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Subluxation Theory: A Belief System That Continues to Define the Practice of Chiropractic

When I graduated from Lincoln Chiropractic College in 1956, I had come to the conclusion that chiropractic’s subluxation theory, that misaligned vertebrae can cause organic disease, was not true. When I began my practice in Panama City, Florida, I limited my practice to care of mechanical-type back pain and related problems. Back then, that was not too much of a stretch, since manipulative services were not readily available in medical practices and there were a number of orthopedic and physical medicine texts recommending use of manipulation in the treatment of back pain.

In 1963, I published my book Bonesetting, Chiropractic, and Cultism, renouncing subluxation theory and recommending that chiropractic be developed as physical treatment specialty in the care of back pain. The book was reviewed by the Library Journal (February 1, 1964) and recommended for inclusion in medical and reference libraries. In 1965, I received a letter from the American Chiropractic Association (ACA) informing me that my application for membership in the ACA had been rejected. In the years to follow, I published many articles in an attempt to initiate an effort to change chiropractic from a subluxation-based practice to a legitimate physical treatment method that would fit in with mainstream health care. My suggestions were ignored and I was called a “chiropractic heretic.” Today, I find myself still saying some of the things I said in my 1963 Bonesetting book, still being rejected by most of my colleagues and still voicing opposition to subluxation theory.

There are now some chiropractors who do not subscribe to the theory that some kind of segmental dysfunction in the spine can cause organic disease, but they are overshadowed by subluxation-based chiropractors who publish their own journals, using scientific-sounding jargon to defend implausible theories and dubious treatment methods. Some of these chiropractors do not use the “subluxation” word, instead substituting some other vague description of a spinal lesion, such as “joint dysfunction,” alleged to have the same affect on the nervous system and general health as a “vertebral subluxation.”

The Status of Chiropractic Vertebral Subluxation

In the United States, state laws and chiropractic publications define chiropractic as a method of correcting vertebral subluxations to restore and maintain health. A 2010 publication of the National Board of Chiropractic Examiners (NBCE), Practice Analysis of Chiropractic, states that “The specific focus of chiropractic practice is known as the chiropractic subluxation or joint dysfunction. A subluxation is a health concern that manifests in the skeletal joints, and, through complex anatomical and physiologic relationships, affects the nervous system and may lead to reduced function, disability, or illness.” This definition of chiropractic is in keeping with a paradigm formulated by the Association of Chiropractic Colleges (ACC) in 1996, signed by 16 North American chiropractic college presidents: “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.”

When the Council on Chiropractic Education (CCE) published its proposed 2012 Accreditation Standards for chiropractic colleges, reference to the word “subluxation” was omitted. The American Chiropractic Association (ACA) responded, in part, arguing that “The elimination of any reference to this term in the proposed standards will be viewed by many within the profession as a counter productive action that will, in the long-term, likely weaken the profession’s collaborative strength and historical identity.“ The CCE compromised by using the nebulous phrase “subluxation/neuro-biomechanical dysfunction” in the final 2012 Standards in order to satisfy advocates of the vertebral subluxation theory. (An open letter to the profession from CCE, Nov 22-11) Obviously, the factory of the chiropractic profession has not discarded subluxation theory. Chiropractic associations continue to reflect the views of the majority, even if such views are based on a belief system.

At least one recent study by individual academic chiropractors has concluded that “No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention.” (Mirtz, et al. An epidemiological examination of the subluxation construct using Hill’s criteria of causation. Chiropractic and Manual Therapies. 2009;17:13)

Another independent study by academic chiropractors revealed that “Despite the controversies and paucity of evidence the term subluxation is still found often within the chiropractic curricula of most North American chiropractic programs.” (Mirtz & Perle. The prevalence of the term subluxation in North American English-Language Doctor of Chiropractic programs. Chiropractic and Manual Therapies. 2011;19:14)

It will not be enough for chiropractors and chiropractic colleges to substitute such words and phrases as “joint dysfunction,” “vertebral subluxation complex,” and “subluxation/neuro-biomechanical dysfunction” for the word “subluxation” if they continue to imply that such disturbances can affect the nervous system to cause illness. A chiropractic subluxation by any other name is still a chiropractic subluxation.

Real and Imaginary Benefits of Spinal Manipulation

Recent reviews of the literature indicate that manipulation may not be any more effective than other treatment methods in affecting the ultimate outcome in recovery from back pain. For symptomatic relief of uncomplicated mechanical-type back pain, however, use of hands-on manipulation may provide more immediate and dramatic relief by stretching tight muscles and mobilizing the spine. Apart from the misinformation provided by chiropractors who keep asymptomatic patients coming back for correction of “subluxations” alleged to cause a myriad of health problems, many back-pain patients return for manipulative treatment for the symptomatic relief they experience. A competent chiropractor would release the patient when back-pain symptoms have resolved, as opposed to subluxation-based chiropractors who lock their patients into lifetime “subluxation correction” as a preventive measure. Endorsement of the use of manipulation in the treatment of mechanical-type back pain is not an endorsement of chiropractic adjustments used to correct subluxations or some other “joint disturbance” alleged to cause illness or poor health.

In rare cases involving articular adhesions, actual locking of a vertebral joint, or post-traumatic loss of mobility in spinal joints, there is no substitute for appropriate manipulation. Recognizing this, physical therapists and orthopedic manual therapists are now including use of manipulation in their treatment armamentarium.

In addition to the effect of mobilization and manipulation in relieving uncomplicated mechanical-type back pain and restoring mobility in spinal joints, there are additional effects produced by “popping” the vertebrae.

When vertebrae are manipulated to produce a popping sound, there is a slight separation of joint (facet) surfaces, producing a vacuum that pulls in nitrogen gas from joint or synovial fluids to fill the space. This is called “cavitation,” an effect that temporarily increases mobility and range of motion. Such an effect may produce a sense of well being, which seems compelling for some people. There might also be some slight temporary increase in height as a result of cavitation and decompression of disc cartilage.

Persons who believe that they have subluxations or vertebrae out of place causing a health problem may be subject to a powerful placebo effect when the spine is popped, leading them to believe that their condition is being helped or cured by replacement of a vertebra. Such popping does not mean that a vertebra was out of place. Normal vertebrae can be popped when thrust-type manipulation forces movement of spinal joints into the paraphysiologic space (beyond the normal range of movement).

After vertebrae have been manipulated to produce cavitation, it may take three or four hours for the joint surfaces to settle back together so that the vertebrae can be popped again. This popping sound may produce fear that failure to get regular adjustments to pop or align the vertebrae will result in development of illness─a nocebo effect often exploited by chiropractors who have asymptomatic patients coming back on a regular basis for “preventive maintenance.”

Alternative Medicine: A Refuge for Chiropractic

In view of increasing opposition to subluxation theory, some chiropractic colleges have read the handwriting on the wall and moved into the camp of alternative medicine. The National University of Health Sciences (NUHS), for example, often referred to as the foremost American chiropractic college, offers Doctor of Chiropractic, Doctor of Naturopathic Medicine, Master of Science in Acupuncture, and Master of Science in Oriental Medicine degrees. NUHS recently announced a new cooperative arrangement with the Graduate Program in Complementary and Alternative Medicine at Georgetown University Medical Center in Washington D.C. Faculty at the two schools will work together to help students seeking advanced degrees in health care by advising students of the benefits of each other’s programs and providing preferential seating and advanced standing in each other’s programs when appropriate.

The web site of the Association of Chiropractic Colleges, in its “What Is Chiropractic?” section, states: “Because of the emphasis on holistic health care, chiropractic is associated with the field of complementary and alternative medicine.” (Accessed December, 13, 2011) Most health-care professionals consider “alternative medicine” to be a haven for unproven and implausible treatment methods.

Few consumers are aware of the great diversity in chiropractic, and few know what questions to ask when looking for a science-based chiropractor. Until all chiropractic colleges uniformly renounce the vertebral subluxation theory and are upgraded to training musculoskeletal specialists, treatment methods will vary from one chiropractor to another, incompatible with exchange in mainstream health care. With increasing numbers of physical therapists using high velocity, low amplitude thrust-type manipulation, physicians and other health-care providers can refer a patient to physical therapy for spinal manipulation, thus avoiding the problems associated with finding a chiropractor who uses manipulation appropriately.

In observing the web sites and promotional materials of newly graduated chiropractors, it appears that many of these chiropractors are combining science and pseudoscience to support treatment methods based on the basic tenets of traditional chiropractic, that is, manipulating the spine for some unverifiable neurological effect that will affect general health or organ function. Some, claiming to be primary care providers, combine “spine care” with “health care” and “wellness care” in a holistic approach that entails treatment and prevention over a broad scope of ailments, using a variety of alternative healing methods. Legislation to allow chiropractors with an “advanced practice” certification to prescribe drugs from a limited formulary has been proposed in New Mexico, South Carolina, and Alabama. Chiropractors would be required to have 90 hours of additional training in pharmacology. So far, such legislation, opposed by chiropractors who feel that chiropractic should remain a drugless healing profession defined by the basic principles of chiropractic, has failed.

Chiropractic and Physical Therapy Are Not the Same

The only thing unique about chiropractic is its basic definition as a method of adjusting vertebral subluxations to restore and maintain health. Any other physical treatment method, including generic spinal manipulation, is physical medicine. The subluxation theory has been the chiropractic profession’s only reason for existence since its inception in 1895. Failure of the profession to establish itself as a legitimate physical-treatment specialty with an armamentarium that includes use of generic spinal manipulation continues to leave the profession dependent upon the basic tenets of chiropractic. Many chiropractors feel that if the chiropractic profession discards the subluxation theory and specializes in the care of back pain and related musculoskeletal problems, it will not be able to compete with physical therapists and other musculoskeletal practitioners who use manual therapy.

With a foundation based on an implausible theory that nurtures a hodgepodge of dubious chiropractic techniques, the chiropractic profession is splintered by philosophies that go in many different directions. The approach of chiropractic colleges may range from “straight chiropractic,” which proposes that most ailments can be treated by adjusting vertebral subluxations, to “alternative medicine,” which permits use of unproven treatment methods to treat a broad scope of ailments without resorting to subluxation theory.

It’s important to understand that manipulation used in the context of chiropractic subluxation theory is not done for the same reasons guiding the use of manipulation by physical therapists. With the exception of a few science-based chiropractors who use manipulation appropriately, it appears that most chiropractors manipulate or adjust putative vertebral subluxations in a misguided effort to restore and maintain health. Physical therapists use manipulation-mobilization primarily to restore mobility in the spine. When chiropractors accuse physical therapists of stealing their treatment method, nothing could be further from the truth. Generic spinal manipulation has long been a part of physical medicine and is unrelated to subluxation-based chiropractic. Chiropractors often say that the difference between physical therapists and chiropractors is that chiropractors adjust vertebrae while physical therapists manipulate the spine.

Entrenched Subluxation Theory

There is no reason to believe that the subluxation theory will ever be discarded by all chiropractors. Unable to demonstrate that real orthopedic subluxations can cause organic disease, some chiropractors refer to a “vertebral subluxation complex,” another name for a chiropractic subluxation that is asymptomatic and undetectable. Belief systems cannot be eradicated by scientific presentations, especially subluxation-based chiropractic which finds support in the pseudoscience of alternative medicine. It seems unlikely that chiropractic, tainted by subluxation theory, will ever be absorbed by physical therapy, become a subspecialty of medicine, or be welcomed by academia. It may already be too late for the chiropractic profession to make the changes needed to train chiropractors to do what physical therapists, physiatrists, and orthopedic manual therapists are already doing. It certainly does not seem likely that the chiropractic profession, as it stands today, could take the path chosen by osteopathy in 1929 when the federal government gave the osteopathic practitioner the same privileges granted to medical doctors.

In the final analysis, we see only what we are ready to see, what we have been taught to see. We eliminate everything that is not part of our prejudices.

— Jean-Martin Charcot, 1825-1893

 

 

Sam Homola, at the age of 82, is the author of 15 books, including Bonesetting, Chiropractic, and Cultism, published in 1963, and Inside Chiropractic, published in 1999. He resides in Panama City, Florida, with his wife, Martha.

Posted in: Chiropractic

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187 thoughts on “Subluxation Theory: A Belief System That Continues to Define the Practice of Chiropractic

  1. marcus welby says:

    Wow! Well said and beautifully explained and summarized. Threatening to the chiropractic mainstream, so it will be vilified and ignored by that set, I predict. Homola, a second generation chiropractor with vast experience, has always been a sober and thoughtful objective observer and explainer.

  2. Blue Wode says:

    What Marcus Welby said. An excellent piece that is now the lead link in the chiropractic section at ebm-first:
    http://www.ebm-first.com/chiropractic.html

  3. marcus welby says:

    As documented by Jann Bellamy in a previous post, the U.S. Dept. of Education allows private post-high school educational institutions to self-accredit, so chiropractors are vetting their schools and curricula. Of some interest, a number of chiropractor graduates who cannot repay their educational loans have been angry at the DOE and other targets over their feelings they were mislead about the value of their education. Also, there are indications the Chronicle of Higher Education will come out with some articles about chiropractic education and the fact some of the DC professors are raking in salaries in excess of 700K although a recent chiro school in L.A. closed and enrollment is dropping in U. S. chiro schools.

  4. elmer says:

    Where all these PTs that do manipulation? After 8 operations on my arm, I’ve seen a lot of them, but only guy, in Taiwan, ever did any kind of manipulation, which always made me feel better, and none of the other PTs had any idea what I was talking about when I described this to them/

  5. elmer says:

    My general experience with PTs is they treat everything with weight lifting.

  6. DrRobert says:

    A few points:

    1. I wholly believe that chiropractors are simply redundant. The profession is rooted in vitalism and is based on a disproven concept, the subluxation. Shifting it towards something more science based is always going to be met with resistance, just as it would if we tried to shift iridology or reflexology to a science based practice.

    Let’s be honest, the only reason some chiropractors want to “shift” to evidence-based practice is because a lot of them “know” that they’re practice is unscientific, but they’ve already invested so much money and time into their education that going to back to school is unfeasible. They want a shortcut to something better.

    Physical therapy is already established as a profession. While it has its own share of pseudoscience, it is much more evidence-based, isn’t rooted in vitalism, and doesn’t claim to be able to treat all sorts of diseases that it has no business treating.

    It doesn’t seem necessary to transform chiropractic care into physical therapy. Chiropractors who want to be science-based picked the wrong profession. They need to go to physical therapy school, sit through their curriculum, and get the degree. They can’t just start shifting their practice over assuming they know everything that a PT does.

