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

  1. nybgrus says:

    This is the purpose of the systematic process, to determine not only what intervention to use but where to use it.

    Where it hurts taking into account referred pain? I learned that in a week during med school.

    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

    How about a list of what you do and what evidence you have for interventions for a few of those? I realize not all of them would have particularly robust evidence, so how about a couple that do and a couple that don’t with a justification that makes scientific sense and also how that is inherently and necessarily different from what a PT would/could do?

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

    Let me re-quote you:

    This is exactly what I meant by the squeeky wheel analogy and is why I have heard the names Mercola, Weil, Oz, etc. but have never heard the name of any MD on SBM

    Let me rephrashe the statement:

    Chiros get a bad rap because some of them are crazy magic believers, but SBM picks on everyone except for their own, because they never call out any MDs

    But, as I said, Weil and Oz are MDs and we are happy to call out anyone who isn’t science based.

  2. nybgrus says:

    @arufa:

    however the language we use is often more important than we think

    I absolutely agree. I just wanted to head off what I thought might go down a flame-y tangent is all.

    I am not one for putting a lot of credence on years of schooling but PTs get 7 vs 8 for MDs.

    I really didn’t know that. I’ll admit that I thought PT was akin to a bachelors in nursing. Is that the only track for becoming a PT? An undergrad degree (is there any restriction in what major it must be or pre-reqs?) and then a 3 year graduate program? What is the official title at that point?

    My apologies for my ignorance.

    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.

    How to treat, definitely not. How to diagnose…. I am still not sold. I’m also thinking from a practical standpoint. How many sinister diagnoses can present with MSK type issues?

    Multiple myeloma, various sarcomas, prostate mets, rhabdomyolysis secondary to medication (statins or tendon rupture from levaquin for example), septic joints, osteomyelitis, or the (albeit rare) dangerous fracture that is just stable enough to be very dangerous (an occult hangman’s fracture for instance).

    So I would say a PT would need to know how to at least differentiate those diagnoses, and I would argue it is actually harder to try and restrict the education of differentiation than to just teach the diagnosis as a whole.

    And then the practical side become this – is it really more efficient to have patients go directly to PTs and essentially force all PTs to refer to a PCP unless they can absolutely diagnose an MSK issue? (And that’s a genuine question). And how about the people with sinister underlying causes that are lost to follow up (I won’t get into the ones that are misdiagnosed – physicians are able to make mistakes too)?

    If the PT is on site with the physician, then I think a lot of that can be mitigated. But being completely standalone with a referral to a different office as the only option, I am concerned about the practical issues therein.

    Do you think the conversation your surgeon had really made any major difference in your PT outcomes?

    I can’t say. I’ve never had PT for anything before or since. However, the relationship between the ortho and PT seemed quite good and the surgeon’s words were essentially “I want him to focus on X and Y but beyond that you should do what you think is best.”

    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.

    Anecdote time. My girlfriend has knee issues and I had her see an ortho friend of mine. He recommended PT trial first and if that didn’t work out surgery later (in brief she has her inferior patellar ligament fused to her MCL after an injury, so the patella tracks over the medial femoral condyle and leading to pain and chronic inflammation as well as dystrophic calcification). She said that she would just “do it at home” and not bother with the PT. I told her that she should go for at least a few sessions so she could get a good head start and learn all the right exercise to do. She did and, sadly, has not followed up with her exercises as well as she should.

    So perhaps to moderate DrRobert’s statement a bit (which I am certain he is well aware of anyways) there is something to be said for going to PT since it provides the motivation to do it and do it right (just like a personal trainer). However, it became too expensive for her to go so it was a moot point.

    Just food for thought.

  3. nybgrus says:

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

    In Australia they have a pretty rigorous “go to PCP (GP) first for referral” system for precisely such reasons. They pay their GPs a LOT more than their US counterparts and the hours are very reasonable, plus teaching opportunities abound, so it is actually an attractive option for medical graduates. This creates a system that is much more efficient for proper referral because they GPs are extensively trained post-grad for exactly this, and since there is no (well, very little) pressure to pay back loans, it becomes a very feasible career option.

    In my limited experience and knowledge that seems like a much better solution than trying to get NPs, PAs, and PTs to act as their own primary-yet-still-specialist-care-providers. Of course I speak in principle, not necessarily in practical application to the US.

  4. arufa says:

    A lot of great comments and nybgrus you have some good points. My thoughts on this debate is that it could go on forever with lots of anecdotes and what ifs. The bottom line is all the evidence (I realize there is not a lot of peer reviewed evidence) points to the fact that getting patients to PT soon (and even first) is safe, effective and cost saving. Many of the valid concerns about safety have not come true. The Army (I posted a study about the military’s use of PTs first) several other countries (including Australia), large organizations like Kaiser Permanente and Virgina Mason have put PT first and have found it to be safe, effective and cost efficient We can debate if PTs are qualified but the evidence suggests that they are. I agree that we need more studies about this and they are coming.

    We all want what is best for the patient and that is great. I am confident that the data will continue to show that PT first or at least very early in the process is safe, effective and cost savings. I will be very willing to change my position/bias if the literature swings the other way. I am not so sure that others in this conversation would do the same, but I could be wrong.

    http://fearonphysicaltherapy.com/_media/media/file/342138/LBCareDelivery-VMason.pdf

    http://content.healthaffairs.org/content/30/9/1680.short

  5. arufa says:

    nybgrus,

    I think every PT school is at the doctorate level at this point. There may 1 or 2 which are still masters but if they they won’t be for long. A student, like with medical school, can have whatever undergrad major they want but there are some specific pre-reqs needed. They graduate with a DPT, doctor of physical therapy degree.

  6. lilady says:

    I didn’t go to my G.P. first because the pain in my knee was obviously an orthopedic problem…I palpated the crepitus myself and there were no “typical signs” of rheumatoid arthritis such as multiple joint swelling and redness.

    My family (husband, daughter and I) have a long-standing professional relationship with the orthopedist…he operated on my daughter’s knee after a skiing accident and the resulting ACL tear and fx. of the tibial plateau.

    I was correct in my diagnosis, but if the orthopedist thought it might be Rheumatoid Arthritis, he would have ordered a rheumatoid arthritis panel blood test. I believe I saved myself an extra trip and the expense of going to my G.P. prior to being seen by my orthopedist. I am very “sensitive” and concerned about the burgeoning costs of health care, and quite politically vocal about a national health care plan so that everyone in our society has the benefit of good health care.

    As Nybgrus has correctly pointed out BSc. nurses cannot make a medical diagnosis, but we can and do “play doctor” for ourselves and our family members…before we go to a doctor…not in lieu of a doctor’s consultation. And, I usually nail down the “medical diagnosis” correctly.

