I should be more clear; you are not directly palpating anterior vertebral bodies (or upper posterior ribs). You are palpating the tissues above them in a fashion similar to a masseuse; claiming anything else is a delusion.

    Semantics aside, your hypothesis is idiotic. If it were even remotely true I’d be able to remove the scar tissue on the back of my hand (from an old football injury) by simply rubbing it away. Well, I’ve been doing that for ~10 years and, guess what, its still sitting there. Actually, if you could just massage away scar tissue why can’t you do it for any organ?

    And if you aren’t removing it where does it go? Dissolve into the subcutaneous tissue?

    And the study you cited sucks; it is 20+ years old (old enough that I can’t get anything more than the abstract through my university) and the authors admit in the abstract that it doesn’t answer the question about interobserver reliability.

  93. JPZ says:

    @pmoran

    “Of course, how you view this study depends upon what hypothesis you think it is testing. The SBM approach will be to always dismiss such studies as too weak to mean much, because intrinsic efficacy is mainly what matter to us/them. If, however, you are asking “which approach will produce the more satisfied clientele?” then that hypothesis IS supported at least under the conditions that applied to this study. If you are asking “will either approach get patients back to work quicker?” then even the results of this study don’t seem to support that, as there was no difference between the groups in measures of back function.”

    Well, that is the disadvantage of my being uninformed about chiropractery, I do get the wrong impression some times. You’ve posted some very detailed discussions on the topic before, so your insights are very much appreciated.

    In answer to your implied question above, I looked at the study from the perspective of a patient who has LBP and wants to know if FD or ATEP is the better treatment. There is no sham control and the study can’t be blinded (which of course introduces lots of biases), but it is randomized (which takes a few biases out). I thought PTs and DCs spent about the same amount of time and attention with their patients, so I assumed that the patient interaction confounder was minimized. I didn’t know how to interpret the back function data (so thanks for your comment on that too), but the reductions in pain were there it seemed.

    So, I guess I just saw the study as one imperfect way of comparing two different treatment modalities, and, accepting its inheirant limitations, there is some data there (just data, not proof). If I completely missed the boat, please let me know.

  94. pmoran says:

    JPZ, ah yes! No problem. For the patient there are other legitimate perspectives.

    They will usually not have any depth of knowledge of the subject, and when eager to find relief from a distressing condition, they will not be too bothered with the niceties of ultra-science. If they find a study suggesting ANY superiority for one affordable treatment over another they will have no incentive to be too sceptical of the claim.

    And the odds are that most will have a happy outcome. They will never know what role placebo responses, reversion to the mean and other aspects of the therapeutic interaction have played. They hardly matter at the level of patient perceptions.

    It is only when you require a more detailed understanding of what is going on, or when cost-effectiveness considerations intrude that we need to dissect things out in more detail.

    I have no doubt that chiropractors are very helpful to some patients. They merely need to have fewer illusions as to why. Basically, medical practice is a breeze when you can select and be selected for the conditions that you will treat. If you have a treatment that truly works a bit, all the better.

  95. JPZ says:

    @pmoran

    Um, that was an odd response. I would prefer to steer clear of the potential illusions of patients. And, I am not even sure what ultra-science is, though there was a movie called “Ultra-Man” at one point.

    This is the second time in the same day that someone on SBM has taken my remarks and portrayed them as equivalent to hocus-pocus. Bloody hell, but I think I do my best to provide a scientific basis for my comments even if I can’t cite them to my satisfaction given the 3 link rule. I hope I have demonstrated that I welcome criticism and thank someone who proves me wrong. I don’t have patience for anyone who can’t support their opinion with science, and I do try to encourage those fumbling around with science they are starting to understand.

    Meh, I don’t mean to sound like a “gloomy gus.” Today (on another thread) was the first time on SBM that I made what I thought would qualify as a series of “science-based” arguments with evidence that got countered with what sounded like an evidence-based dismissal (sorry nybgrus) and an amazing disregard for standardized protocols that I have used myself topped off with a separate high-handed schooling about (what I thought were) unrelated issues (not sorry, Scott Gavura).

    I mean, I am not trying to support magical hand waiving here. I am presenting science that is based on my own experience being the project manager for RA trials and quoting studies as much as this forum allows. But, my own response to their comments got me thinking about the gap between “these are an interesting collection of scientifically cohesive results pointing in the same direction” and “enough RCTs have been done to convince me (based on my personal standard set by my utter dismissal of any nutritional product) that something I don’t think will ever work actually might” (Baysean play understood). Which is more SBM and which is more EBM? I really didn’t realize how far apart those two POVs might be. You know, I play the corporate game where you have to go way beyond evidence to get your funding, but I thought the academic game here was to present the science, and they will come. In my labs, we say “data wins.”

    OK, maybe I am a “gloomy gus” at this hour! LOL Today just introduced a different set of variables about “SBM.” I need to process all of them.

    *cue sequence from the Simpsons where Lisa writes to Washington and gets everyone to work together because “a child is discouraged with government!”* ROTFL – OK, that cheered me up!

  96. pmoran says:

    LPZ: — I looked at the study from the perspective of a patient who has LBP and wants to know if FD or ATEP is the better treatment.

    That is what I was responding to, LPZ. I was thinking of the average patient. I was not questioning your commitment to science. I was not suggesting suggesting that you were favoring hocus- pocus.

    I was merely pointing out that we cannot derive secure knowledge on some matters from that kind of study. That justifies some flexibility for the patient in what they may choose to do.

  97. Jann Bellamy says:

    @jhawk

    Thanks for the additional information and references. I will check these out and perhaps they will lead to another post.

  98. Blue Wode says:

    NMS-DC on 10 Nov 2011 at 10:35 pm wrote: “Subluxation-based chiropractic is dying; because it’s premise is unsustainable and it refuses to adopt mainstream scientific research agenda which is the only way to move ahead in EBM. Blue Woode may be right in the US chiropractic may shrink, but it’s because it presents 2 models to the public and has 2 national associations (ICA, ACA) whereas the majority of the chiropractic, in countries outside the US have 1 national association and are committed to pursuing scientific chiropractic. “

    FYI, in the UK there are still very deep divisions in chiropractic with three of its four chiropractic associations openly supporting subluxation-based chiropractic:
    https://images.vortala.com/chiropractor/England/United%20Kingdom/United%20Kingdom/PP1742_UCA_Assoc_Prem/documents/AUKC_Oct_Newsletter.pdf

  99. Blue Wode says:

    @ NMS-DC

    Also, the Chiropractors’ Association of Australia is blatantly a subluxation-based group:
    http://www.ebm-first.com/images/files/BRETT-KINSLER-INTERVIEWS-JOHN-REGGARS-DC.pdf

  100. Blue Wode says:

    @ NMS-DC

    And then there’s this from the new President of the New Zealand College of Chiropractic:

    Quote
    “The New Zealand College of Chiropractic has a great reputation for supporting vitalism throughout the curriculum, rigorous and innovative academic instruction, and progressive subluxation-based research,” said Dr. Russell. “These competencies that have distinguished the New Zealand College as an academic leader in our profession are very dear to me, competencies that I personally strive to develop and uphold. These characteristics, coupled with a culture of love and certainty are what make the New Zealand College unique and what, quite frankly, made me fall in love with their students, faculty, administration and institution as a whole.”
    http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=55087

    Hardly a sign that subluxation-based chiropractic is dying outside the US, is it?

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