    Chiropractic curriculum spends a lot of time on non-existant subluxations (12-22%, in fact – Mirtz TA, Perle SM. “The prevalence of the term subluxation in North American English-Language Doctor of chiropractic programs.” Chiropr Man Therap. 2011 Jun 17;19:14.) I don’t have any evidence of this, but I would assume that if someone went to school and 1/10th to 1/5th of what they learned was based on pseudoscience, then they would definitely have some gaps in their knowledge.

    If I’m a family medicine doctor, and want to start doing neurosurgery, I just don’t start slowly operating on people. I have to go to a residency or fellowship training program and start from the beginning. Likewise, if a chiropractor wants to be a physical therapist, then they need to go to school for that.

    2. You wrote: “Recent reviews of the literature indicate that manipulation may not be any more effective than other treatment methods in affecting the ultimate outcome in recovery from back pain.”

    I can’t help but be bothered by this statement. The recent reviews that I’ve read found that manipulation may not be effective. Period. Not that they may not be MORE effective than other treatments. It’s that they aren’t effective period.

    Ernst E, Canter PH. “A systematic review of systematic reviews of spinal manipulation.” J R Soc Med. 2006 Apr;99(4):192-6. – Found spinal manipulation to not be effective for any medical condition. They found spinal manipulation was only superior to sham manipulation for back pain.

    But that review was updated:

    Ernst E, Canter PH. “A systematic review of systematic reviews of spinal manipulation.” J R Soc Med. April 2006 vol. 99 no. 4 192-196. – Found spinal manipulation to not be effective for any medical condition.

    Another review:

    Ernst E. “Deaths after chiropractic: a review of published cases.” Int J Clin Pract. 2010 Jul;64(8):1162-5. – The risks of chiropractic manipulation far outweigh any benefit a patient may receive from it. Given that reviews find there is essentially no benefit from spinal manipulation, any risk at all makes it a negative risk-benefit analysis. I equate it to sticking my finger in an electrical socket. There’s just no good reason to do it.

    (I can’t begin to imagine how much alternative medicine practitioners hate Dr. Ernst.)

    Note: The studies are interesting, because (for anyone who doesn’t know, Sam, I know you know this) there is a distinction between “spinal manipulation” and “chiropractic care.” Spinal manipulation is self described, but “chiropractic care” can encompass spinal manipulation and any other of a number of treatment modalities, including massage, heat, exercise, etc. Just something to keep an eye on when reading these studies.

    3. You wrote: “For symptomatic relief of uncomplicated mechanical-type back pain, however, use of hands-on manipulation may provide more immediate and dramatic relief by stretching tight muscles and mobilizing the spine.”

    The use of “may” is ambiguous. You’re saying that for some very specific type of back pain, some technique may or may not provide some type of relief. But you also say “may provide more” – more than what? Nothing? More than standard medical care?

    The latest Cochrane review would disagree. For spinal manipulation, they found: “There was little or no difference in pain reduction or the ability to perform everyday activities between people with low-back pain who received spinal manipulation and those who received other advocated therapies. This review of 39 trials found that spinal manipulation was more effective in reducing pain and improving the ability to perform everyday activities than sham (fake) therapy and therapies already known to be unhelpful. However, it was no more or less effective than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner.”

    For combined chiropractic interventions, they found: “The review shows that while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low-back pain, there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain. Any demonstrated differences were small and were only seen in studies with a high risk of bias.”

    When we combine data from reviews like Cochrane and Ernst, we can see that chiropractic care probably has a very small effect on specific types of low-back pain. For anything else, we can see it’s likely to be ineffective. … So what is the point of chiropractors again?

    4. Because of #3 (chiropractic care has almost no effect, except a very small possible effect for specific types of low-back pain), it seems that chiropractors are pigeonholed in their profession. They simply can’t sustain a practice if they practice in an evidence-based manner.

    Please note: I am not attacking you. I just have different feelings about chiropractic. I have the writing ability and wit of a corpse. I wish I could have WLU construct these posts for me.

  7. daijiyobu says:

    Perhaps this is a false prediction but, if you look at National University of Health Sciences, which was once a chiropractic degree granting institution only, they have now expanded to include naturopathy and TCM.

    All, by magic of institution title, instantly

    SCIENCE.

    Prediction: the DC education machine will further diversify, and science, academically speaking at least,

    will continue to be degraded to the point of meaninglessness.

    In terms of commerce: the consumer, because this occurs so institutionally nested, will have no rights in terms of fair trade, because in complaining that ‘I wasn’t treated per science’ or ‘I wasn’t educated per science’, a bunch of “fully accredited” eggheads will defend such legal action and win merely by dog-piling.

    -r.c.

  8. DrRobert

    “It doesn’t seem necessary to transform chiropractic care into physical therapy. Chiropractors who want to be science-based picked the wrong profession. They need to go to physical therapy school, sit through their curriculum, and get the degree. They can’t just start shifting their practice over assuming they know everything that a PT does. ”

    That approach is not how osteopathy got to where it is today in the US. Sam is likely correct that it’s too late for chiropracty to go the route that American osteopathy went, but it might be possible to design a specialized course/ set of courses and certification to help transition chiropractors who want to be science-based into PT without requiring them to start over from scratch. To say “Chiropractors who want to be science-based picked the wrong profession” is to give up on a group (however small) that want to be on our side. I’m not sure that’s the best idea or only practical option.

    “If I’m a family medicine doctor, and want to start doing neurosurgery, I just don’t start slowly operating on people. I have to go to a residency or fellowship training program and start from the beginning. Likewise, if a chiropractor wants to be a physical therapist, then they need to go to school for that.”

    Yes, but you wouldn’t have to go back to medical school and start from square one. Perhaps chiropracty is so far off base that there’s nothing in their education and training that can be of use in the transition to a science based PT practice, but maybe there’s a way to transition them to PT without them completely starting over. Maybe it’s less than ideal, and you’d have a generation of slightly wooey PT practitioners that came over from chiropractic, but it might be a step in the right direction. On the other hand, maybe the reality is that the number of hypothetical chiropractors we’re talking about is so incredibly small that it’s a moot point anyway.

  9. Janet Camp says:

    “It doesn’t seem necessary to transform chiropractic care into physical therapy. Chiropractors who want to be science-based picked the wrong profession. They need to go to physical therapy school, sit through their curriculum, and get the degree. They can’t just start shifting their practice over assuming they know everything that a PT does.”

    I was thinking this throughout the article. There is simply no justification for anything called chiropractic. It also seems reasonable to offer some kind of “transition training” as mentioned by Karl W., but it must be rigorous and root out the woo. Students who feel cheated by the training they got in chiropractic need to address this through the licensing bodies of their states. We could simply dispense with the whole notion of chiropractic and offer some assistance for these people to retrain–paid for by the lawsuits they are now involved in (assuming some would succeed).

    I’m not sure what part of chiropractic training would help in a transition, but presumable they learn some basic anatomy and terminology. There probably isn’t much that would carry over, though.

    Mr. Homola (Dr?) seems very well-intentioned and I applaud his long term effort to dignify his profession, but you cannot simply take people’s word that they are now interested in SBM and want to restyle themselves as a PT. I am very grateful to the PT who helped me following rotator cuff surgery and I would hate to think that next time I might get a former chiropractor with no additional training, who would “manipulate” my shoulder!

  10. arufa says:

    Great conversation all. My eyes always widen when I see posts on manipulation and PT since I am a manual physical therapist and academic.

    Karl:
    There is no way chiros will be given a fast tract to a PT license. Being a PT is about thinking like a PT. There really is not anything PTs do that is not done by other professionals. Joint manipulation, soft tissue massage, exercise, education, modalities are all done by other professionals. To be a PT you need to learn how to think like a PT, with a focus on movement. This thought process (along with literature and scientific thinking) is what guides a good PT’s decision making. To get that one has to go through the whole course work. Comparing changing medical specialties to moving from chiro to PT is a poor example. One is moving within a profession and the other is changing professions entirely. Orthopedic manual PT is only a small part of what PTs do. PTs work in all types of setting and with patient who have varying diagnosis/movement dysfunctions. Would a chiro be prepared to treat a patient with a stroke, CP, unhealed wound, massive burn, amputation, hip replacement, developmental delays, is in the ICU etc…? Also I can’t see the politics allowing it. We can’t even agree to grandfather PTs with masters to a doctorate.

    Dr. Robert:
    Much of orthopedic care suffers from a lack of good quality evidence and treatment of low back pain is not an exception (in fact it is the rule). High velocity, low amplitude thrust techniques to the low back (HVLA) has been studied a decent amount and as you pointed out in general the results have been underwhelming. I call it HVLA because the vernacular for any manual therapy technique moving the spine is manipulation. This can include both low velocity (mobilization) or high velocity (often called manipulation but this term is not exclusive). So most if not all of the systematic reviews include studies looking at both high and low velocity techniques. So we need to be careful to acknowledge that these reviews are lumping two very different techniques under the same umbrella. Another potential problem is that most RCTs make very little attempt to sub categorize individuals with low back pain beyond duration of symptoms. The reason for this is that in most cases a clear way to sub categorize them is not evident. In the PT literature we are starting to see attempts at classification beyond duration of symptoms. This has shown some promise in identifying individuals who respond very dramatically and consistently to HVLA spinal thrust. By dramatic I mean more than a 50% improvement in disability and by consistent I mean over 90%. This has been demonstrated in several studies.

    But lets face it, when dealing with low back pain, we are dealing with pain. Pain is inherently a complex experience which is influence more by the individuals beliefs, perspective, fear, past experience etc.. then it is by pathology, structure, damage or injury. This makes treating patients with low back pain as clear as mud (really, really dark mud).

  11. jhawk says:

    @ Janet Camp

    “I’m not sure what part of chiropractic training would help in a transition, but presumable they learn some basic anatomy and terminology. There probably isn’t much that would carry over, though.”

    Chiro schools require ~24 credit hours of basic/gross anatomy and PT schools require ~5 credit hours. As for the rest of the cirriculum, I think you should compare them before you make these ill informed statements.

    I will make it easy for you. Here are two links, one is chiro requirements and is one PT.

    http://www.ahs.uic.edu/pt/programs/dpt_requirements.php (PT)

    http://www.uws.edu/Academic_Programs/Doctor_of_Chiropractic/DC_Program_Curriculum.pdf (chiro)

  12. elmer says:

    previous comment inspires the following:

    I believe the manipulation of my shoulder (performed by a PT in Taiwan who’d received his doctorate from NYU) was a form of muscle energy technique, where the practitioner manipulates and the patient resists. It was very useful in getting me to find and fire up the right muscles and not the wrong ones (I’ve noticed that I tend to overuse my scalenes and sternocleidomastoids and the expense of other muscles both in breathing and moving my arms, and have learned on my own to control this). It helped, although unfortunately he could only see me briefly.

    I have no idea what the effect of weightlifting was on the rotator cuff tear that was incidentally discovered and repaired in one of my subsequent operations. I do know that after a few months of weightlifting my neck and shoulder were extremely tense, painful and hypersensitive to touch, especially at the nerve running down the neck.

    I have no particular interest in manipulation per se, but I do think there are a lot of modalities out there that are too rare among PTs, such as Feldenkrais, muscle energy technique, and the Edgelow protocol, on which there isn’t much research, and which, like so much of physical therapy, doesn’t lend itself to placebo controlled trials.

  13. elmer says:

    oops, no longer the “previous” comment; I meant Janet Camp’s

  14. arufa says:

    Elmer:
    Thanks for sharing your experience! Your post highlights the reason why we need “science-based medicine”.

    Although your experience and your beliefs:
    “I’ve noticed that I tend to overuse my scalenes and sternocleidomastoids and the expense of other muscles both in breathing and moving my arms, and have learned on my own to control this)”, “I do think there are a lot of modalities out there that are too rare among PTs, such as Feldenkrais, muscle energy technique, and the Edgelow protocol,”
    seem very real and accurate to you, they are simply anecdotes and don’t tell us much.

    What if I were to tell you that “weightlifting” (I will call it strength and or endurance training) help improve symptoms in 90% of people with rotator cuff problems and METs only help 3% of people. Maybe your experience simply fell outside the norm? Does this mean that PT practice should be changed based on your experience or should it be based on scientific reasoning and probability of success. It is pretty clear that if you can convince patients of the efficacy of a treatment several of them will get improvement regardless of the efficacy of the treatment (especially when dealing with pain). Before I get jumped on, I simply made up those numbers to prove a point.

    Bottom line, if we rely on anecdotes and beliefs (which are not critically and skeptically appraised) I think we are likely to be mislead far more than we will come to the correct conclusion.

    So I appreciate you sharing your experience with us, however don’t expect the PT profession to move in a direction based on your personal experience or the personal experience of any other person.

  15. zimney3pt says:

    @jhawk

    In regards to comparisons Chiro to PT schooling and curriculum it may be difficult with the information that you provided. Quarters and Semesters are different time frames. Also there are different accredidating bodies for these different schools (Chiro and PT) so it is difficult to measure if there are similarities or differences of curriculum within those classes and the hours listed based just on the title of the class.

    I would agree that the basic anatomy would most likely not be a significant difference between the schoolings though. I think comparing a technique to equate professions is problematic. Many different professions use manipulation techniques (Chiro, PT, Osteopaths, and others) they are all distinct professions in of themselves with separate schooling and body of thought. I often use an analogy of health care providers that use a sphygmomanometer to measure blood pressure. Many of health care providers are trained in its use, but obviously those professions are significantly different. The profession should be defined by its school of thought not the techniques used.

    So while Chiro and PT use some similar techniques, the school of thought and range of treatment areas are considerably different and any attempt to equate them is wrong on many levels.

  16. Harriet Hall says:

    It seems to me that a critical thing that should be required for a chiropractor to transition would be re-education directed at correcting the pseudoscientific beliefs many chiropractors hold, from anti-vaccine fallacies to applied kinesiology.

  17. DevoutCatalyst says:

    But if they insist on applied kinesiology, the transition should instead be directed to a career on the carnival midway. That one is inescapably ridiculous. Are there papers supporting its diagnostic abilities in the industry journals?

  18. DrRobert says:

    @Devout:

    http://en.wikipedia.org/wiki/Applied_kinesiology#Scientific_research

    Double blinded RCTs are negative. Biased trials that were designed by people who believe in things as ridiculous as AK are positive.

  19. Earthman says:

    Good piece. Now, what about Osteopathy? I have always thought of this as a parallel to Chiropractic, but is it?

  20. elmer says:

    arufa:

    As I said, the rotator cuff was just one thing I was dealing with. My story is a long one, and I get tired of telling it. But I know from reading case histories and discussion forums (fora?) that there are a lot of long stories out there.