  7. jhawk says:

    @nybgrus

    “Where it hurts taking into account referred pain? I learned that in a week during med school.”

    Apparently you have not heard of MSK compensation leading to pain at a region away from the dysfunction which is extemely common and much different than referred pain but why would I expect you to as most MD’s have no education in biomechanics. Once again, those who treat the site of pain are lost.

    “Chiros get a bad rap because some of them are crazy magic believers, but SBM picks on everyone except for their own, because they never call out any MDs”

    So now you get to re-phrase my sentences and then come to a conclusion of what I was saying? MD’s and DC’s with extreme viewpoints get all the press. You are arguing the exact point I was making, end of story.

    “How about a list of what you do and what evidence you have for interventions for a few of those? I realize not all of them would have particularly robust evidence, so how about a couple that do and a couple that don’t with a justification that makes scientific sense and also how that is inherently and necessarily different from what a PT would/could do?”

    plantar fasciitis- myofascial release (sometimes instrument assisted) to plantar foot stuctures that are “tight” (possibly different than many physical therapists) , at home stretching and icing before walking in am (probably same as PT’s), Check ankle dorsiflexion and use selective tension and palpation to find out if a soft tissue structure is limiting this range leading to increase load on the plantar foot structures and use myofasical release to increase range (different from majority of PT’s), check LE functional eval including lunge, squat, hip E etc. and fix any problems I find (similar to a few PT’s but not others), possibly mobilization (same) of foot bones and HVLA (different) of ankle mortise joint.

    CTS- myofascial release to soft tissue wrist, hand and forearm structures. Some PT’s do this and some do not. At home stretches, night splints and ergonomics eval (PT’s do this). palpation exam to search for double/triple crush with nerve entrapment release (not many PT’s to my knowledge). If unresponsive surgical referral.

    As to evidence for interventions, a few of these have high quality, many moderate quality and some no evidence either way in which case I use my clinical judgement. This is the case for all NMS medicine. The treatments are inherently difficult to study even on top of the difficulties of sham and blinding. Lets use plantar fascitis as an example. You can not take a group of people with plantar fascitis and lump them in a group and apply a single Tx and expect great results. Why? MSK compensation. Is this patients plantar fascia being overloaded and causing pain due to a decreased/increased arch, overpronation during gait, decreased dorsiflexion, narrow toe box, hallux valgus, hypertonic tib post, etc. If these are not treated along with the plantar fascia then the plantar fasica will not heal properly.

    As to different to a PT, some is and some is not. I know many chiro’s including myself that work along side PT’s. We are similar but can bring different approaches to the table. Also, chiro’s are trained in reading and ordering imaging and as far as I know PT’s are not and can not.

  8. DrRobert says:

    Warning, very unfriendly and unpolitically correct post coming:

    @jhawk, chiropractors may have training in ORDERING X-rays, but they certainly do not have any training in READING them. I would have more faith in a homeless person off the street reading an X-ray than a chiropractor.

    Just today, I had a patient who was told by their chiropractor that they had multiple herniated discs in their cervical spine, and the chiropractor pointed them out to her on X-ray. If anyone knows imaging, they don’t need to be told how stupid, careless, idiotic, and quacky it was for a chiropractor to say that. X-ray of her neck was indicated and besides some loss of lordosis (likely due to muscular strain), her neck was fine. You can’t diagnose a herniated disc on X-ray alone. That’s a quack for you. And for this absolute quack to tell her that she had herniated discs at specific levels, it’s just revolting.

    I’ve seen many hundreds of patients come in with ridiculous and impossible findings on X-rays from chiropractors. One patient was told by the chiropractor that he “healed” her scoliosis, and showed her an X-ray (I doubt it was HER X-ray). On physical exam I could see she still had a curvature in her spine. X-ray revealed a > 10 degree scoliosis. Or the chiropractor who X-rayed my wife’s spine (before I met her), and told her she had scoliosis and spinal spurs. Later on, she needed a chest X-ray and her spine was perfectly straight, no spurs, etc. Or the chiropractor that had a overdeveloped X-ray and said he noticed lots of “inflammation.”

    The fact that chiropractors take X-rays is PURE QUACKERY. Physical therapy is superior to chiropractic treatment for every indication, and PT’s don’t need imaging studies. There is not a SINGLE CONDITION that chiropractors can treat (prove it with legitimate systematic reviews that aren’t published in “Journal Of Manipulative Therapy”, ok?) that is diagnosed by X-ray. Nothing. They simply have no reason to be taking them.

    There’s a story about a chiropractor in our town whose X-ray machine was broke, and when the repair guy came to fix it, he said “I don’t care if it takes pictures, as long as it makes the beeping sound. I have all the X-rays I need already.”

    Here’s an excerpt from something I wrote about chiropractic X-ray abuse:

    The decision by medical professionals to utilize X-rays is a risk-benefit analysis, which means the practitioner must have a clear reason for taking an X-ray, and the X-ray should yield information that will influence the treatment the patient receives.

    Chiropractors are often criticized for their excessive and unnecessary use of X-rays. Chiropractors routinely take full spine X-rays without a clear indication for them, and as with NUCCA therapy they take multiple X-rays of the upper neck.

    Indeed, multiple studies have found that chiropractors use X-rays unnecessarily. Studies have shown that up to 71% of patients being treated for low-back pain by chiropractors have been X-rayed by them.147 Other studies have found that up to 96% of new patients are X-rayed, and 80% of patients on follow-up visits are X-rayed by chiropractors. (Ernst 1998)

    Currently, there is no good reason for chiropractors to X-ray the spine. Many utilize X-rays to diagnose subluxations of the spine, despite the fact that the concept of subluxations is disproven and even evidence-based chiropractors no longer claim they exist.

    Experts on low-back pain uniformly agree that X-rays are usually not useful for diagnosis. In fact, chiropractic textbooks point out that “routine radiographic investigation of the lumbar spine should be avoided because of the radiation hazard but also because inappropriate X-ray examination contributes little to the solution of a particular problem and may even obscure it.”

    Chiropractic guidelines recommend that X-rays are unnecessary for the management of uncomplicated acute low-back pain. Studies show that chiropractors do not adhere to these guidelines and continue to use X-rays excessively.

    Chiropractors routinely employ the use of full spine X-rays, which have been calculated to be more likely to cause cancer than detect bone cancer in the average patient.

    In fact, high-quality systematic reviews (see “Investigations” in this post) have shown that chiropractors are unable to treat any condition that would diagnosed by X-ray. Therefore, it is suggested by the author that if a chiropractor suspects a condition that necessitates X-ray, the appropriate course of action should be to refer the patient to a medical doctor.