    Earthman, the page about Osteopathy at Quackwatch is pretty interesting. I don’t feel like googling it.

  21. elmer says:

    I also understand that the core of PT techniques was developed to get injured soldiers back up and fighting in WWI. When a doctor writes a script for weightlifting do deal with a repetitive-stress injury, what he’s most likely prescribing is more of what caused the injury in the 1st place, depending on the PT’s skill set. If anybody has real (not made-up) data showing that this is effective, I’d like to see it. In the meantime, I’ll say that it doesn’t seem reasonable to me.

  22. leschitzdpt says:

    Dr Robert,

    With respect to your comment on the efficacy of spinal manipulation, research has shown there is a great heterogeneity in patients with low back pain (LBP) which accounts for the results of the systematic reviews you stated. It’s not the same as taking a drug for a particular disease. The drug, ie manipulation, has only been found to be effective in a subgroup of patients. Thus in PT, the ICD-9 diagnoses that apply to LBP do not guide specifics of treatment. Of course, a spondylolisthesis will guide precautions/contraindications, but LBP/lumbago/stenosis does not help. Particularly since the medical profession only knows the exact cause of the pain in 15% of cases due to the complexity of anatomy and false positives with imaging.

    For instance, in a validated clinical prediction rule conducted by Fritz et al in 2002, it was found that in a subgroup of patients with LBP “The presence of four of five of these variables (positive likelihood ratio = 24.38) increased the probability of success with manipulation from 45% to 95%.” See the results abstract below.

    “Seventy-one patients participated. Thirty-two had success with the manipulation intervention. A clinical prediction rule with five variables (symptom duration, fear-avoidance beliefs, lumbar hypomobility, hip internal rotation range of motion, and no symptoms distal to the knee) was identified. The presence of four of five of these variables (positive likelihood ratio = 24.38) increased the probability of success with manipulation from 45% to 95%.”

    ARTICLE: A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. – http://www.ncbi.nlm.nih.gov/pubmed/12486357

    Mr Homola,
    Regarding the indications for manipulation or “thrust mobilization” used by PTs, it is mainly for pain, or muscle guarding. The mechanism is most likely via a neurophysiological inhibition of pain and muscle guarding at the spinal level. The biomechanical model has been shown to be an unlikely explanation for changes in pain, muscle turgor (reflexive muscle guarding), and mobility.

    Here is a nice listing of other Treatment Based Classification rules either in progress, or validated in PT literature:
    http://physicaltherapydiagnosis.blogspot.com/2011/12/new-treatment-based-classification.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+physical-therapy-diagnosis+%28Physical+Therapy+Diagnosis%29

    Re: research in PT, one reader pointed out the difficulties with having high quality studies. Just a few things: blinding can be difficult, and usually treatments are used in combination. I would NEVER use manipulation in isolation despite short term benefits. Also, the patients we see are again very heterogeneous. Patient management decisions are influenced by a number of variables, including psychological measures. For example, one indicator of poor prognosis in LBP or cervical patients is a high score on the fear avoidance beliefs questionnaire (see Steven George, PhD, PT et al).

    Other techniques used such as muscle energy can work via reciprocal/autogenic inhibition of muscle tone and again, neurophysiological inhibition of pain. We know from scientific study that muscles relax after a contraction, and also contraction of a muscle agonist can inhibit the antagonist muscle. All clinical decisions I make have a scientific backing and a PT that does not use an evidence based rationale is behind the times. There is a lot of clinical research that needs to be conducted, but a great deal currently exists published by “PT, PhD” researchers. Systematic reviews or other studies that lump together poorly defined “physical therapy” into non-surgical or conservative management go nowhere near what is required to determine true treatment effects. The TBC article cited above is just one example of that.

    As a resident, and possible future fellow, I also using many other scientifically based decision making tools to guide outside referral, including but not limited to CPRs for cancer, vertebral fracture, DVT, PE, stenosis, cervical radiculopathy, and the list goes on. In school I have studied the same interviewing techinques, systems review/review of systems influenced by the medical model, ICF model, and of course PT researchers/clinicians. We are trained at a much higher level than sometimes portrayed so please forgive me for taking the opportunity to comment and plug my profession.

    Many here are correct in saying that there are many more differences between the professions of PT and Chiro which include at least philosophical, educational, extent of scientific rationale, clinical reasoning paradigms, etc…

    I hope this provided at least some insight into a PTs mind.

    I enjoyed the article and comments and have followed this blog for some time!

    J

  23. lizditz says:

    Earthman, as I understand it, the case of osteopathy is confusing. In the US, osteopathic training is similar to that for MDs, and they practice side-by-side. Some may have quack leanings (see John Upledger DO for an example). What Barrett recommends:

    If you wish to select an osteopathic physician as your primary-care provider, your best bet is to seek one who: (a) has undergone residency training at a medical hospital; (b) does not assert that osteopaths have a unique philosophy or that manipulation offers general health benefits; (c) either does not use manipulation or uses it primarily to treat back pain; and (d) does not practice cranial therapy.

    I’m not sure about the UK. Perhaps someone more knowlegeable will tell us.

  24. lilady says:

    It is an interesting article but I keep re-reading one statement…which I believe needs clarification:

    “It may already be too late for the chiropractic profession to make the changes needed to train chiropractors to do what physical therapists, physiatrists, and orthopedic manual therapists are already doing.”

    Physiatrists are physicians who specialize in physical medicine…they are not physical therapists or orthopedic manual therapists. And Elmer, you might want to seek a consultation with a physiatrist…by getting a referral from your primary MD or a teaching hospital that has an orthopedic rehabilitation department.

    I have a degree in nursing and I never worked with orthopedic patients, but I’ve forgotten more information about the human skeletal/musculature structure and body kinetics than any practicing chiropractor I have ever met. They simply do not have the education background that a physical therapist has. So, no, they are not qualified to transfer their education background and their skill set to “become” physical therapists.

    Through circumstances (my very profoundly/multiply disabled son, who had spastic quadriplegia, bilateral dislocated hips, severe scoliosis and kyphosis), I have had a lot of experiences with orthopedists, physiatrists and many physical therapists. All of the physical therapists that provided therapies for my son were very well versed in providing the appropriate passive range of motion therapies, stretching of heel cords and hamstrings and rehabilitating his right leg after 10 weeks in a hip spica cast following a supracondylar femur fracture. I never worried that any of them would inadvertently dislocate a joint or fracture his brittle bones. I would never allow any chiropractor to touch him.

    I’ve known nurses who have returned to school to become PTs and one particular wonderful pediatric PT specialist who was firstly a nun, secondly a registered nurse and finally a licensed physical therapist. BSc-Nurses have the education background and the experience in a clinical setting…to switch careers and become PTs or physicians…chiropractors don’t.

  25. ConspicuousCarl says:

    On the issue of the unknown number of non-crazy chiropractors, I note that all 6 DCs on the Texas Board of Chiropractic Examiners (the board consists of 6 chiropractors and 3 laypersons) have nuttery on their websites:

    CYNTHIA TAYS, D.C. – President
    “discount program for our acupuncture services”
    “If the nervous system is impaired, it can cause malfunction of the tissues throughout the body.”

    KAREN CAMPION, D.C.
    “Acupuncture works to reprogram, and restore normal functions by stimulating certain points on the meridians in order to free up the Chi energy.”
    “Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health.”

    JANETTE KURBAN, D.C.
    “Fellow of the Acupuncture Society of America” (no real website, just a Tripod page)

    TIM MCCULLOUGH, D.C.
    “He is an experienced physician in [...] homeopathy, ”

    LARRY MONTGOMERY, D.C.
    “Keeping your spine in proper alignment will help everything else in your body function better.”
    “People can now be examined by the Insight Subluxation Station,™”

    PATRICK THOMAS, D.C.
    “Dr. Thomas is committed to providing relief for many conditions through the use of chiropractic and acupuncture ”
    “Electro Meridian Imaging”
    “With Infertility, only one spinal nerve involvement or acupuncture meridian can be out of balance and it will not allow conception. ”

    I don’t know how many reformed we-only-treat-lower-back-pain chiropractors are out there, but they sure as hell are not occupying the TBCE.

  26. DrRobert says:

    Science Based Quackery!

  27. DrRobert says:

    The biggest issue with chiropractors who want to be evidence-based is the stigma associated with the name of their profession. It will be extremely difficult for any evidence-based chiro to convince a practitioner they have given up all woo and are now focused on what the evidence says. And many patients have a bad impression of chiropractors as well. A study I read recently found the “usage” of chiropractors has been pretty stable over the last 10-15 years (study was in 2005-ish), so it’s not like people are utilizing them more and more.

    I just don’t see chiropractors ever achieving mainstream acceptance when they advertise things like this:

    (Warning, very graphic images of children having their necks manipulated)
    http://www.kidchiro.com/children/

  28. DevoutCatalyst says:

    @lilady

    They’d have to start from square one. They might as well go to college and pursue a degree in trombone. I do know of a massage therapist who threw it all away and went back to school to become a physical therapist. My guess is that this is a pretty rare occurrence. What pains me about alternative medicine is the inadvertent arrogance practitioners pick up along the way, that is, I believe they start out as innocent, well intentioned people, and thereafter it all goes sour. Thus we have the massage therapist here in my town who believes their product is superior to what a PT can offer, when there is no comparison. I wouldn’t let your son near a massage therapist, either, it’s not a predictable profession when it comes to whether or not any given practitioner possesses the simple error correction necessary to prevent delusions of grandeur. No telling how they might decide to “improvise”.

    My guess is that the utility of chiropractic is that it gives pleasure to the clients who enjoy that kind of snap crackle pop thing, but I can’t take the profession seriously. Harriet Hall admits that chiropractic can help simple lower back pain, but would she refer anyone to a chiropractor? It’s a can of worms, a can of octopuses. Or…

    “Unfortunately , a thorough examination of the individual vertebra is not within the scope of most Western trained pediatricians.”

    …indistinguishable from PT Barnum.

    (quote is from DrRobert’s link)

  29. arufa says:

    Elmer
    Thank you for not providing your life story and I think you missed the point of my post. The point I was trying to make had nothing to do with the effectiveness of the interventions you had. My point was that you were making comments on the types of treatment a profession should use, based on your experience and with an ignorance of the evidence. This is exactly the kind of ‘logic’ used by CAM practitioners to justify their treatment decisions. It is dangerous.

    To your question on the effectiveness of “weightlifting”, your question is way to vague. What do mean by weightlifting, (type of exercise, dosage etc..) for what condition and compared to what?

    Exercise may not always be the best choice, however there is no other treatment around which has been shown to be effective at treating so many different disorders. There is evidence for use in many orthopedic problems, heart disease, high blood pressure, obesity, depression, dementia, etc… o and it is associated with lower cancer risks.

  30. Harriet Hall says:

    “Harriet Hall admits that chiropractic can help simple lower back pain, but would she refer anyone to a chiropractor?”

    No I wouldn’t. I might do so in specific instances if I knew of one like Samuel Homola who could be trusted to only provide expert spinal manipulation and other evidence-based treatments for short-term care of amenable musculoskeletal problems without any nonsense like applied kinesiology, without risky neck manipulations or inappropriate treatments, and without anti-vaccine or anti-mainstream propaganda. Sam is now retired, and anyway I live at the other end of the country, and I have never found anyone even remotely like him in my area. Here they all seem to do crazy things like rejecting the germ theory, using applied kinesiology, assessing brain function by the size of the blind spot, charging patients thousands of dollars for spinal decompression treatments, or treating newborns in the delivery room for subluxations caused by the birth process. One even let his own child die, manipulating him and refusing to allow hospitalization and antibiotics for his meningitis.

  31. jhawk says:

    @zimney3pt

    “In regards to comparisons Chiro to PT schooling and curriculum it may be difficult with the information that you provided. Quarters and Semesters are different time frames.”

    My apologies, the 24 to 5 comparison was not fair (not my intention) due to quarters vs. semesters but all that needs to be done is multiply the quarter hours by 2/3. So, 24*2/3= 16 hours of anatomy in chiro compared to 5 hours in PT. Lets take a peek at the rest of the core basic science classes: Physiology is 7 (chiro) and 3 (PT). Histology equal at 4. Neuroanatomy 5 (chiro) and 3 (PT). pathophys is 8 (chiro) and 4 (pt). biomechanics is 11 (chiro) and 10 (pt). Basic science courses taught in chiro but not in pt include biochemistry,cell biology, microbiology, nutrition and genetics.

    “Also there are different accredidating bodies for these different schools (Chiro and PT) so it is difficult to measure if there are similarities or differences of curriculum within those classes and the hours listed based just on the title of the class.”

    The basic science courses in chiro school are taught by PhD’s in their respective fields ( Is this true for PT?)
    so I think a comparison can be made to these basic science courses. I am only comparing because others here are completely misinformed about chiropractic education.

    @arufa

    “Much of orthopedic care suffers from a lack of good quality evidence and treatment of low back pain is not an exception (in fact it is the rule).”

    I agree and have said the exact same thing there here. Interesting when said by you (non-chiro I assume) you get no response but when said by me (chiro) I get bombarded with the tu quoque logical fallacy argument.

  32. nybgrus says:

    I find it interesting that after numerous vociferous calls for a “debate” with Sam Homola, NMS-DC is nowhere to be found here….

    I also agree wholeheartedly with Dr. Hall’s reasons for reticence in referring any patient to a DC.

    And as for jhawk:

    The basic science courses in chiro school are taught by PhD’s in their respective fields ( Is this true for PT?)

    Even if I were to grant that the basic sciences component of DC training is at least on par and perhaps better than that of PT, it is a total wash because the context in which it is taught mitigates most of that.

    If you look at the prospectus for a degree in Homeopathy at a popular school in Australia (PDF) you will find that they have courses titled:

    Chemistry and Biochemistry
    Foundations of Critical Inquiry
    Human Biological Science
    Pharmacology (which is separate from Foundations of Homeopathy and Materia Medica
    Clinical Examination and Biomedical Techniques

    Interspersed with:

    Miasms and Chronic Disease
    Materia Medica Studies
    Homeopathic Research Skills
    New Developments in Homeopathic Method

    So having a listing of courses means rather little when we know that they are coached in the magical thinking of subluxation theory. Especially considering that you have stated it is possible to palpate and manipulate the anterior vertebral bodies through the back – something which a knowledge of anatomy would preclude. And yes, I do remember your claim about palpating the spleen not being direct due to skin and viscera in the way. But even in that sense, palpation of the L spine anterior vertebral body is simply not possible – only perhaps from an anterior approach in a very thin person, but that is clearly not what you meant by it.