    In 1994, a survey of chiropractors in America found that 96% of new chiropractic patients are X-rayed, and 80% of patients are X-rayed on follow-up visits. (Plamindon 1994)

    In 2002, a study assessed the views of chiropractors on the use of radiography (X-rays) for evaluating patients with acute low back pain. The study found that 63% of chiropractors stated they would use radiography on patients with uncomplicated acute low back pain lasting 1 week. 68% stated that radiographs were useful in the diagnostic evaluation of patients with acute low-back pain lasting less than 1 month. The study noted that the reasons given for use of radiography in this study are not supported by existing evidence. The study concluded that there appears to be a high rate of radiographic use by chiropractors which is consistent with findings in previous studies. (Ammendolia 2002)

    In 2008, a study examined the instructions provided at chiropractic schools worldwide on the use of spine radiography (X-rays) compared with evidence-based guidelines for low-back pain. The study found that 56% of chiropractors believed, against evidence-based guidelines, that they should Xray the lower back in the absence of “red flags” for serious disease. The study concluded that this may be responsible for chiropractic over-utilization of radiography for low back pain. (Ammendolia 2008)

    In 2011, a study aimed to determine how well chiropractors manage low-back pain in accordance with recommendations from an evidence-based acute low-back pain guideline. The recommendations were directed at minimizing the use of plain x-ray and encouraging the patient to stay active. The study found that 68% of chiropractors would take an X-ray even when it was not indicated, and 51% would give advice to stay active when it was indicated. The study showed a low adherence to recommendations from an evidence-based guideline for acute low-back pain. (Walker 2011)

  9. rwk says:

    @ DrRobert
    Somethings just don’t sound right about your first ” anecdote”. So the patient happened to have their xrays with them and were intelligent enough to show you exactly what and where the chiropractor had shown them. Did they have symptoms or signs of IVD herniation? Was IVD herniation the sole reason for the films?Why didn’t you call the chiropractor or vice versa. If you really cared for the patient ( and the public as is your “mission”)that’s the first thing you should’ve straightened out.

    “Physical therapy is superior to chiropractic treatment for every indication, and PT’s don’t need imaging studies”

    That’s because you, Nybgrus,WUL and Hall have examined,diagnosed and ordered imaging already,right?

    “There is not a SINGLE CONDITION that chiropractors can treat (prove it with legitimate systematic reviews that aren’t published in “Journal Of Manipulative Therapy”, ok?) that is diagnosed by X-ray. Nothing. They simply have no reason to be taking them.”

    Unless they were about to manipulate a spine with a tumor or saw some other pathology.

    “I’ve seen many hundreds of patients come in with ridiculous and impossible findings on X-rays from chiropractors.”

    Hundreds ?,now that’s an exaggeration. Can you prove that? How come the other MDs like Hall don’t ever criticize you?

    Considering the wonderful relationship between MDs and DCs I find it unlikely that that many people would be carting around their Xray films after just leaving a chiropractor to see you.

    “Chiropractic guidelines recommend that X-rays are unnecessary for the management of uncomplicated acute low-back pain. Studies show that chiropractors do not adhere to these guidelines and continue to use X-rays excessively”.

    You repeat that in the last paragraph.( Walker 2011). In that robust study, it was 68% of 273 chiropractors.
    ( maybe 0.3% of all chiropractors).

    I won’t suggest there aren’t a lot of needless imaging studies done on both sides.

  10. Harriet Hall says:

    Hundreds? Quite possibly, yes. As far as I know, there is no reason to call him a liar. Patients carting around x-rays? No, but I don’t think that’s what he meant. I interpreted it to mean that the patients had reported ridiculous and impossible findings by chiropractors, not that he had seen the x-rays themselves.

  11. Harriet Hall says:

    @ rwk,
    68% of 273 chiropractors. ( maybe 0.3% of all chiropractors).

    Are you mathematically challenged? Studies like that are based on representative samples. The fact that the other 99.7% of chiropractors were not subjects in the study is irrelevant to their conclusions.

  12. DrRobert says:

    @rwk:

    >>”Somethings just don’t sound right about your first ” anecdote”. So the patient happened to have their xrays with them and were intelligent enough to show you exactly what and where the chiropractor had shown them. Did they have symptoms or signs of IVD herniation? Was IVD herniation the sole reason for the films?Why didn’t you call the chiropractor or vice versa. If you really cared for the patient ( and the public as is your “mission”)that’s the first thing you should’ve straightened out.”

    I never wrote nor implied that the patient had their X-rays with them. If it seemed that way I apologize. The patient told me, verbatim, the exact three cervical levels the chiropractor told them were herniated. They said the chiropractor showed them the c-spine X-ray and pointed out the herniations to them.

    Sure, it’s possible the patient misunderstood the chiropractor in some cases. We’ve all had our patients that have “ostopopoloris” and “avanicular nicolorosis”. But when a patient is told they have specific findings that are absolutely untrue… There’s no weaseling out of that.

    Why didn’t I call the chiropractor?When the patient comes to me, they are under my care. I recommend discontinuing chiropractic treatment and recommend PT. The chiropractor is no longer part of the equation.

    >>“There is not a SINGLE CONDITION that chiropractors can treat (prove it with legitimate systematic reviews that aren’t published in “Journal Of Manipulative Therapy”, ok?) that is diagnosed by X-ray. Nothing. They simply have no reason to be taking them”. Unless they were about to manipulate a spine with a tumor or saw some other pathology.

    So your only justification for chiropractor use of X-ray is that they may have a chance finding? Wow. (Personally, I doubt they would be able to diagnose a chance finding anyway, given my experience with their inability to read an X-ray)

    >>“I’ve seen many hundreds of patients come in with ridiculous and impossible findings on X-rays from chiropractors.”
    Hundreds ?,now that’s an exaggeration.” Can you prove that? How come the other MDs like Hall don’t ever criticize you?

    Can I prove what? That I have patients? I swear on my life that my “anecdotes” involving chiropractors’ incompetence with X-rays are absolutely true. And they are only scratching the surface. You can’t criticize fact. Sure, the authors of this blog may criticize me for being unfair and just plain rude towards chiropractors, or for being slanted or biased. I admit that. But after reading hundreds of chiropractic studies, I find that it’s an essentially worthless profession that is more likely to do harm than good. I will not write nice things about it. There may be “legit” chiropractors out there, but I think they are extremely rare and few and far in-between.

    >>”Considering the wonderful relationship between MDs and DCs I find it unlikely that that many people would be carting around their Xray films after just leaving a chiropractor to see you.”

    I’m not sure if you’re being facetious or not. No one ever said patients are walking around with their X-rays. If patients want copies of their X-rays, they pay for them.

    >>“Chiropractic guidelines recommend that X-rays are unnecessary for the management of uncomplicated acute low-back pain. Studies show that chiropractors do not adhere to these guidelines and continue to use X-rays excessively”.
    You repeat that in the last paragraph.( Walker 2011). In that robust study, it was 68% of 273 chiropractors.
    ( maybe 0.3% of all chiropractors).

    See Dr. Hall’s comment. I guess they don’t teach statistics in chiropractor school?

  13. DrRobert says:

    @rwk, regarding this:

    >>”In that robust study, it was 68% of 273 chiropractors. ( maybe 0.3% of all chiropractors).”

    Refer to this:

    In 2007, a study evaluated the perceptions of research, frequency of use of research findings in practice, and the level of research skills of chiropractors. Surveyed chiropractors acknowledged the importance of research to validate their practice, but had little confidence in their research skills and the overall application of research in practice was limited. The study concluded that chiropractors do not consistently apply research in practice, which may result from a lack of research education and research skills. ( Suter 2007 – http://www.ncbi.nlm.nih.gov/pubmed/17320731 )

  14. DrRobert says:

    @rwk, I apologize if these replies are rather rude. I don’t want to create online enemies. I know not every chiropractor is a quack, and I do feel bad for those that aren’t quacks but somehow ended up in chiropractic school.

  15. jhawk says:

    @DrRobert

    “@jhawk, chiropractors may have training in ORDERING X-rays, but they certainly do not have any training in READING them. I would have more faith in a homeless person off the street reading an X-ray than a chiropractor.”

    Not so says this study: Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists.

    “Just today, I had a patient who was told by their chiropractor that they had multiple herniated discs in their cervical spine, and the chiropractor pointed them out to her on X-ray. If anyone knows imaging, they don’t need to be told how stupid, careless, idiotic, and quacky it was for a chiropractor to say that. X-ray of her neck was indicated and besides some loss of lordosis (likely due to muscular strain), her neck was fine. You can’t diagnose a herniated disc on X-ray alone. That’s a quack for you. And for this absolute quack to tell her that she had herniated discs at specific levels, it’s just revolting.”

    Nice anecdote. Are you sure the patient didn’t mean degenerated and not herniated?

    “Physical therapy is superior to chiropractic treatment for every indication, and PT’s don’t need imaging studies.”

    Nice opinion. Evidence please. Here are 2 studies that say otherwise; (Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up.) and (Health maintenance care in work-related low back pain and its association with disability recurrence.)

    “There is not a SINGLE CONDITION that chiropractors can treat (prove it with legitimate systematic reviews that aren’t published in “Journal Of Manipulative Therapy”, ok?) that is diagnosed by X-ray. Nothing”

    This is easy, rib fracture.

    “They simply have no reason to be taking them.”

    How about to rule contraindications to HVLA, acute sports injury, MVA, non-response to Tx.

    “There’s a story about a chiropractor in our town whose X-ray machine was broke, and when the repair guy came to fix it, he said “I don’t care if it takes pictures, as long as it makes the beeping sound. I have all the X-rays I need already.”

    Wow, another anecdote.

    “Studies have shown that up to 71% of patients being treated for low-back pain by chiropractors have been X-rayed by them.”

    Yep a study from 1977 with patients that had LBP for over 3 months. Need I say more.

    “In 1994, a survey of chiropractors in America found that 96% of new chiropractic patients are X-rayed, and 80% of patients are X-rayed on follow-up visits. (Plamindon 1994)”

    You really do like this Ernst article don’t you. I can not get to this article (the one ernst is citing) and can not take his citing seriously due to the 1977 study he cited.

    “In 2002, a study assessed the views of chiropractors on the use of radiography (X-rays) for evaluating patients with acute low back pain. The study found that 63% of chiropractors stated they would use radiography on patients with uncomplicated acute low back pain lasting 1 week. 68% stated that radiographs were useful in the diagnostic evaluation of patients with acute low-back pain lasting less than 1 month. The study noted that the reasons given for use of radiography in this study are not supported by existing evidence. The study concluded that there appears to be a high rate of radiographic use by chiropractors which is consistent with findings in previous studies. (Ammendolia 2002)”

    N=26 with a 76% response rate which means total N=20. Is this generalizable? Hell no. Talk about homeopathy level evidence.

    “In 2008, a study examined the instructions provided at chiropractic schools worldwide on the use of spine radiography (X-rays) compared with evidence-based guidelines for low-back pain. The study found that 56% of chiropractors believed, against evidence-based guidelines, that they should Xray the lower back in the absence of “red flags” for serious disease. The study concluded that this may be responsible for chiropractic over-utilization of radiography for low back pain. (Ammendolia 2008)”

    Interesting how you cherry picked the conclusion. It also said, This survey suggests that many aspects of radiology instruction provided by accredited chiropractic schools appear to be evidence based. And from the results: Of the 33 chiropractic schools identified worldwide, 32 (97%) participated in the survey. Consistent with the guidelines, 25 (78%) respondents disagreed that “routine radiography should be used prior to spinal manipulative therapy,” 29 (91%) disagreed that there “was a role for full spine radiography for assessing patients with low back pain,” and 29 (91%) disagreed that “oblique views should be part of a standard radiographic series for low back pain.”

    “In 2011, a study aimed to determine how well chiropractors manage low-back pain in accordance with recommendations from an evidence-based acute low-back pain guideline. The recommendations were directed at minimizing the use of plain x-ray and encouraging the patient to stay active. The study found that 68% of chiropractors would take an X-ray even when it was not indicated, and 51% would give advice to stay active when it was indicated. The study showed a low adherence to recommendations from an evidence-based guideline for acute low-back pain. (Walker 2011)”

    A survey with a response rate of 37%. Nice evidence.

    Your extreme bias, cherry picking, and citing of worthless studies leads you to your unscientific conclusions.

  16. rwk says:

    @DrRobert and Hall
    Statistics or Biostatistics was not a requirement to chiropractic school admission in 1987. I can find no US medical
    school that requires it at entrance. Yes, it is taught in medical schools and also my Alma Mater. I believe it is only in the last
    twenty years with the advent of EBM that it began to be slowly included in medical curriculum. So there are a lot of
    older practitioners of all disciplines that are deficient.

    By the way,here’s the full study done in Australia:
    http://chiromt.com/content/pdf/2045-709X-19-29.pdf

    Notice the Study Limitations section. As I said this is not a robust study.

  17. DrRobert says:

    @rwk, every medical school teaches biostatistics. I don’t believe it is a pre-requisite for medical school, although it is a required class for science majors, etc.

    @jhawk, link to high quality systematic review showing chiropractic care is effective for broken rib?

    It’s so strange, because when I look for evidence, I keep finding this :)

    Posadzki P, Ernst E. “Spinal manipulation: an update of a systematic review of systematic reviews.” N Z Med J. 2011 Aug 12;124(1340):55-71.

    “Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition.”