    Interesting when said by you (non-chiro I assume) you get no response but when said by me (chiro) I get bombarded with the tu quoque logical fallacy argument.

    Because stating a deficiency in our own practice for improvement is inherently different than stating it as an indictment of a practice different from your own in an attempt to prove the validity of yours. The former is merely stating fact that we all agree on. The latter is what you and NMS-DC have done in order to try and establish the validty of chiropractic and indeed the very definition of tu quoque. In other words, intent of the statement is important.

  33. elmer says:

    What I mean by “weightlifting” is the experience I have had with almost every one of the many PTs I’ve seen: essentially, “Here, lift this weight.” Me: “How?” PT: “Just lift the weight.” Me: “Ow!”

    And I do exercise now, a lot. But I’ve had to figure out on my own how to do this without screwing myself up worse. I’ve been more focused on trying things on myself than gathering data, but I’ve seen articles about “evidence-based” PT that admit the limitations on experimental evidence for PT by its nature. The protocols I’ve mentioned, especially Feldenkrais and Edgelow, which are general methodologies for teaching a patient to become more sensitive to the sensations associated with various movements, can’t be compared to an injection that’s contrasted with a placebo.

    Here’s a quote I like by physical therapist Jan Dommerholt that I typed out elsewhere (I’m leaving my original typos intact, out of laziness):

    “Although there appears to be consensus that pysical therapy is an integral component of pain management centers, few physical therapists have received adequate training in clinical pain mechanisms and pain management strategies, which is somewhat remarkable considering that the chronic pain prevalence is estimated to range from 10% to 55%. The International Associaton for the Study of Pain (IASP) has developed a specific pain curriculum for occupational and physical therapy education (http://www.iasp-pain.org/ot-pt_toc.html), yet there is no evidence that htis or similar curricula are commonly taught in physical therapy academic programs. It should then come as no surprise that many phsyical therapists lack knowledge on pain managment and may not be all that interested in working with persons with chronic pain.

    According to Wolff and colleages, 96% of orthopedic physical therapists prefer to work with patients who are not likely to have chronic pain. A search of the membership directory of the Orthopedic Section of the American Physical Therapy Association (APTA) suggests that its Pain Management Special Interest Group has less than 400 physical therapy members out of a total APTA membership of about 64,000, which equates to approximately 0.6 percent (from “members only” section of http://www.orthopt.org, accessed October 30, 2004). A similar search of the membership directory of the American Academy of Pain management suggests that there are less than 100 identifiable physical therapy members out of a total of approximately 6,000 members (less than 1.7 percent)(http://www.aapainmanage.org/search/MemberSearch.php, accessed October 30, 2004). The apparent lack of professional interest and insufficient education and knowledge in pain mechanisms and pain management strategies can create multiple challenges for physical therapiests to become effective pain management clinicians.”

  34. jhawk says:

    @nybgrus

    “So having a listing of courses means rather little when we know that they are coached in the magical thinking of subluxation theory”

    How do you know this? My school had only a 1 credit hour course on chiropractic history and philosophy. This is how it was taught, as history. Actually, in Sam’s article where he talks about cavitation being a nitrogen gas influx due to facet joint gapping is exactly what was taught at my school.

    “Especially considering that you have stated it is possible to palpate and manipulate the anterior vertebral bodies through the back – something which a knowledge of anatomy would preclude.”

    Actually, I was talking about the cervical spine palpation of the longus colli which can easily be done if trained correctly.

    “But even in that sense, palpation of the L spine anterior vertebral body is simply not possible – only perhaps from an anterior approach in a very thin person, but that is clearly not what you meant by it”

    If I had been talking about the L spine this is exactly what I would have meant and should not have to explain that to a medical student. Anyone with any knowledge of anatomy would know you can’t palpate the L ant v body from the back.

    “The latter is what you and NMS-DC have done in order to try and establish the validty of chiropractic and indeed the very definition of tu quoque. In other words, intent of the statement is important.”

    Your assumptions could not be more wrong. I was never establishing validity of chiropractic when stating lacking evidence in orthopedics. I think it is unfair of you and SBM to ask for evidence of chiro when the rest of manual medicine is lacking as well. I fully understand that both fields need to up their respective evidence base.

  35. Janet Camp says:

    @jhawk

    I think your ideas have been adequately rebuked by other commenters, so I’ll not belabor any points. I kind of think calling me “ill-informed” was a bit much, however, and not in the spirit of a civil discussion. My comment was practically in the form of a question and I don’t mind you responding with your info on the actual hours, but I think my point stands in light of further info offered in subsequent comments.

    My comment was actually meant to be supportive of moving those chiropractors who want to do real medicine into other fields, and I cannot see why you took it to be pejorative.

  36. jhawk says:

    @ Janet Camp

    I am sorry if I offended you as it was not my intention.

    “I’m not sure what part of chiropractic training would help in a transition, but presumable they learn some basic anatomy and terminology. There probably isn’t much that would carry over, though.”

    How can I not take this to be pejorative. You are saying I may have some basic anatomy knowledge at best and that this knowledge of anatomy is inferior to “medical anatomy” and would not carry over to anything.

    How does this point stand? Not much that would carry over? When chiro school has more basic science education than pt school.

  37. arufa says:

    jhawk,

    “@arufa

    “Much of orthopedic care suffers from a lack of good quality evidence and treatment of low back pain is not an exception (in fact it is the rule).”

    I agree and have said the exact same thing there here. Interesting when said by you (non-chiro I assume) you get no response but when said by me (chiro) I get bombarded with the tu quoque logical fallacy argument.”

    It was not my intent, and I don’t think it came across that way, to imply that we should give HVLA thrust a pass because other interventions don’t have supporting evidence. I was simply trying to point out the difficulty and frustration one can go through when trying to pick a treatment technique which has evidence behind it and/or makes logical scientific sense. The problem with spinal manipulation is that we really don’t know what the mechanism is, so it is difficult to come up with a logical reason to use it.

  38. nybgrus says:

    How do you know this? My school had only a 1 credit hour course on chiropractic history and philosophy. This is how it was taught, as history.

    How do I know? Because your licensing exam tests you on a working knowledge of magical thinking. No matter how small it may be (and by my previous calculations it was roughly 5-10%, which is hardly that small) the fact stands that to be licensed in your profession it is expected that you know of the application of verterbral subluxation theory beyond just “history.” That, and acupuncture is another license administered by the same accrediting body. And as ConspicuousCarl pointed out, 6 out of 6 DCs on the Texas accrediting board themselves practice magical thinking.

    But the point is, once again, not specifically your education and how you act. As Dr. Hall pointed out, we have only your word on that – nothing about the actual accreditation, licensing, and stated teaching points of the vast majority of DC programs can assure us of this a priori.

    Your argument is like a homeopath coming to us and saying they only listened to the courses that made sense and eschewed the rest.

    Actually, I was talking about the cervical spine palpation of the longus colli which can easily be done if trained correctly.

    Fair enough. I stand corrected.

    Where is the eviednce that doing any C-spine manipulation is of any benefit?

    I think it is unfair of you and SBM to ask for evidence of chiro when the rest of manual medicine is lacking as well.

    And that is not only the definition of tu quoque but also being self unaware. It is inherently and definitively very fair for us to ask for eviednce for chiro since you (both in the singular and plural) are claiming its efficacy, using it daily, and training and licensing people as “doctors” of it. The point of tu quoque is that your claim that it is unfair for us to ask you for evidence because of any supposed or real lack of evidence on our part is a fallacy.

    You are saying I may have some basic anatomy knowledge at best and that this knowledge of anatomy is inferior to “medical anatomy” and would not carry over to anything.

    I will actually voice my opinion as being more in line with yours than the remainder of the commentariat here. I do think that, in general, the basic anatomical knowledge of a chiropractor is very likely to be at least on par with a PT. If something like a transition from PT to DC were to happen, I don’t know that I would press very hard for remediation of anatomy.

    The issue however, as was pointed out above, is that the pathology and treatment of said anatomy is coached in magical thinking and this is what would need to be significantly remediated and (as you consistently point out) standardized so that a (soon-to-be) physician like myself could be confident that a referall to a DC would not be likely to entail magical thinking, pseudoscientific CAM, or anti-vaccine propaganda.

  39. DrRobert says:

    @jhawk, you’ll have to excuse us if we aren’t impressed by the chiropractic curriculum. All that education and anatomy and chiropractics still think that vertebrae can magically become subluxated via some mystical way that isn’t perceptible, yet is diagnosable. And all of that pathophysiology and yet most chiropractors still think that disease is caused by these non-existant subluxations of the vertebrae.

    Not to mention, four years of school to learn a trade that is essentially useless. Let’s be honest. The root of chiropractic is manipulation, and manipulation is by and large useless. It may or may not be useful for a couple of types of low back pain, but it certainly isn’t superior to any medical treatment, except for perhaps sham chiropractic.

    Sure, chiropractors can adopt and implement other treatment modalities, but, they still carry the stigma of being a chiropractor, and will therefore never earn a referral from me. I just cannot imagine a scenario that results in both me acting in my patient’s best interest and referring to a chiropractor. As Dr. Hall said, the mere stigma of chiropractors, with all of their quackery and anti-vaccination nuttery, simply means to me that I can never trust them to act in a patient’s best interest.

    P.S. the other thing that drives me nuts about chiropractors is they always refer to themselves as Dr. X, D.C. Do they not understand that D.C. stands for Doctor of Chiropractic? It’s rather redundant.

    ——

    OH, and by the way.

    I’m looking at this chiropractic college curriculum:

    http://www.nycc.edu/webdocs/registrar/DC_Curriculum.pdf

    It was the first that came up on Google.

    Some thoughts:

    2 hours only dedicated to the science behind chiropractic. I imagine this could be covered in about 5 minutes.

    I notice only 1 hour dedicated to the ethics of chiropractic, but ten hours dedicated to running the business behind a chiropractic office. That’s pretty damn funny. Do you know how many hours of medical school (for real doctors) is dedicated to running a business? Zero.

    I simply can’t imagine that they teach autonomy, beneficence, non-maleficence, and informed consent in chiropractic school. If they did, the practice wouldn’t exist. Most studies have shown that chiropractors ignore informed consent.

  40. arufa says:

    A lot of talk about anatomy education. Basic anatomy education is first grade stuff at best. It is purely memorizing a structure which helps very, very little when trying to make decisions about proper care. There is a lot of anatomy that I have forgotten and you know what, it takes me about 30 sec to look it up if I need to know it. Having the critical thinking and decision making skills to properly treat a patient is the real skill and challenge of educating medical professionals. This skill is a seed that we try to plant in PT students and it hopefully never stops growing. Who cares how much anatomy training someone has (unless maybe they are a surgeon). Teach them lots of anatomy and then train them to look for subluxations on x-rays and you have just wasted a lot of time in the anatomy lab.

  41. nybgrus says:

    Do you know how many hours of medical school (for real doctors) is dedicated to running a business? Zero.

    And by contrast I had a very extensive ethics component to my first 2 years, including (but not even remotely limited to) a 10ish page paper each year on a topic of ethical concern in medical practice. Also, the USMLE Step 1 tests you on ethical scenarios.

    Contrasted with the DC licensing exam which tests you on vertebral subluxation theory, it is a pretty wide gulf.

    Basic anatomy education is first grade stuff at best. It is purely memorizing a structure which helps very, very little when trying to make decisions about proper care… Having the critical thinking and decision making skills to properly treat a patient is the real skill and challenge of educating medical professionals

    I completely agree, hence my comment above where I found the conversation of whether a DC would need to remediate anatomy to be off the mark. The issue is the application of that and how to critically think your way to a correct diagnosis and management – a skill that is difficult and, IMO, lacking amongst many MDs despite the fact that medical education at least attempts to drill that in your head. Being taught subluxations instead completely short-circuits that. And it seems that our best case scenario is that the short-circuit isn’t there, but neither is the active training and teaching of said critical thinking.

  42. ConspicuousCarl says:

    DrRobert on 31 Dec 2011 at 10:14 pm

    OH, and by the way.

    I’m looking at this chiropractic college curriculum:

    Also worth noting, NYCC doesn’t just teach chiropractic. They also offer degrees in acupuncture and oriental medicine. Not just classes which study it academically, but actual degree programs. They just can’t help themselves.

    But more on topic, their actual curriculum is not the only place where they expose their inadequacies. You can just search for “subluxation” in their search box at the top of their website to find more shady stuff than what is merely in their curriculum. They are quite interested in subluxations, both in practice and in various extra-curricular lectures. They even have a document which talks about treating asymptomatic subluxations, as though it is a curiosity in exception to the normal subluxation which is causing diseases.

  43. DevoutCatalyst says:

    Pour me another beer, Carl.

  44. Cowy1 says:

    “Teach them lots of anatomy and then train them to look for subluxations on x-rays and you have just wasted a lot of time in the anatomy lab.

    Couldn’t have said this any better. Kudos.

  45. jhawk says:

    @ arufa

    “It was not my intent, and I don’t think it came across that way, to imply that we should give HVLA thrust a pass because other interventions don’t have supporting evidence.”

    I was not implying a pass on HVLA either as there is a good number of studies on HVLA already. I was talking about how it is difficult to study manual medicine via RCT and hence lacking evidence in all areas of manual medicine. This does not mean any treatment should get a pass, just that it may have to be studied differently. A Possibility could be pragmatic trials to compare treatment approaches.

    “The problem with spinal manipulation is that we really don’t know what the mechanism is, so it is difficult to come up with a logical reason to use it.”

    Spinal manipulation imparts motion so it would make biomechanical and logical sense to use it on a patient with decreased ROM, pain/tenderness, and/or tissue texture change. The mechanism is not fully elucidated yet but there are theories that make biomechanical sense (periarticular facet capsule adhesion and meniscoid extrapment to name two).

    “A lot of talk about anatomy education. Basic anatomy education is first grade stuff at best. It is purely memorizing a structure which helps very, very little when trying to make decisions about proper care. There is a lot of anatomy that I have forgotten and you know what, it takes me about 30 sec to look it up if I need to know it.”

    Anatomy is mostly memorizing structures but if you don’t have a solid foundation in anatomy it would be difficult to understand how this anatomy moves and works. For example, a patient comes into my office with ankle pain and I note he/she has limited dorsiflexion. If I don’t know every structure by heart that crosses the ankle joint posterior to the instantaneous axis of rotation then how can I even begin to Dx what is limiting this ROM. Also, if you don’t know a structure is there how could you possibly arrive at this structure being the problem?