    It just seems that if a reasonable person looked at the big picture, where there are a ridiculous number of studies that together show spinal manipulation is essentially worthless for every single condition (either in the form of studies, systematic reviews, or systematic reviews of systematic reviews), that they would just push chiropractic to the side and start investing time in something else.

    But instead, these quacks design and construct ridiculous studies (such as the recent chiro neck study) in a vain and futile attempt to show that the care is somewhat effective for at least one condition. They are so proud to have at least one study that says “hey we might almost be effective as a xerox’ed piece of paper showing some exercises, only we cost over 25,000 times as much and have a risk of death.”

  18. DrRobert says:

    @rwk, excuse me, statistics, not biostatistics, is a req class for most science majors.

  19. jhawk says:

    @ DrRobert

    So you have given up providing weak “evidence” (I hate to even call it evidence) to support your unscientific opinion of radiology and chiropractic and moved on to SMT.

    Ernst study: 4 of the negative studies are done by the authors….. selection bias. 16 (studies included in the review)-4=12. Of these 12 another 4 were for non MSK. 12-4=8. Of the last 8, 3 are for LBP and all conclude that SMT is as effective as any other medical Tx. 2 are for neck pain of which one concludes it is a viable option and the other concludes it is effective with exercise (normal practice). The last 3 are for HA: one concludes better than massage and as effective as meds, second one does not support effectiveness, and third one not enough evidence either way. So LBP: SMT is effective. neck pain; SMT is effective. HA: not enough evidence to say, more needed. All this from an Ernst paper none the less. I must ask did you actually critique this study or just take your buddy Ernst’s word for it?

    This coupled with the American College of Physicians, American Pain Society, AHCPR guidelines and the NICE guidelines and the inherent difficulties in studying manual medicine I am led to a more evidence based conclusion than your bias opinion.

  20. DrRobert says:

    @jhwak, thats’s just sad.

  21. Blue Wode says:

    @ jhawk

    Please note that NICE didn’t take into account the chiropractic ‘bait and switch’ when it made its recommendation:
    http://www.dcscience.net/?p=1516

    Nor did NICE take into consideration the fact that chiropractic back pain patients are often given potentially dangerous neck manipulations. Perhaps the reason for these serious omissions lie in the following quote lifted from the above link:

    “Proponents of spinal manipulation/mobilisation were [therefore] over-represented in the generation of these guidelines, which, in turn could have generated the over-optimistic conclusion regarding this intervention.”

  22. Blue Wode says:

    @ jhawk

    Interestingly, despite the NICE recommendations, many GPs in the UK aren’t referring to chiropractors:

    Quote

    “GPs are being prevented from putting controversial NICE guidance on low back pain into action because primary care organisations [PCOs] are refusing to fund its recommendations of acupuncture and spinal manipulation. Of 127 PCOs responding to requests under the Freedom of Information Act, half said they were currently providing no funding for spinal manipulation…The institute’s guidance on low back pain advises that patients should be offered exercise, a course of manual therapy or acupuncture as first-line treatments. The recommendation was fiercely attacked by musculoskeletal specialists, who questioned whether there was evidence the treatments were effective on top of standard care. Pulse’s investigation suggests PCOs have felt able to ignore NICE’s recommendation because of the controversy surrounding it.”

    http://tinyurl.com/5wjwes7

  23. Blue Wode says:

    @ jhawk

    Re your accusation of selection bias in the Ernst study, you might be interested to read Ernst and Canter’s response to that criticism following the publication of the original study:
    http://jrsm.rsmjournals.com/content/99/6/279.full

  24. rwk says:

    @ Blue Wode
    C’mon! I’m sure you’ve done at least a little study on your own and verified some of the things that Ernst says
    here:

    http://jrsm.rsmjournals.com/content/99/6/279.full

    First he says
    “Spinal manipulation was first described in 1895 by the `magnetic healer’ D D Palmer as a treatment of `subluxations’ of the spine and other joints”

    Wrong Wrong not even close. Osteopathy was discovered ~ 1874 by AT Still. His first school was started in 1892.
    DD Palmer not only was aware of what was going on there but took some classes ! So, chiropractic and spinal manipulation are not original ideas. They’re borrowed. All of you SBM people who think crazy chiropractors started this for spurious reasons need to hone your “research” skills.
    So first of all,Herr Ernst the chiropractic inquisitor immediately looses credibility. If he can’t get that right, and he wrote a book about it, how can you trust him to be unbiased when decided if a study is valid or not? And it can go both ways, that what this site is all about: arguing who’s evidence is better.

    So you, Hall, Dr Robert, Nygmus, WUL,Scott ,Chris,Quill blah blah blah ought to read this and then tell us that there is no value to spinal manipulation whatsoever:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565620/

    Herr Ernst should be forced to read this .

  25. Blue Wode says:

    @ rwk

    Ernst doesn’t use the word ‘discovered’. He uses the word ‘described’ in the context of chiropractic, presumably because he is addressing chiropractors due to most of the criticisms being made by them, and because spinal manipulations (adjustments) are their hallmark intervention.

  26. Harriet Hall says:

    @rwk,

    Your reference doesn’t support your claim. It says manipulations date back to 400 BC. Still is considered the father of osteopathy, Palmer of chiropractic. It says on his tombstone that he founded chiropractic on September 18, 1895. Manipulation existed long before either of them. Still and Palmer adopted it for different rationales: one involving blood circulation and the other, nerves.

    You are attempting to create a diversion. Even if you think Ernst is not “credible” on a historical issue (which you haven’t proven), you have not refuted the findings of his many studies.

    I have never said that spinal manipulation has no value. It is a reasonable alternative for early relief of low back pain for patients who want to avoid medication and don’t mind many visits to a provider’s office.

    If all you can do is lash out like this with insults and put words in people’s mouths, you are the one who will lose credibility.

    How about a little respect? “Herr” Ernst is Doctor Doctor Ernst, both MD and PhD, and you may be surprised to know that he learned to do manipulation as part of his training. Rather than being an “inquisitor” he was favorably inclined towards manipulation and other types of alternative medicine at first, and became disenchanted when he studied the evidence.

  27. rwk says:

    DrHall

    Do you not read the vile comments about chiropractic on this site?
    You chide me but DrRobert( and others) says things like
    “The fact that chiropractors take X-rays is PURE QUACKERY”
    and
    “But instead, these quacks design and construct ridiculous studies (such as the recent chiro neck study) in a vain and futile attempt to show that the care is somewhat effective for at least one condition. They are so proud to have at least one study that says “hey we might almost be effective as a xerox’ed piece of paper showing some exercises, only we cost over 25,000 times as much and have a risk of death.”

    I can dig up some others if you’d like.

    I’ve never seen you criticize any of the insulting comments against by SBM members,did I miss something?

    And of Ernst

    In 2002 Ernst said of homeopathy:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1874503/

    “Until more compelling results are available, homeopathy cannot be viewed as an evidence-based form of therapy”.

    Ernst, in a 2003 interview:
    http://www.guardian.co.uk/science/2003/sep/25/scienceinterviews.health

    He treats his French wife with homeopathy, he says. “We were both brought up with it.”

    In 2010, he calls it unethical to use homeopathy as a placebo
    http://www.guardian.co.uk/commentisfree/2010/feb/22/science-homeopathy-clinical-trials

    I wonder if he still dabbles in a little homeopathy with his wife.

  28. rwk says:

    DrHall

    Do you not read the vile petty comments about chiropractic on this site as well as participate?
    You chide me but DrRobert( and others) says things like
    “The fact that chiropractors take X-rays is PURE QUACKERY”
    and
    “But instead, these quacks design and construct ridiculous studies (such as the recent chiro neck study) in a vain and futile attempt to show that the care is somewhat effective for at least one condition. They are so proud to have at least one study that says “hey we might almost be effective as a xerox’ed piece of paper showing some exercises, only we cost over 25,000 times as much and have a risk of death.”

    I can dig up many many others if you’d like.

    I’ve never seen you criticize any of the insulting comments against chiropractic by SBM members,did I miss something?

    And of Ernst

    In 2002 Ernst said of homeopathy:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1874503/

    “Until more compelling results are available, homeopathy cannot be viewed as an evidence-based form of therapy”.

    Ernst, in a 2003 interview:
    http://www.guardian.co.uk/science/2003/sep/25/scienceinterviews.health

    He treats his French wife with homeopathy, he says. “We were both brought up with it.”

    In 2010, he calls it unethical to use homeopathy as a placebo
    http://www.guardian.co.uk/commentisfree/2010/feb/22/science-homeopathy-clinical-trials

    I wonder if he still dabbles in a little homeopathy with his wife.

    Finally:

    http://www.guardian.co.uk/lifeandstyle/2011/jul/30/edzard-ernst-homeopathy-complementary-medicine

    Ernst says the evidence – though not his own clinical research – supports some uses of acupuncture, herbal medicine, massage, hypnotherapy and relaxation techniques

    And we know what you think of Acupuncture

  29. jhawk says:

    @ Blue Wode

    you said: “Re your accusation of selection bias in the Ernst study, you might be interested to read Ernst and Canter’s response to that criticism following the publication of the original study:”

    I assume you were mostly pointing me to this quote from the article; “The fact that four of the 16 included articles were our own simply shows that we are research-active in this area. To exclude one’s own work in systematic reviews would be woefully unscientific.”

    Just for shits and giggles lets say Ernst is not biased in his reporting and add back in the 4 studies he cited of himself in his review. There is 1 (SMT not effective) for LBP so 3 positive and 1 negative. There is 1 for neck pain which concludes SMT is not more effective than exercise- so it is as effective as exercise and the study does not compare to other Tx’s. The other 2 are for non-NMS issues.

    When you look at the results from this review and even allow Ernst’s reviews of himself it still shows SMT is as effective as any other Tx for LBP and neck pain. And Ernst’s conclusion says this:”Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.” This conclusion is rather disengenous as it comlpetely contradicts the results of the study. This along with his citing of the 1977 study (mentioned earlier in this thread) of LBP patients of 3 month duration to demonstrate that chiro’s x-ray excessively leads his work to be extremely suspect and bias.

  30. jhawk says:

    @ Blue Wode

    you said: “Re your accusation of selection bias in the Ernst study, you might be interested to read Ernst and Canter’s response to that criticism following the publication of the original study:”

    I assume you were mostly pointing me to this quote from the article; “The fact that four of the 16 included articles were our own simply shows that we are research-active in this area. To exclude one’s own work in systematic reviews would be woefully unscientific.”

    Just for shits and giggles lets say Ernst is not biased in his reporting and add back in the 4 studies he cited of himself in his review. There is 1 (SMT not effective) for LBP so 3 positive and 1 negative. There is 1 for neck pain which concludes SMT is not more effective than exercise- so it is as effective as exercise and the study does not compare to other Tx’s. The other 2 are for non-NMS issues.

    When you look at the results from this review and even allow Ernst’s reviews of himself it still shows SMT is as effective as any other Tx for LBP and neck pain. And Ernst’s conclusion says this:”Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.” This conclusion is rather disengenous as it comlpetely contradicts the results of the study. This along with his citing of the 1977 study (mentioned earlier in this thread) of LBP patients of 3 month duration to demonstrate that chiro’s x-ray excessively leads his work to be extremely suspect and bias.

  31. jhawk says:

    Maybe a third time is a charm. Sorry if all three of these get posted. I am not sure why this comment is awaiting moderation as there are no links posted.

    @ Blue Wode

    you said: “Re your accusation of selection bias in the Ernst study, you might be interested to read Ernst and Canter’s response to that criticism following the publication of the original study:”

    I assume you were mostly pointing me to this quote from the article; “The fact that four of the 16 included articles were our own simply shows that we are research-active in this area. To exclude one’s own work in systematic reviews would be woefully unscientific.”

    Just for shits and giggles lets say Ernst is not biased in his reporting and add back in the 4 studies he cited of himself in his review. There is 1 (SMT not effective) for LBP so 3 positive and 1 negative. There is 1 for neck pain which concludes SMT is not more effective than exercise- so it is as effective as exercise and the study does not compare to other Tx’s. The other 2 are for non-NMS issues.

    When you look at the results from this review and even allow Ernst’s reviews of himself it still shows SMT is as effective as any other Tx for LBP and neck pain. And Ernst’s conclusion says this:”Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.” This conclusion is rather disengenous as it comlpetely contradicts the results of the study. This along with his citing of the 1977 study (mentioned earlier in this thread) of LBP patients of 3 month duration to demonstrate that chiro’s x-ray excessively leads his work to be extremely suspect and bias.

  32. Harriet Hall says:

    @rwk,

    You didn’t respond to what I said. You continue to attack Ernst and to provide links that don’t support your points. The Guardian article shows that he is anything but biased against CAM, that he started out with a very favorable impression but was forced to change his mind by the evidence. You continue to attack the writer rather than the content of the writing. You continue to create diversions. You have offered us nothing of substance. I don’t think there is anything to be gained by continuing this discussion.

  33. rwk says:

    @drHall
    And you didn’t answer the first part of last response.
    How about it?

  34. jhawk says:

    @ moderators,

    any particular reason my comment is still awaiting moderation? There are no links.

  35. WilliamLawrenceUtridge says:

    @rwk

    Wrong Wrong not even close. Osteopathy was discovered ~ 1874 by AT Still. His first school was started in 1892.

    DD Palmer not only was aware of what was going on there but took some classes ! So, chiropractic and spinal manipulation are not original ideas. They’re borrowed. All of you SBM people who think crazy chiropractors started this for spurious reasons need to hone your “research” skills.