    “Who cares how much anatomy training someone has (unless maybe they are a surgeon).”

    This is sad to hear a pt say. Anatomy and biomechanics are the core of manual medicine and if you don’t know it cold, then you might not be able to arrive at an accurate and specific diagnosis.

    “Teach them lots of anatomy and then train them to look for subluxations on x-rays and you have just wasted a lot of time in the anatomy lab.”

    Chiro school does not train you to look for subluxations on x-rays.

    @nybgrus

    “How do I know? Because your licensing exam tests you on a working knowledge of magical thinking. No matter how small it may be (and by my previous calculations it was roughly 5-10%, which is hardly that small) the fact stands that to be licensed in your profession it is expected that you know of the application of verterbral subluxation theory beyond just “history.” ”

    The licensing exam on on chiropractic history and philosophy is ~3%. Testing on historical concepts does not equate to application.

    “Where is the eviednce that doing any C-spine manipulation is of any benefit?”

    Bone and joint decade task force on neck pain. Also, there is evidence for moderate effectiveness for neck pain relief by adjusting the thoracic spine (effectiveness of manual therapy: UK evidence report)

    “And that is not only the definition of tu quoque but also being self unaware. It is inherently and definitively very fair for us to ask for eviednce for chiro since you (both in the singular and plural) are claiming its efficacy, using it daily, and training and licensing people as “doctors” of it. The point of tu quoque is that your claim that it is unfair for us to ask you for evidence because of any supposed or real lack of evidence on our part is a fallacy.”

    I did not mean you should not ask chiro for evidence. I was trying to say that you should not expect evidence for chiro that is above and beyond other manual medicine treatments. Manual medicine is inherently difficult to study via RCT due to many factors that have been discussed here before.

    “The issue however, as was pointed out above, is that the pathology and treatment of said anatomy is coached in magical thinking and this is what would need to be significantly remediated and (as you consistently point out) standardized so that a (soon-to-be) physician like myself could be confident that a referall to a DC would not be likely to entail magical thinking, pseudoscientific CAM, or anti-vaccine propaganda.”

    I think when you get into practice you will be able to spot the non magical thinking chiro’s pretty easy as they will be writing letters and referring patients to you. Obvioulsy this depends on the specialty you choose.

  46. ConspicuousCarl says:

    Name your poison, my Catalytic friend. If you can’t decide, I happen to have a nice tall glass of “my patient has no symptoms, but I am imagining that I see subluxations”…

    Asymptomatic Patient with Identifiable Subluxation [....]
    PHASE 1: Initial care
    Plan of care may include:
    1. Adjust subluxated joints(s) [...]
    *3. Ice may be used post adjustment if inflammation occurs (see Chapter 4 – 1).*[....]

    PHASE 2: Follow-up care
    Plan of care may include:
    Periodic adjustments may be necessary to correct or reduce the subluxation. [....]

    PHASE 3: Supportive care
    Plan of care may include: Adjust as necessary
    Time Frame: 7 weeks and beyond
    http://www.nycc.edu/webdocs/ic/IQA/IQAFiles/Protocols/Chapter6/AsymptomaticSubluxation6_4.pdf

    So someone with no symptoms is apparently to receive “adjustments” for 7 weeks or more, even if those adjustments are causing inflammation?

    I am not sure in what context this document is meant to be presented, though it has the college’s seal on the first page and appears to be a straightforward list of things to do. Maybe there is a preceding document which ends with “…but be sure not to do the following:”

  47. ConspicuousCarl says:

    jhawk said:
    Chiro school does not train you to look for subluxations on x-rays.

    Can you specify which school you want to talk about? Maybe we are just looking at the wrong schools.

    “Medicare requires that subluxation be documented either by x-ray or physical examination.”
    http://www.nycc.edu/webdocs/IC/IQA/IQAFiles/Protocols/Chapter1/WritingSOAPNote1_4.pdf

    If that’s true, it would be kind of lame for a chiropractic school not to train its students on how to find subluxations in x-rays.

  48. jhawk says:

    @ConspicuousCarl

    “Can you specify which school you want to talk about? Maybe we are just looking at the wrong schools.”

    The course cirriculum I posted earlier was for University of Western States.

    The key part of the sentence is or physical exam. Since subluxations (hypomobile joint) can’t be found on x-ray then you must use the phyiscal exam via findings of decreased ROM, tenderness/pain, and tissue texture change.

  49. ConspicuousCarl says:

    OK, just one last slam on NYCC before I await jhawk’s choice of schools. I couldn’t help it, because the subject of this course is a sure sign that a person has lost their mind…

    DIA 6557
    Introduction to Homeopathic
    Therapeutics

    30 hours, 2 credits

    This is a lecture course that
    introduces basic principles
    and practical therapeutics of
    homeopathy in the care of fi rst
    aid, acute illnesses and selected
    neuromusculoskeletal conditions.
    The emphasis is to prepare the
    student in understanding the
    basic applications of this form
    of therapy and how to make
    recommendations for their use
    in clinical practice and/or for
    personal health care. In addition
    it provides the student with
    information relevant to educating
    and understanding patients who
    may be utilizing this type of
    therapy as a self-help treatment.
    The history and philosophy of
    this form of therapeutics will be
    introduced. Current literature in
    research and practice will also be
    discussed.
    http://www.nycc.edu/pdfs/NYCCCATALOG.pdf

    No, definitely not just an FYI course so you will know what kind of nutty junk your patient may have been using. That’s the bonus. “The emphasis” is on recommending that people use homeopathy… for FIRST AID.

  50. DrRobert says:

    @jhawk, did you really just say that RCTs “just don’t work” for chiropractic?

    Someone else worded it better, but after 100 years, the best quality evidence says chiropractic doesn’t work. It may or may not have a very slight and short-term benefit for a couple of types of back pain. Give it up. Chiropractic is worthless. Quit trying to validate it by molesting science and inventing new things that don’t work.

    Also, having homeopathy in the chiropractic curriculum imparts as much respect into your “doctorate” as naturopathy does. ND = doctor of quackery.

  51. DrRobert says:

    I just completed a complete deconstruction of chiropractic, the indefensible profession:

    http://www.skepticalhealth.com/2012/01/02/chiropractic-an-indefensible-profession/

  52. jhawk says:

    @DrRobert

    “@jhawk, did you really just say that RCTs “just don’t work” for chiropractic?’

    Nope, but nice try putting words into my mouth. If you don’t understand the drawbacks of RCT’s then you should take a methods course.

    “Someone else worded it better, but after 100 years, the best quality evidence says chiropractic doesn’t work.”

    This statement is false.

    “It may or may not have a very slight and short-term benefit for a couple of types of back pain. Give it up. Chiropractic is worthless. Quit trying to validate it by molesting science and inventing new things that don’t work.”

    Your extreme bias is showing here.

    “Also, having homeopathy in the chiropractic curriculum imparts as much respect into your “doctorate” as naturopathy does. ND = doctor of quackery.”

    Homeopathy is not a required part of chiropractic cirriculum. If an institution has a department that offers homeopathy it does not vilify other departments (chiro) of the institution. And if you say it does then any undergrad college that has a theology department is null and void as well as any hospital that offers these “CAM” treatments.

  53. nybgrus says:

    The licensing exam on on chiropractic history and philosophy is ~3%. Testing on historical concepts does not equate to application.

    I have shown this to be false in the comments of Jann Bellamy’s post. The textbook cited as the best reference to study for this section is unequivocally one that espouses the traditional Palmer-esque vertebral subluxation.

    Bone and joint decade task force on neck pain. Also, there is evidence for moderate effectiveness for neck pain relief by adjusting the thoracic spine (effectiveness of manual therapy: UK evidence report)

    I suppose that was somewhat rhetorical. There is no good evidence of its utility as has been discussed her numerous times.

    I did not mean you should not ask chiro for evidence. I was trying to say that you should not expect evidence for chiro that is above and beyond other manual medicine treatments. Manual medicine is inherently difficult to study via RCT due to many factors that have been discussed here before.

    When you are basing an entire doctoral profession on it, then yes, it is reasonable to demand more evidence. It is not even remotely the same to compare a stand-alone profession that started out (and as we have demonstrated continues by and large) with purely magical thinking with a subset of an actual science based profession. A large part of that is the tack of approach between the two schools of manual therapy. While certainly lacking in any camp, the onus is distinctly more upon chiropractic than subsets of science based medical practice.

    I think when you get into practice you will be able to spot the non magical thinking chiro’s pretty easy as they will be writing letters and referring patients to you. Obvioulsy this depends on the specialty you choose.

    I won’t hold my breath. And even then, I wouldn’t consider that good enough to refer to chiros. Note that NDs are trying to “work alongside” actual medical doctors in cancer institutes while still retaining and practicing their nuttery.

    Spinal manipulation imparts motion so it would make biomechanical and logical sense to use it on a patient with decreased ROM, pain/tenderness, and/or tissue texture change.

    Except that is not the actual application of SM in the majority of cases. As we have said here before, if that is truly all the SM was limited to, then you would be a very bored and broke chiro. Though the “tissue texture change” is a new one that makes little sense to me, but I’ll give it a by.

    Also, if you don’t know a structure is there how could you possibly arrive at this structure being the problem?

    I agree. But the issue was that the application of said knowledge is questionable, not the possesion of it. I think the point arufa was trying to make was that my Galaxy smartphone has more anatomical knowledge than I ever will, but I wouldn’t trust it to diagnose or treat my patient.

    @ConspiciousCarl:

    “Medicare requires that subluxation be documented either by x-ray or physical examination.”
    http://www.nycc.edu/webdocs/IC/IQA/IQAFiles/Protocols/Chapter1/WritingSOAPNote1_4.pdf

    To be fair (and since I damned near wrote a treatise on it before), the language was obfuscated to allow medicare reimbursement for such things. However, the definition that medicare uses is an orthopedic subluxation (actual and independently verifiable dislocation of articular surfaces) whereas the chiro usage slips seemlessly between that and the magical version, as necessary to justify whatever argument they may be making.

    but to flip it back a bit, jhawk then says:

    Since subluxations (hypomobile joint) can’t be found on x-ray then you must use the phyiscal exam via findings of decreased ROM, tenderness/pain, and tissue texture change.

    Which, taken with CC’s note of the medicare rules, demonstrates quite nicely said seemless transition of definitions.

    Nope, but nice try putting words into my mouth. If you don’t understand the drawbacks of RCT’s then you should take a methods course.

    I’ll have to side with jhawk on this one (sorry DrRobert). However, that said, there is research methodology much more robust than “pragmatic studies” which demonstrate chiro to have little, if any, value.

    This statement is false.

    That which is asserted without evidence can be refuted without evidence. Your statement is false.

    Your extreme bias is showing here.

    Once again I agree. However, it is justified bias, though I personally do my best to eschew it from such discourse.

    Homeopathy is not a required part of chiropractic cirriculum. If an institution has a department that offers homeopathy it does not vilify other departments (chiro) of the institution. And if you say it does then any undergrad college that has a theology department is null and void as well as any hospital that offers these “CAM” treatments.

    The theology department is null and void. Quite frankly, so was the majority of my undergrad anthro department. The difference is that a theology department at a university makes up a very small portion of the teaching done there (except for some colleges, like Liberty University and Asuza Pacific in which case, yes the whole institution can be written off). It also depends on how they are teaching theology. But I digress. The real point is that nearly the entirety of the offerings at places like NYCC or Bastyr are nuttery.

  54. DrRobert says:

    @jhawk

    Your extreme bias is showing here.

    Guilty as charged. But, rightfully so.

  55. arufa says:

    “This is sad to hear a pt say. Anatomy and biomechanics are the core of manual medicine and if you don’t know it cold, then you might not be able to arrive at an accurate and specific diagnosis.”

    This is true that anatomy and biomechanics have been the cores of manual medicine, which have lead us down the wrong path over and over. Lets just look at LBP. If you think that in most cases you can come to an accurate and specific diagnosis then you are fooling yourself. If you know the literature and are honest with yourself you will realize that in the majority of the cases a pathoanatomical diagnosis can not be made with any degree of certainty. Hence the widely used, non-specific low back pain diagnosis. That is not to say that anatomy and biomechanics are never useful.

    The evidence suggests that it does not matter the direction you manipulate/mobilize in, it does not matter if you are at the “correct level”, heck a thoracic HVLA thrust can help with neck pain, there is no convincing evidence that spinal manipulation increases segmental mobility and it does not seem to matter if you get a cavitation or not. If the mechanism of manual therapy was biomechanical these issues would be much more clear.

    And I am not saying anatomy and biomechanics are not needed. nybgrus said it well

    “I agree. But the issue was that the application of said knowledge is questionable, not the possesion of it. I think the point arufa was trying to make was that my Galaxy smartphone has more anatomical knowledge than I ever will, but I wouldn’t trust it to diagnose or treat my patient. ”

    If you are learning calculus yes you need to know about addition, but be prepared to get laughed at when you brag about the number of hours you have spent learning addition. No one cares, if you can’t add pick up a calculator. But if you don’t know how to think, no calculator, book or smart is going to help you.

  56. WilliamLawrenceUtridge says:

    jhawk isn’t throwing out a lot of logical fallacies in his posts here (there may be some, but s/he’s downright reasonable compared to Thing or Dana Ullman’s burning stupid) and I wonder at the details that might be glossed over here. Jhawk, would you mind telling me, based on your education in chiropractic, what you would recommend for the following conditions, including basic follow-up questions?

    1) Low back pain
    2) Breast cancer
    3) Measles
    4) Restricted flexion/extension of the neck
    5) AIDS due to HIV infection
    6) Restricted shoulder mobility post-dislocation
    7) Nonspecific fatigue

    From the somewhat reasonable debate, it looks like there may be a disconnect between the most-, more- and somewhat-egregiously bad America schools and wherever jhawk may have studied. I know in Canada, American chiropractors trained in certain schools are not permitted to practice; further, I have had chiropractic care that varied from “applied kinesiology + iridology” to simple “do these exercises and your shoulder tear will heal in 10-12 weeks” (and it did!)

    I think there is a substantial diversity in the schooling and approach of chiropractors, and it’s possible Jhawk hails from the tailing end of a binomial distribution with “nutjob” on one and and “physiotherapist with a twist” on the other. Some more questions which might help, jhawk:

    1) Do you believe subluxations exist?
    2) Do you support vaccinations in some or all cases?
    3) Do you oppose vaccinations in some or all cases?
    4) Do you believe in the germ theory of disease?
    5) Do you believe acupuncture “works”, and if yes, do you believe it works through manipulation of chi, placebo effect or another (possibly undiscovered) mechanism?
    6) Did you get your schooling in the United States, or elsewhere? If elsewhere, are you willing to tell us where?