    So first of all,Herr Ernst the chiropractic inquisitor immediately looses credibility. If he can’t get that right, and he wrote a book about it, how can you trust him to be unbiased when decided if a study is valid or not? And it can go both ways, that what this site is all about: arguing who’s evidence is better.

    Assuming that Ernst got the date wrong (which is itself questionable vis. Blue Wode), that puts his credibility as a historian into question. However, he’s primarily writing as a scientists and medical doctor.

    You trust reviewers to be unbiased by laying out their selection criteria in advance and sticking to it.

    Citing a historical overview to demonstrate that spinal manipulation is a valid medical intervention is curious.

    As for Ernst’s use of homeopathy on his wife – first that interview is from 2003 and it’s quite possible that he’s changed his mind since then. Second, the rest of the interview pretty clearly demonstrates that he believes homeopathy “works”, but it’s his definition of “works” and the “how” that is questionable. He’s pretty obviously stating (and again, in 2003) that he’s open to, if not actively believing, that it works through placebo.

    Part of the problem with the chiro threads is the diversity of the field. Some are essentially indistinguishable from physiotherapists (jhawk seems to be in this group). Others are distinguishable from quacks like homeopaths and acupuncturists only because of their favoured form of intervention and woo. Everyone seems to be getting tarred with the same brush, which doesn’t mixes valid criticisms of nutjobs with invalid criticisms of people who seem to be simple flavours of manipulative therapists (again, I would suggest jhawk fits into this category). A proposed way forward would be for jhawk to admit some of his peers are loons and lunatics, and Sam Homola, Dr. Hall and much of the SBM primary contributors to admit that not all of them are loons and lunatics. I think jhawk would happily admit that vaccinations are good and chiropractic can’t cure cancer, and Drs. Homola and Hall would happily admit spinal manipulation may have some benefit in the treatment of back pain.

  36. Harriet Hall says:

    @WLU,

    I’ve already said it, repeatedly, but I’ll say it again. I support chiropractors like Sam Homola who limit their practice to short-term treatment of musculoskeletal conditions and avoid the nonsense (like applied kinesiology, the subluxation concept, and discouraging vaccination). And SMT is a reasonable alternative for patients with garden variety low back pain who prefer not to take pills and who don’t mind multiple trips to a provider’s office.

  37. WilliamLawrenceUtridge says:

    My apologies Dr. Hall, I believe you have said that exact thing in the past. I’m wondering if jhawk agrees with you, which was more the thrust of my comment.

    Cue dramatic reconciliation music?!?!?!

    SBM needs dramatic music HTML tags.

  38. BillyJoe says:

    jhawk,

    “any particular reason my comment is still awaiting moderation? There are no links.”

    There is also some randomness in which posts go to moderation.
    It should be disabled. The reason I say this is that moderated posts probably never get read because everyone has moved on by the time they get posted.
    I suggest reposting it.

  39. jhawk says:

    @WLU

    “A proposed way forward would be for jhawk to admit some of his peers are loons and lunatics”

    “I think jhawk would happily admit that vaccinations are good and chiropractic can’t cure cancer”

    Yep, I agree with both of these comments and believe I have said this before at some point as well. I also agree with Dr. Hall’s comments.

    @BillyJoe

    Thanks for your input. I posted it three times already and don’t want to add multiple posts of the same comment but I will try once more.

  40. jhawk says:

    WordPress stopped me for duplicate comment. I will change it a bit. Not sure my comment is really worthy of this hassle!!

    @ Blue Wode

    you said: “Re your accusation of selection bias in the Ernst study, you might be interested to read Ernst and Canter’s response to that criticism following the publication of the original study:”

    I assume you were mostly pointing me to this quote from the article; “The fact that four of the 16 included articles were our own simply shows that we are research-active in this area. To exclude one’s own work in systematic reviews would be woefully unscientific.”

    Just for fun, lets say Ernst is not biased in his reporting and add back in the 4 studies he cited of himself in his review. There is 1 (SMT not effective) for LBP so 3 positive and 1 negative. There is 1 for neck pain which concludes SMT is not more effective than exercise- so it is as effective as exercise and the study does not compare to other Tx’s. The other 2 are for non-NMS issues.

    When you look at the results from this review and even allow Ernst’s reviews of himself it still shows SMT is as effective as any other Tx for LBP and neck pain. And Ernst’s conclusion says this:”Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.” This conclusion is rather disengenous as it comlpetely contradicts the results of the study. This along with his citing of the 1977 study (mentioned earlier in this thread) of LBP patients of 3 month duration to demonstrate that chiro’s x-ray excessively leads his work to be extremely suspect and bias IMO.

  41. Cowy1 says:

    “When you look at the results from this review and even allow Ernst’s reviews of himself it still shows SMT is as effective as any other Tx for LBP and neck pain”. So a 3-year post-graduate degree’s primary (and some may argue, rightfully, only treatment modality) is roughly equivalent to a couple of Tylenol for LBP. Hardly impressive and certainly not worth wasting my time looking for the few EBM practitioners when I can just tell the patient that the LBP will go away without treatment in a couple of weeks without going to the local back-cracker (or PT or MD, for that matter) 5 or 10 times.

  42. Cowy1 says:

    “And SMT is a reasonable alternative for patients with garden variety low back pain who prefer not to take pills and who don’t mind multiple trips to a provider’s office.”

    Sure but, Dr Hall, if each of these visits costs 40 bucks and the average chiromancer gets 5 visits (an obnoxiously low estimate) before the insurance stops covering the essentially useless treatment (at least compared to placebo or no treatment) this is going to be an awfully expensive therapy for everyone that experiences LBP.

    Simply, if everyone in the US starts collecting on this “benefit” then add at least a couple billion to the annual HC budget. Hardly chump change and certainly something we could drop with affecting mortality or morbidity to any great extent.

    1. Harriet Hall says:

      @Cowy1,

      I was talking about what works. Cost effectiveness is a different subject altogether. Chiropractors have claimed that their treatments are more cost-effective; but I question that, especially considering that patients are often persuaded to return for maintenance adjustments and for conditions where manipulation is not effective. The most effective treatments are usually cost-effective in the long term.

  43. rwk says:

    Conwy1 could not possibly be a medical doctor or have anything to with money other than collecting his check

    More stupid comments Dr Hall.

  44. rwk says:

    Ps Cowy1
    If you are a medical doctor or soon to be you’ll make alot more than $40 a visit and do a lot less.

  45. nobs says:

    @ Dr. Robert:

    “After all, the neck pain study showed us that pain meds, home exercise, and the deluxe, all-inclusive care package are essentially equivocal…..”

    HUH? “equivocal”? Seriously?

    Perhaps you read a different study? Per this study, the pain medication group had clear and profoundly poorer results.