    This may have been covered previously. Trying to tar, or vindicate, an entire profession is always going to have exceptions – as Sam Homola himself is evidence of.

  57. jhawk says:

    @WLU

    1)LBP- my recommendation depends on the pain generator. LBP is only a sx and not a specific enough Dx to recommend any tx. IMO, this is exactly why the majority of LBP studies in all area’s of medicine have failed to show anything over modest results. The researchers are taking a crappy non-specific Dx and throwing a single tx at a multifaceted condition.

    2) Breast CA- I would first make sure they are following up with their oncologist and PCP. I would also be careful to ask more constitutional sx for these pt’s if they are experiencing some new pain as the Hx of CA is considered a red flag. For conservative Tx if they have had lymph node removal and subsequent lymphedema I would reccommend they see an manual lymphatic drainage practicioner and get compression stockings.

    3) measles- this is an odd question. I can’t imagine anyone going to a chiropractor for measles but the majority will probably just need rest. I would send them to check up with their PCP. I would also ask about continual fever and cough and watch for rash.

    4) restricted F/E of neck- this depends on why they have this restriciton. Do they have fever, nuchal rigidity, HA and confusion then refer out. Were they just in a severe MVA? If no other red flags then I would look to parse out cx F into upper cx F, cx F and CT F first and look for what structure(s) is restricting this ROM and then use myofascial release to increase this ROM.

    5) AIDS due to HIV infection- again being more cautious and looking for new pains and constitutional sx. Make sure they are following up with their PCP.

    6) resticted sh mobility post dislocation- Have they had it reduced yet? If not, send them for reduction.I would be a little more careful here in checking and making sure the neurovasculature has not been comprimised once they returned to my office post reduction. If already reduced, take them through sh ROM and see what structure is limiting this range.

    7) non-specific fatigue- I would ask if they are sleeping well, any extra stress, fever, weight loss/gain, loss of appetite, malaise, Hx of CA, pt over 50, new onset of pain they have never had before, have you discussed this with your pcp, naseau, vomiting, shortness of breath, meds, last lab work, how much does this interfere with your day, Hx of depression, sor throat, cough, etc. I am trained to order and read labs but my personal preference is to refer to their pcp for this as it is most likely not a NMS issue.

    second set of questions
    1) Do you believe subluxations exist? ACA definiton of subluxation: A motion segment, in which alignment, movement integrity, and/or physiological function are altered although contact between joint surfaces remains intact. Basically a hypomobile joint so yes. If you are talking about the historical veterbral subluxation complex with the vitalistic properties then no.

    2) Do you support vaccinations in some or all cases? I guess I would have to say some as I do not personally get a yearly flu shot but my own personal opinion is not always what is discussed with patients.

    3) Do you oppose vaccinations in some or all cases? I would not say oppose but if I had a child I might want to spread out his/her inoculations rather then an all at once thing. Furthermore, I have never had a discussion about vaccines with any patient and never plan to as I will fully admit I have not waded through the evidence. Obviously, vaccines have done some wonderful things but I can’t just say all vaccines are good without looking at the evidence and this is out of my area of expertise (NMS). Also, at my school we had a micro/immunology/public health course and not one anti-vax peice of info.

    4) Do you believe in the germ theory of disease? yes, this is a rather demeaning question.

    5) Do you believe acupuncture “works”, and if yes, do you believe it works through manipulation of chi, placebo effect or another (possibly undiscovered) mechanism? no chi, yes placebo and possibly another mechanism.

    6) Did you get your schooling in the United States, or elsewhere? If elsewhere, are you willing to tell us where? US, I went to University of Western States. I posted this earlier for conspiciouscarl and he seemed rather excited to slam my school but I have not heard from him.

    Hopefully this helps.

  58. arufa says:

    “LBP- my recommendation depends on the pain generator. LBP is only a sx and not a specific enough Dx to recommend any tx. IMO, this is exactly why the majority of LBP studies in all area’s of medicine have failed to show anything over modest results. The researchers are taking a crappy non-specific Dx and throwing a single tx at a multifaceted condition.”

    I agree with this to a point. Researchers often use this “crappy” diagnosis of non-specific low back pain because in most cases there is no other option. And that is a big limitation of the LB literature.

    Based on my experience and my reading of the literature there seems to be no reliable and valid method to determine a patho-anatomical diagnosis for the majority of people with low back pain. Until we come up with a valid way to classify these people the non-specific low back pain diagnosis will not go away.

    I would like to know how you determine the cause of a person’s low back pain. I know that is a complicated question but a general idea of how you go about the process and what validated/unvalidated tools you use.

    It seems that many of the tools we have (history, palpation, segmental and global movement testing and imaging) are not very useful at identifying the pain triggers in most cases. One big problem is that we have no gold standard to identify a pain trigger (I use the term trigger because only the brain can generate pain, everything else can only be a factor in triggering pain generation).

    How do you confirm that you have actually found the “reason” for the pain?

    We know that just about every kind of patho-anatomical disorder of the spine can be present without any symptom, so how do we tell if it is the pain trigger or not?

    I don’t know of any direct way of doing that. If you do let me know because it would be a great topic for my PhD.

  59. WilliamLawrenceUtridge says:

    Jhawk, the vehement opposition you are finding on SBM might have to do with the company you don’t exactly keep, but move in the same circles as. There are chiropractors that deny the germ theory of disease, believe acupuncture manipulates chi, think spinal adjustment can treat and cure infections, and that subluxations are the root of all disease. Not all do, but certainly there are vocal proponents of chiropractic who would consider you a deluded tool of Big Pharma for not embracing the One True Cure for all of life’s ills. Judging by your responses, you appear to be closer to the “chiropractors are a flavour of physiotherapists” school of thought than the “chiropractors are the only true healers in the world” school. Do you recommend nutritional supplements in some or all cases? If so, do you recommend dosages beyond the RDI established by the IOM (I think it’s the IOM anyway)?

    Again, there is diversity within chiropractics the world over. Canada doesn’t allow at least some America-trained chiros to practice here, and my experience with them has usually been reasonable. I wonder what you would think of Sam Homola’s books, and chiropractors trained in other schools…

  60. jhawk says:

    @ arufa

    Yes this is a complicated question. I doubt this is to far off of how other manual medicine practicioners think but here we go! First lets say everything but uncomplicated LBP has been ruled out already and the LBP has at least a 3 wk duration of insidiuos onset. Next, I think what are the possible pain generators (pg) of which there are a lot in the LB (top 3 are disc, facet and SI). I think Hx can actually be a good tool here for placing pg at the top or bottom of the DDX list. Some examples: no neuro signs-HNP causing n compression goes way down on the list, no neuro sx-any n irritation goes way down on the list, no am pain along with no antalgia and no pain with ROM-IDD way down on the list, after these three the disc as pg goes way down on the list. Also having pt map out locaiton of pain can be helpful in narrowing down structures but we must be careful here (“those who treat the site of pain are lost”-somebody smarter than me said this but I can’t remember who!). No catching in LB, no excessive motion via palp and neg prone instability test- instability way down on list. Next is facet joint, no pain with laoded E and palpation-facet joint way down on the list. Third is SI- no pain with provocation and not hypomobile-SI way down on the list. A positive to any of these would obviuosly put them at the top of the list. Now we are left with the muscles, tendons and ligamnets of the LB. Here I use gross and segmental ROM eval. Gross Lx F- if limited what structures can limit this range (pretty small list actually). This does not necessarily mean that the structure limiting the range is a pg only that it is likely casuing a faulty movement pattern which leads to tissues being excessively loaded which could lead to degeneration and pain. Next I look at Segmental Lx F- visualizing if every sp is flexing properly. Then I will palpate to feel if a certain structure is pulling tight during Lx F. My goal is to find the structure limiting the ROM and to increase this ROM to decrease tissue compensation and change faulty loading patterns. I will also check hip, knee, and ankle ROM to see if these could be contributing factors to the LBP as well as performing functional evals such as squat, lunge and active hip E. When we add everything up form the Hx, exam and functional eval I think a reasonably specific diagnosis can be made. At least hopefully more specific than LBP!

    How do you confirm that you have actually found the “reason” for the pain? I use some sort of provocative test. Example: Lx F increases P to a 7/10 at 30 degrees and active hip E is postive for R Lx deviation upon first visit pre-tx . First visit post treatment of R Lx multifidi from L3 to L5 the pt’s Lx F increases P to only 3/10 at 60 degrees. At next visit pre-tx the Lx F has sustained at 3/10 at 60. I can reasonably assume the R Lx multifidi was a contributing factor to the Pt’s LBP. Then I re-test acitve hip E pre-tx and find R Lx deviation so I treat R psoas. post tx test shows active hip E is neg for R Lx deviation and Lx F now only increases P to 1/10 at 80. This 1/10 at 80 is has sustained at next visit pre-tx as well as the neg active hip E. Now I can reasonably assume the R psoas and R multifidi were contributing to the pt’s LBP.

    Now obviously this system has its flaws and you can’t be 100% sure of the Dx but I think this does a good job of increasing the specificity of your Dx.

    As an aside and in regards to your PhD topic, have you seen the CPR’s for LBP that delineate who should get SMT, mckenzie or stabilization? I think it’s a good start at subgrouping LBP patients.

  61. jhawk says:

    @WLU

    “Jhawk, the vehement opposition you are finding on SBM might have to do with the company you don’t exactly keep, but move in the same circles as. There are chiropractors that deny the germ theory of disease, believe acupuncture manipulates chi, think spinal adjustment can treat and cure infections, and that subluxations are the root of all disease. Not all do, but certainly there are vocal proponents of chiropractic who would consider you a deluded tool of Big Pharma for not embracing the One True Cure for all of life’s ills.”

    There definitely are some, I am just not sure they are in the numbers proposed here at SBM. IMO, I think to a point it is the squeaky wheel gets the grease. The ones with the most extreme viewpoints are the ones that express them and are therefore the ones that are heard. Since they don’t get referrals from other providers they need to market, market, market.

    “Judging by your responses, you appear to be closer to the “chiropractors are a flavour of physiotherapists” school of thought than the “chiropractors are the only true healers in the world” school.”

    I would agree with this comment but I think both professions have seperate things to offer in some regards as I treat pt’s in my office and receive and give many referrals to pt’s as well as MD’s for that matter.

    Do you recommend nutritional supplements in some or all cases? If so, do you recommend dosages beyond the RDI established by the IOM (I think it’s the IOM anyway)?

    Almost never. Sometimes I talk about vit D due to my more northern latitude. I do talk about diet more than supplements but not horribly often. Honestly, many of the people I see are in general good health outside of MSK issues and have been referred from another healthcare provider (who usually have discussed these issues already) or have been injured during sporting activities.

    “Canada doesn’t allow at least some America-trained chiros to practice here, and my experience with them has usually been reasonable.”

    Interesting. I did not know this. The school I went to had a good chunk of Canadians that came down for their education and then returned to their respective provinces post graduation.

    ” I wonder what you would think of Sam Homola’s books,” I have never read them.

  62. Dr D says:

    Wonderful piece, thank you. For your interest, there is a debate going on in Australia on the validity of chiropractic degrees and the delivery of pseudoscience in our Universities, which can be followed here https://theconversation.edu.au/theres-no-place-for-pseudo-scientific-chiropractic-in-australian-universities-4576

    A rebuttal from a chiropractor stated that there was a whole of of research to provide them an evidence base. To my knowledge the chiropractic schools in Australia have very few PhD students, very few post-docs and very few researchers, which translates to a (disappearingly) small research output. I assume that is also the case in the US?

  63. Dr D says:

    Wonderful piece, thank you. For your interest, there is a debate going on in Australia on the validity of chiropractic degrees and the delivery of pseudoscience in our Universities, which can be followed here https://theconversation.edu.au/theres-no-place-for-pseudo-scientific-chiropractic-in-australian-universities-4576

    A rebuttal from a chiropractor stated that there was a whole lot of research to provide them an evidence base. To my knowledge the chiropractic schools in Australia have very few PhD students, very few post-docs and very few researchers, which translates to a (disappearingly) small research output. I assume that is also the case in the US?

  64. nybgrus says:

    There definitely are some, I am just not sure they are in the numbers proposed here at SBM.

    Despite the extensive amount of evidence documented here at SBM, along with the licensing exams you guys take. And even if it is just the squeeky wheel effect, that doesn’t negate the fact that the leading chiro journals and the ACA itself don’t jibe with the non-vitalistic viewpoint.

    But even then, I still fail to see how a purely NMS practice, without any utilization of pharmaceuticals or non-manual therapeutic modalities warrants a 4 year post graduate doctoral degree. Nor do I see how that justifies the DC desire to act as PCPs, or really anything else except for referall for a very specific subset of patients much like PT would. It seems like a really extensive pigeon hole at best – trained to figure out who to refer (which is tough!) but to basically do so very little as a stand-alone practice.

  65. arufa says:

    Jhawk,

    Great answer to my complicated question. You did a wonderful job of explaining how you come to a conclusion regarding the cause of a person’s low back symptoms (better and more concise then I could). I agree with you that what you explained is pretty close to what most PTs would do. I don’t want to spend too much time on this because it may be a bit off topic but I do think it speaks to scientific thinking.

    Your process makes sense however in my experience lots of things that have made sense to me (and others) end up being bogus. The method you use while logical is not backed by science. I understand why we need to use a method like yours in the clinic however we need to be honest with ourselves and understand that systematic methods like this are probably not that accurate. Researchers don’t like using the heterogeneous term non-specific low back but they cannot classify subjects with a patho-anatomical diagnosis based on a system that simply makes sense. They need a system that has been shown to be reliable and valid. There have been many attempts at trying to find methods to reliably and accurately diagnose a specific patho-anatomical diagnosis and they have all failed. Even in the few cases where a clear patho-anatomical diagnosis can be made, the research has shown that the diagnosis often does not predict which interventions will be most effective.

    In the clinic, the success of treatment is often used to confirm that the specific cause of the LBP has been found. This is very flawed as I am sure you are aware.

    I am very familiar with the treatment based classification system and the CPR for manipulation and stabilization. That system came about because we are unable to find the cause of LBP. John Childs, Julie Fritz and Tim Flynn decided that instead of trying to find a patho-anatomical cause, they would try to come up with a tool to help clinicians predict the effectiveness of an intervention. The fact that the treatment based classification system ignores the “cause” of the back pain is exactly what makes it unique.

    Bottom line it looks like you make decisions in a similar fashion as much of the PT world. However, without any evidence for the effectiveness of a system like yours, it is very possible that flipping a coin would be just as effective.

  66. WilliamLawrenceUtridge says:

    Jhawk:

    There definitely are some, I am just not sure they are in the numbers proposed here at SBM. IMO, I think to a point it is the squeaky wheel gets the grease. The ones with the most extreme viewpoints are the ones that express them and are therefore the ones that are heard. Since they don’t get referrals from other providers they need to market, market, market.

    Nonscientific practitioners have a disproportionate impact over their scientific competitors. They use rhetorical (and at times political) strategies to compensate for the dearth of scientific evidence supporting their chosen interventions. This is a greater poison than their day-to-day treatment of the worried well; I would be that most people at SBM would be perfectly happy to let people waste their money on chiropractic, acupuncture and homeopathy were it not for the corrosive effect on the overall reputation of medicine and efforts to get public support. As a Canadian with medical insurance, I really don’t want either covering (most) chiropractic care, homeopathy, acupuncture, Gerson therapy for cancer and the Liberation procedure for MS until they’re proven to work (assuming they ever are).

    My main objections to nonscientific practitioners are not about people wasting their time and money. I object to:
    * Misuse of public funds (only a concern in countries with national health care systems)
    * Higher premiums for insurance companies
    * Criticisms of mainstream medicine, particularly if a patient is too young to understand or they quackery for substitute conventional care
    * General erosion of public respect for science and scientific medicine
    * “Big Pharma” accusations that divert time and attention from scientific investigation as well as meaningful efforts to regulate the pharmaceutical industry

    If you really want to do something to help your profession and reduce criticism from this blog, I would suggest advocating for a separate regulatory body and professional identity that separates you from the lunatics who think spinal manipulation cures cancer. It would help pretty much everyone if we could point to chiropractors and say “they’re nuts” while pointing to your profession, calling it something different and saying “they’re not”.

    Again, you’re being tarred by brushes with your less respectable colleagues. If you wish to avoid being blackened, the solution is distance.

  67. rwk says:

    @Harriet Hall,Jann Bellamy,Nybgrus,Sam Homola and especially Dr Robert

    Who’ll be the first of you to dismiss this:

    http://www.pulsetoday.co.uk/newsarticle-content/-/article_display_list/13254843/spinal-manipulation-and-exercise-best-for-neck-pain

  68. Harriet Hall says:

    Edzard Ernst was the first to comment. He said “This study has numerous rather obvious flaws. For several reasons, the comparisons between the SMT or HEA and the medication group are of questionable validity: the latter group was treated in a different setting with medications that are only loosely described, at unspecified doses and durations; amazingly we are even told in the small print (legend of appendix Table 5) that “6 participants in this group… received no treatment”.

    This leaves us with the comparison between the SMT and the HEA groups which, I fear, is equally problematic. Not only was there no attempt to control for placebo effects, but the patient- therapist contact time differed considerably between both groups. While the SMT group enjoyed an average of 15 “hands on” treatment sessions of 15-20 minutes each, the HEA group merely had two 1-hour sessions of instructions. It seems reasonable to assume that the non-specific effects of patient-therapist interactions involving touch, verbal and non-verbal communications etc, determined the outcome.

    In my view, a rational conclusion from the reported data would be that 1) different therapeutic setting can lead to different outcomes, 2) despite strong non-specific effects, SMT is not better than HEA, 3) this study continues the long list of NCCAM-funded RCTs of chiropractic which are ill-conceived and poorly reported (2).”

    My interpretation is similar. The abstract even says “No important differences in pain were found between SMT and HEA at any time point.” So it means home exercise works just about as well as manipulation; and home exercise has the added advantages of greater safety, fewer trips, and less expense.

  69. jhawk says:

    @ arufa

    I agree with much of what you are saying but I do have a few thoughts and questions. I think the “cause” of LBP has not been “found” because it is different for each individual. Each individual most likely has many compensation patterns and degenerated (not necessarilly cartilage degeneration more dis-use atrophy) tissues over mutliple years leading to a multicausal origin, which in some is going to include casues outside of a patho-anatomical Dx such as psychosocial factors. This is why I am not sure researchers will find a way to reliably classify LBP subjests. Is it possible to amount an evidence base through this systematic process that is used in the clinic? Has this been studied? I know the seperate parts have been studied but what about the system as a whole as many data points need to be added up from each part to arrive at a Dx. It seems to me that it could be done in at least a single blind manner. The only other flaw that I could see (at this point) would be that the sham Tx would have to be made up on fly by the practicioner and therefore would be different for every pt. Is this to much of a confounding variable? Example: take a group of ULBP patients and then randomly allocate them to 3 or more cohorts. Cohort 1- clinical systematic process (CSP), cohort 2- sham (CSP), cohort 3- watch and wait, cohort 4,5,6- Rx, SMT, back school, etc. I know this leaves us with interaction bias but wouldn’t this at least show us which Tx approach is most effective for LBP and that this CSP that many manual medicine practicioners use is either more or less effective than the controls (watch and wait and sham) and therefore better than a coin flip?

  70. nybgrus says:

    @rwk:

    That was easy.

    Oh yeah, and lets see. What else.

    A 6 year long study that had a whopping 272 patients.

    Pain scores in all all groups dropped to: 1.5, 2.08, and 1.74. Can anyone say “statistical significance but no clinical significance?”

    Study leader was vice president at an chiro and acupuncture school.

    And like Dr. Hall (and Ernst) said, many, many more chiro adjustments and “No important differences in pain were found between SMT and HEA at any time point”

    Oh yeah, and they didn’t even define their groups “No specific criteria for defining clinically important group differences were prespecified or available from the literature”

    Looks like a great study to show how chiros can pump more money out of people.

    Did you honestly think that was a good study that showed any sort of vindication for cervical spine manipulation??

  71. jhawk says:

    @nybgrus

    “But even then, I still fail to see how a purely NMS practice, without any utilization of pharmaceuticals or non-manual therapeutic modalities warrants a 4 year post graduate doctoral degree.”

    I don’t think NMS Dx and Tx is as simple as you think. Chiro’s see NMS issues without referral so chiro’s must have training to take a full Hx, do a full exam and arrive at a Dx and be able to spot non-NMS issues (not that easy sometimes as I am sure you are aware) and refer. I think 4 years is sufficient just as optemetry and dentistry are sufficient.

  72. jhawk says:

    @ WLU

    “Nonscientific practitioners have a disproportionate impact over their scientific competitors. They use rhetorical (and at times political) strategies to compensate for the dearth of scientific evidence supporting their chosen interventions.”

    This is exactly what I meant by the squeeky wheel analogy and is why I have heard the names Mercola, Weil, Oz, etc. but have never heard the name of any MD on SBM. In anticipation of your response to this comment: is there a disproportionate amount of these nonscientific practicioners in chiro as opposed to medicine? I would say yes but I do think there is change in the chiro profession (U. of Western States I believe is an example as well as the closing of Cleveland school and the addition of the research department at Palmer which is considered to be one of the least scientific schools.

    http://www.palmer.edu/FundedResearchProjects/)

    I will try and answer more later but I have to go exercise this damn holiday weight off yet again!

  73. DrRobert says:

    There’s an extremely well written critique of that chiro neck pain study here:

    http://updates.pain-topics.org/2012/01/chiropractic-or-exercise-tops-meds-for.html

    My comments, which are in that thread:

    - I think it’s rather important to note that medical doctors do not simply treat pain disorders with only pain medication. No medical doctor believes that pain medication cures the body. Not one. Pain medication is a “crutch” to help while the patient receives treatment that will cure the body.

    - In the example of neck pain: the patient’s medical doctor may or may not prescribe pain medication, but will also prescribe a slew of other treatment modalities for the patient. For example, depending on the actual severity and cause of neck pain, the doctor may prescribe home exercises (we have sheets pre-printed to give patients.) Or, we may prescribe for the patient to attend physical therapy X number of days per week. Or, if indicated, we may ask the patient to consider undergoing surgery. Obviously, it depends on the actual pathology.

    - I think it’s a major point about the gigantic discrepancy in the number of follow-up visits each set of subjects had. Chiropractic care subjects received the most number of follow ups, and I’m sure they were given enthusiastic statements such as “We are really going to tackle that neck pain! We really want that neck pain to go away!” HEA subjects had fewer follow-ups, and medicine subjects had fewer follow-ups too.

    - I also think it’s a major point that “chiropractic care” in this circumstance included essentially everything possible (SMT, massage, hot/cold compresses, etc) which, if anything, validates physical therapy and not chiropractic manipulation.

    So what did that study tell us? It told us that having a patient miss work and come in to a chiropractors office 5 days a week and receive expensive and possibly lethal manipulation of the neck is just as poor of a treatment for neck pain as having a patient meet a couple of times over a period of many months and showing them a few exercises and encouraging them to do them. Fantastic. Chiropractic = completely obviated by a xerox machine and exercise handouts.

    I think, if anything, this study just damns chiropractic. It shows that chiropractic is no better than minimal contact while showing patients a few exercises, and not any better than pain medication, which isn’t even a treatment for neck pain (as I stated above.) If anything, the specific neck pain in this study heals over time.

    I also think the “significant statistical difference” of a subjective pain score between 1.5 and 2.08 is hilarious.

  74. arufa says:

    Off topic and pet peeve of mine,

    Dr. Robert, please do not “prescribe” physical therapy. Physical therapy is not a thing like a medication. Physical therapy is a profession. You would not prescribe neurology for a patient, you would refer them to a neurologist.

    Please refer someone to a physical therapist so that the therapist can evaluate the patient and treat them appropriately.

    It seems like a small point but this attitude leads to paper titles like “physical therapy vs. education for treatment of X”. Often these studies make no sense because what they call PT is way off and the education they give is exactly the education a patient would get from a good PT.

  75. Harriet Hall says:

    @arufa,

    Perhaps you can clarify something for me. When I practiced in the Air Force, I could put in a consult to physical therapy but I was required to specify what I wanted. I was not allowed to simply ask them to evaluate and treat. It seems like you’re saying that is exactly what doctors should do. Has the situation changed?

  76. arufa says:

    @ Hall

    I am saying that all you should put is evaluate and treat. Sometimes other info may be helpful like MRI findings or precautions after surgery if they are not standard. Often it may be required by insurance that you put down a diagnosis, but I am going to evaluate them and treat them based on my diagnosis.

    I cannot speak about the Air Force and its policy. I will say that in the Army, PTs are primary care for musculo-skeletal disorders. Most times soldiers will see a PT first who then decides if the patient is appropriate for PT or needs to be seen by another specialist. This system works amazingly well and saves a boat load of money. There are many other examples of PT being put first and patients get better faster with less expense.

    In just about every state in the US, PTs see patients direct access (without a referral). Some insurances may require that the MD sign off on the plan of care but that is simply and outdated, wasteful and unnecessary step. The vision of the APTA (American physical therapy association) is that PTs will be recognized as the first line provider of choice for musculoskeletal management (non-operative) by 2020.

    It makes no sense to tell a therapist what to do. If you have such little confidence in the PT you are sending your patients too then you should find a new one. I guarantee that I know a lot more about physical therapy then any practitioner who sends a patient to me. I am always open to suggestions but I am going to treat the patient based on my judgment not based on what I am told to do.

  77. DrRobert says:

    @arufa,

    I apologize if I offended you. I do think you’re overreacting though. I never stated I would tell the physical therapist how to do their job. On the form I fill out I put the recommended number of treatments per week and what my diagnosis is. Of course if the PT wants to change the number of sessions per week, or anything else, that is completely fine and I wouldn’t argue. I certainly hope the PT knows more about PT than I do. Otherwise your profession would be redundant. But yes, I do prescribe physical therapy.

    Sorry, but I don’t like your idea of letting the physical therapist come up with their own diagnosis and going from there. Also, I think the idea of a physical therapist acting as a “primary care provider” for musculoskeletal pain is an absolutely horrible idea. A few years back my mother had skeletal pain in her ribs. Turns out it was multiple myeloma, and we were able to put her into remission because we caught it so early. How many months would that have gone untreated if she first presented to a person who is musculoskeletal oriented?

    Honestly, from your comment above it seems that PTs are making the same mistakes chiropractors made. You want to be seen as a “primary care doctor” but that’s just an absolutely horrible idea. You say it’s an “outdated, wasteful and unnecessary step” to have a MD refer to a PT. I think it’s a dangerous and unwise proposition to have a PT be a “primary care provider.” Honestly, that’s the type of PT that I would never refer a patient to.

  78. rwk says:

    @DrRobert
    Your above example is political correctness at it’s worst. What if Arufa was a chiropractor? You may not like the headlines or the study behind it :

    http://well.blogs.nytimes.com/2012/01/03/for-neck-pain-chiropractic-and-exercise-are-better-than-drugs/

    but do know you’re along way off from your goal of eliminating the chiropractic profession.

  79. arufa says:

    jhawk,

    If every patient’s low back pain is caused by something different, then how would we ever be able to chose the appropriate treatment. Wouldn’t every patient need a different intervention if the cause was unique to that patient?

  80. arufa says:

    Dr. Robert,

    No offense taken just pointing out that you prescribe a treatment or a medication and you refer patients to professionals. PT is not a treatment.

    I would put a PT up against an MD any day in determining if a musculoskeletal complaint was mechanical or non-mechanical. I would not expect a PT to diagnose a myeloma but I would expect them to catch that the condition was not simply musculoskeletal and get the patient to an MD. There are always cases where more serious conditions mimic msk sx very closely. I would say that most people would miss this unless they are doing advanced imaging on everyone. The great advantage we have is that I am seeing the patient weekly. After a few weeks if they are not progressing as expected off they go to the MD.

    The PT profession is nothing like Chiro. We do not want to be primary care physicians. If someone has back pain it is wasteful to have them wait 3 weeks to see their MD, then get meds, then get unneeded images and then after 5-6weeks get sent to a PT. If they have symptoms and risk factors which make them likely to have a more serious problem then the PT will “prescribe”(j/k) doctoring and send them to their MD.

    I mean think about it. Someone has back pain they can go see a massage therapist, a chiro, an acupuncturist, yoga therapist etc… and you have a problem with them seeing a PT? A PT who has been trained very well to identify individuals who need further workup. It has worked for the military, several other countries and it is working in the US in many states.

    Don’t get me wrong. I love being part of a team and I love getting referrals from MDs, DOs, PAs, NPs etc… However, if a patient wants to see me there should not be an extra hurtle.

    Bottom line there is no evidence that seeing a PT direct access is a danger to patients. There has been no increase in malpractice suites and other litigation against PTs in states with direct access. Check out this study from the military.

    http://www.jospt.org/issues/articleID.814,type.2/article_detail.asp

  81. arufa says:

    Dr. Robert

    I am curious as to what your specialty is and what state (or country) you live in.

    There are very few states (less than 5 I think) that don’t allow direct access to PT. So if a patient walked off the street into a PTs office and that PT did not turn them away, you would not send any of your patients to them? If you are in a direct access state I am sure that the PTs you send patients to accept patients direct access.

  82. nybgrus says:

    I don’t think NMS Dx and Tx is as simple as you think.

    Its not that. It is that what we are getting to is that the only scope of practice that seems to be of any remote utility in chiro is so limited, that the extra training seems completely extraneous. If all you can do is a couple of maneuvers for low back pain (as we’ve seen, cervical manipulation is, well, pointless) then why need to have any other skills? And as I’ve said before – pare it down to that alone, and you areone bored and broke chiro. Start adding stuff that is more in line with science based thinking, and you are merging lanes over to PT.

    …and is why I have heard the names Mercola, Weil, Oz, etc. but have never heard the name of any MD on SBM.

    Weil and Oz are MDs. MDs we think are a crock and whom we call out regularly. If you are going to try and play the persecution card, don’t dismiss your argument in the same sentence.

  83. nybgrus says:

    @arufa:

    When I had my shoulder surgery a couple years ago, my ortho “prescribed” PT. He came in with me (it was an adjunct to his office) and told the PT what my surgery was about and why, my particular time frame, and a few suggestions as to exercises he thought would be most beneficial. From there, the PT tailored everything based on my ability and his experience.

    From my understanding the insurance wouldn’t cover it if it wasn’t “prescribed.” I get where you are coming from but it seems purely semantic in this case.

    As for PTs acting as PCPs…. well, I’m not 100% sold. I fully agree with your arguments, and I definitely see the utility there. However, catching red flags and not missing sinister diagnoses is actually a very difficult thing. I’m not even 100% sold that NPs or PAs could do it entirely stand alone. The difference is they work in the same office as a physician, so if a question arises they can just excuse themselves for 5 minutes and get a quick “consultation.” I reckon with the proper education, a PT could do something similar, but how would you propose to handle the “consulation” issue? Or do you even think it is an issue? I think it is, but my knowledge and experience is limited compared to some of the commentariat here.

    As my step-father quips, “85% of medicine is what the girls in the beauty shop can diagnose. The reason we train for 14 years after high school is to catch that last 15%” And I have seen many real world examples of nurses we were really good – very knowledgeable – think that they were just as knowledgeable as a physician. Because they saw the same thing over and over again enough, combined with a decent base of knowledge, to think that had it nailed down. And then make a mistake.

    So I’m not saying PTs couldn’t do it in principle, but that the education necessary to make them truly stand-alone as PCPs is not too far off from just getting an MD. Unless there is a system wherein the MD can be readily accesible at all times to act as a “consultant” for any cases that get slightly trickier.

    Anyways, just my thoughts on it.

  84. lilady says:

    @ JHawk: I don’t want to be picky here. Your reply on January 3rd regarding “measles” is IMO, (coming from a public health background), totally unsatisfactory:

    “3) measles- this is an odd question. I can’t imagine anyone going to a chiropractor for measles but the majority will probably just need rest. I would send them to check up with their PCP. I would also ask about continual fever and cough and watch for rash.”

    No, no, no, You should immediately call their PCP, not send them to their PCP’s office…thus increasing the risk of exposing additional people to a measles case.

    You should also immediately call your local department of health. If you have seen this patient in the evening or on a weekend…there is always a public health physician or public health nurse “on call” that you will speak with. If there is a possibility that the patient does in fact, have measles, the doctor/nurse will come to your office prepared to draw blood from the “suspect” case and to begin an extensive case investigation. The “typical” telephone conversation with that doctor or nurse would be:

    1. To hold the patient in your office and close off the examination/treatment room where the patient is.

    2. To explain to other patients in your waiting room and to your staff that a health department doctor/nurse is in transit because there is a possible measles exposure and to please wait until the doctor/nurse arrives.

    3. To telephone patients who are “expected” and cancel their appointments…with no discussion about a possible measles case presently in your office.

    4. To have the names, addresses, telephone numbers of patients who were exposed to the possible measles case within the previous two hours, available for the public health doctor/nurse.

    Measles is a high priority “reportable communicable disease” in all of the United States and suspect or confirmed cases require immediate notification to the local health department. Exposures in waiting rooms of doctor’s offices or in other health care facilities, have been implicated in large outbreaks of measles.

    BTW…I reside in New York State…always have, and have had a number of medical insurance plans. Each of those plans do not permit a policyholder to “refer” themselves directly to a PT, yet do permit the policyholder to go to an orthopedist without referral from a primary care doctor. As much as I love my PCP, if my pain is so bad that I need to see a doctor, I go directly to the “specialist”…the orthopedist. Whenever I or a member of my family has required PT, the orthopedist writes the orders describing the location of the pain, the results of their physical examination and the results of any X-rays taken in the orthopedist’s office.

  85. jhawk says:

    @ arufa

    “If every patient’s low back pain is caused by something different, then how would we ever be able to chose the appropriate treatment. Wouldn’t every patient need a different intervention if the cause was unique to that patient?”

    Not necessarily a different intervention but an intervention (same or different) to different areas of the MSK system. This is the purpose of the systematic process, to determine not only what intervention to use but where to use it.

  86. jhawk says:

    @nybgrus

    “Its not that. It is that what we are getting to is that the only scope of practice that seems to be of any remote utility in chiro is so limited, that the extra training seems completely extraneous. If all you can do is a couple of maneuvers for low back pain (as we’ve seen, cervical manipulation is, well, pointless) then why need to have any other skills?”

    Chiro scope of practice includes all MSK issues (plantar fasciitis, achilles tendonopathy, carpal tunnel syndrome, med/lat epicondylitis, shoulder impingement, rotator cuff strain, meniscal injuries, ITB syndorme, and hamstring strain to name a few) with a focus on spinal MSK issues.

    “Weil and Oz are MDs. MDs we think are a crock and whom we call out regularly. If you are going to try and play the persecution card, don’t dismiss your argument in the same sentence.”

    No persecution, I was just pointing out that the most extreme viewpoints are the ones that get all the press.

  87. arufa says:

    nybgrus,

    You are right that the prescribe vs referral thing is a bit about semantics however the language we use is often more important than we think.

    You are also correct that some insurances will not cover PT without a referral, similar to how they won’t cover a specialist without a referral. Every state and every insurance company has different rules/regs.

    I am not one for putting a lot of credence on years of schooling but PTs get 7 vs 8 for MDs. We are not required to do a residency but that is why many states require a certain number of years of experience before a PT can see patients without a referral. In schooling there is a good deal of emphasis put on differential diagnosis and clearing for red flags. I do not agree that “the education necessary to make them truly stand-alone as PCPs is not too far off from just getting an MD”. I think it is very far off from an MDs education. I don’t need to know how to diagnosis and treat anything but neruro/msk problems. I simply need to be aware of, patient and symptom characteristics which raise the probability of a non nmsk condition enough that further workup is needed. We see so many patients with nmsk conditions that we get very good at picking out those which don’t fit the normal patterns and who are at higher risk for mets, infections and other such bad things.

    All a PT has to do is determine if something is neuro/msk related and is appropriate for PT care. If not, or if in question we simply send the patient on (either to the er or physician). I sure that PTs will miss things on occasion but not at a higher rate than other professional. PT without a referral is not new and the fears that conditions will be missed have not come true.

    Your example of the shoulder surgery is interesting. I have a few thoughts on that. First, post surgery is a little different than walking off the street with back or neck pain. Do you think the conversation your surgeon had really made any major difference in your PT outcomes? My guess is that it did not. But, if a surgeon or any practitioner has information about a patient’s condition they should communicate the info to the PT.

  88. arufa says:

    lilady,

    I also live in NY state and you are correct that few insurances will pay for services without a referral. But there are some that do and the momentum is moving towards more allowing it.

    Think about this case, which is a very common situation I deal with. A patient has low back pain and gets an appointment with their PCP. This takes 3 days and the PCP takes an x-ray (which is not needed) and prescribes medication. The PCP also sets up a referral to an orthopod. 3 weeks later the patient gets in to the orthopod who orders an MRI (which is not needed). The ortho then sends the patient to me and in 2 visits they are 80% better and independent with a home exercise program. 6 months later that patient has a re-occurrence of low back pain. That patient now wants to see me as soon as possible and not jump through all those hoops. So they call my office I get them in and they get treated in 1-2 days not in 4 weeks. Plus the expense of medication, office visits and unneeded imaging are gone. There is a growing number of examples where PTs are being put first and the results have been great as far as outcomes and expense. This article was just published.
    http://www.usatoday.com/money/industries/health/story/2012-01-05/health-care-collaboratives/52394918/1

    rwk,

    Thanks for bring up that wonderful study that shows a 1 hour visit to a PT is better than medication and just as good as weeks of chiro. Talk about a low cost, low risk intervention!

  89. rwk says:

    @ Arufa
    “Thanks for bring up that wonderful study that shows a 1 hour visit to a PT is better than medication and just as good as weeks of chiro. Talk about a low cost, low risk intervention”

    The only thing is no one is going to spend an hour showing anybody these exercises:

    http://www.annals.org/content/suppl/2011/12/29/156.1_Part_1.I-30.DC1/156-1-I-30-supplement.pdf

    You wouldn’t get paid.

  90. DrRobert says:

    @rwk exactly. Arufa proposes a rather ridiculous and expensive scenario supposedly showing the incompetence of medical doctors in managing simple LBP. I have a scenario for Arufa: pt presents to GP with c/o mild LBP. GP spends $0.05 to photocopy exercise handouts, spends a few minutes or has nurse go over exercises, and offers mild pain meds as a crutch while patient does home exercises. No referral to PT or chiro necessary.

    After all, the neck pain study showed us that pain meds, home exercise, and the deluxe, all-inclusive care package are essentially equivocal. Again, I point out that no medical doctor says that pain medication will heal the patient. This study showed that simple pain medication and time allowed the patient to heal just about as well as more expensive therapies (well 6 patients didn’t even get medication…) I obviously support home exercise because anything getting the patient moving around and, well, exercising is fantastic. (Note: I don’t believe that 0.58 difference on an extremely subjective 10-point pain scale is significant, considering most patients when I ask them to rate pain on a scale of 1 to 10, give me answers such as “I don’t know, maybe 5-7.”)

    Don’t get me wrong. I have faith in PTs to handle nmsk pain, despite being treated with ultrasound by multiple PTs over the years. But I do wonder if some of this drive to be a “primary care nmsk provider” is reactionary in light of some studies showing perhaps home exercise is equivalent to the care they provide. I don’t doubt the PT does a better job, but we can’t deny that it’s incredibly easier on the patient, and cheaper, to do things at home as opposed to spending hours with a PT.

  91. arufa says:

    No arguments from me Dr. Robert however there is some major risk with some of the medications used.

    I am a little bias that a few visits with a PT to educate and problem solve to make sure the “right” exercises (those that don’t make the patient worse) are used. I would guess that a less cookie cutter set of exercises would have shown better results but I could be wrong.

    There has been a good study on low back pain that showed a lot of cost reduction if patients saw a PT soon and got good PT. Not the magic wand (ultrasound) which is a waste of time and money. I have not done an ultrasound in, I can’t even remember.

  92. lilady says:

    @ arufa: I guess with the scenario and the linked article that your provided about patients who have intermittent episodes of pain, certain insurance companies could permit patients to “refer” themselves to a PT. Just to clarify arufa, according to the scenario and article, these patients have already been seen by an orthopedist to determine that their pain is chronic, correct?

    Also, I don’t set up an appointment with my primary care physician, when the nature of my problem is orthopedic. I’m just full of anecdotes…here comes another one. I dealt with a painful right knee for about ten days, before I made an appointment with the orthopedist for the following day. I could palpate the crepitus and yet I had no signs of inflammation. The doctor examined me and diagnosed a probable spontaneous torn meniscus. We agreed that no MRI was indicated unless the pain was constant and I did not respond to meloxicam and a few PT treatments. Well I responded within 24 hours to meloxicam and “recovered” completely after 3 PT therapies. I also have a stash of meloxicam on hand, for episodic pain and the exercises taught to me by the PT. The MRI would only be necessary to confirm the diagnosis and prior to surgical repair. Other “patient characteristics”…I’m 68 years old and I intend to leave this life without ever having had any surgery.

  93. arufa says:

    lilady,

    I wish you luck on making it though life without surgery. That is a great goal but I question your choice to then use a surgeon as your primary care provider for msk problems. They are really good at surgery but if your goal is to avoid surgery at all costs then I can’t see why you would go right to ortho. It would seem more cost effective to see your primary physician first (I won’t dare say your PT first) and not spend the big bucks on a specialist whos specialty service you don’t want.

  94. Harriet Hall says:

    And what if the knee pain had been from inflammatory arthritis, and a rheumatologist might have been a better choice?

  95. DrRobert says:

    @Arufa, I would accept an orthopedic surgeon’s diagnosis and treatment of msk problems above any other profession’s on the entire planet.

  96. lilady says:

    Another anecdote…I have had right sided (what I believed to be sciatica) episodes since my first pregnancy 42 years ago, then throughout a second pregnancy. I have used this same orthopedist for ~ 30 years. Examination and x-rays never showed any deterioration or misalignment of the spine. I tried to remember to bend properly and to avoid torsion disc injuries. One Saturday evening I just arose from a chair and experienced shooting pain from my right buttock to my knee. I crawled upstairs to bed with a heating pad and some ASA. Early in the AM when I awakened I couldn’t get out of bed…the pain was excruciating.

    I was “rescued” by volunteer EMTs who transferred me on an elongated back board to the hospital, then an MRI. Once the MRI was read and my orthopedist examined me, I was diagnosed with sacroiliitis with possible mild spinal stenosis. I was out of of the hospital in 4 days still in some pain, dulled by some tylenol/codeine. The doctor gave me a corticosteroid shot, but I think the pain would have resolved in the same time frame. I still am very active, a little more careful now whenever I use a ladder to do plastering and painting. (My husbands brags that he buys me the best tools and supplies for my house maintenance.) The only sign of osteoarthritis that I have, are limited to my hands.

    We have found a great PT who also has a plan for $65/month, for unlimited use of the equipment at his rehab center. Great for an older guy like my husband to keep in shape, especially during inclement weather, under the direction of any of the therapists who are at the center. Also great for my husband for returning to a fitness program S/P cardiac stent placements last winter.

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