    1. Harriet Hall says:

      @nobs,
      It was a typo. He meant “equivalent.” And the study showed that home exercise was as effective as manipulation.

  46. Blue Wode says:

    @ jhawk

    Re Ernst and bias.

    Harriet Hall wrote: “…you may be surprised to know that he [Professor Ernst] learned to do manipulation as part of his training. Rather than being an “inquisitor” he was favorably inclined towards manipulation and other types of alternative medicine at first, and became disenchanted when he studied the evidence.”

    That seems to me to be fair comment. For example, in The Desktop Guide to Complementary and Alternative Medicine: An Evidence-Based Approach (2006), 2nd Ed. Ernst E, Pittler MH and Wider B, in the concluding part of the chiropractic section which focuses on giving a risk-benefit assessment, it says:

    Quote
    “Chiropractic treatment might be helpful for low back pain, but the evidence is not convincing. In view of the lack of truly effective conventional treatment for this indication, chiropractic might therefore be worth considering for such patients. For all other indications the evidence is even less compelling. Severe adverse events may be infrequent but mild transient complaints are common.”

    So, in 2006, Ernst concedes that chiropractic *might* be worth considering for *low back pain* sufferers.

    However, in his 2009 paper in the International Journal of Clinical Practice, ‘Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines’, he has become far more cautious:

    Quote
    “It is true that serious complications occur mostly (not exclusively) after upper spinal manipulation. So the guideline authors felt that they could be excluded. This assumes that a patient with lower back pain will not receive manipulations of the upper spine. This is clearly not always the case.
    Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them. And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.
    The guidelines have a number of serious flaws. I contend that they over-estimated the effectiveness of spinal manipulation and under-estimated the risks of this treatment. If evaluated on the basis of the best current evidence by applying the cautionary principle, one will arrive at the following conclusion: it is uncertain whether spinal manipulation generates more benefit than harm for patients suffering from back pain.”
    http://tinyurl.com/6b6nkzg

    Then last year, in his co-authored update of A Systematic Review of Systematic Reviews of Spinal Manipulation in the New Zealand Medical Journal, he doesn’t condemn outright the use of chiropractic in the conclusion:

    Quote
    “The aim of this update is to critically evaluate the evidence for or against the effectiveness of spinal manipulation in patients with any type of clinical condition…Conclusion: Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition.”

    Note the use of the words “collectively” and “convincingly”.

    I’m struggling to understand how you can accuse him of bias.

  47. nobs says:

    @ Hall:

    “The guidelines have a number of serious flaws. I contend that they over-estimated the effectiveness of spinal manipulation and under-estimated the risks of this treatment. If evaluated on the basis of the best current evidence by applying the cautionary principle, one will arrive at the following conclusion: it is uncertain whether spinal manipulation generates more benefit than harm for patients suffering from back pain.”
    http://tinyurl.com/6b6nkzg

    Seriously?

    UMMMM……Your link is to a blog……..

    Can you please provide an objective, preferrably indexed, cite?

    This is, after all, supposed to be a “science based” site…..?

  48. WilliamLawrenceUtridge says:

    rwk, I wasn’t aware that chiropractors were free, thus entitled to criticize MDs for charging for their services. Fantastic, I’ll start going immediately since all it will cost me is time.

    Also, criticizing a doctor for charging for their services doesn’t magically make chiropractic care more effective. You’ve combined two logical fallacies, ad hominem (attacking the person rather than the argument) and false dilemma (assuming that doctors can either give an honest opinion or make money). You’ve mixed in a bit of tu quoque as well I think (doctors and chiropractors both charge money, therefore both have equally valid treatment options). I wonder if your skepticism also applies to chiropractors themselves, since they charge money for their services (but have a significantly less extensive science- and evidence-base to their practice despite many stating they can treat just as many conditions as a doctor).

    Nobs – how about this link, is this indexed enough for you?

    http://www.ncbi.nlm.nih.gov/pubmed?term=19689486

    By the way, there is a trick somewhere in my post. A shiny dollar to whoever finds it!

  49. Blue Wode says:

    @ nobs

    I supplied that link because I couldn’t find a link to the full text online. Hopefully, though, you’ll be able to access the full text via WilliamLawrenceUtridge’s link above.

    BTW, I have a copy of the full text and I quoted the above passage because it is the most relevant to the current discussion. Let me know if you think differently once you’ve read it in full.

  50. WilliamLawrenceUtridge says:

    Aw, BlueWode gave away the trick – that was indeed a pubmed-indexed article he linked to (no full text however, google scholar doesn’t show any). I’m keeping my shiny dollar, mostly out of pique.

  51. rwk says:

    @WilliamLawrenceUrtidge
    A commenter who talks about “chiromancers” ripping off the health care budget for charging $ 40 a visit ?
    Why are you making my comment out to be so complex ?
    Please re-read the tone of the post I commented on.

  52. jhawk says:

    @ Blue Wode

    Re: Ernst and bias

    I have already pointed out 2 instances of bias. His 2006 review of reviews conclusion completely contradicts the actual results of the paper. This is either a monumental mistake, bias, or seriously flawed research-take your pick. Here is a more formal review of his 2006 article. http://chiromt.com/content/14/1/14

    “Then last year, in his co-authored update of A Systematic Review of Systematic Reviews of Spinal Manipulation in the New Zealand Medical Journal, he doesn’t condemn outright the use of chiropractic in the conclusion:”

    I can not get to this article and will not take his conclusion at face-value for reasons I have mentioned previously.

    “Quote
    “The aim of this update is to critically evaluate the evidence for or against the effectiveness of spinal manipulation in patients with any type of clinical condition…Conclusion: Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition.”
    Note the use of the words “collectively” and “convincingly”.”

    This conclusion is the same conclusion he wrote in the 2006 article with the added word convincingly. I can only take this to mean that he actually found more evidence for SMT in this review than the 2006 review, which I have shown that the results actually favor SMT and are in direct contradiciton to his conclusion.

  53. jhawk says:

    @Cowy1

    “primary (and some may argue, rightfully, only treatment modality)”

    This comment is ridiculously misinformed to put it nicely. What about chiro’s training in exercise prescription, Mckenzie, myofascial release, any number of pt modalities, postural retraining, stability training, mobilization, stretching techniques, PIR, PNF, etc.

    “when I can just tell the patient that the LBP will go away without treatment in a couple of weeks without going to the local back-cracker (or PT or MD, for that matter) 5 or 10 times.”

    I wish I could be in the treatment room when you tell this to your first LBP with a 10/10 ops, severely guarded ROM, unable to work, and barely able to get out of bed. This is the exact moment when the pt leaves your office, crosses the street and goes to the chiro. By the way, a majority of patient’s have already taken Tylenol and have had sx lasting longer than 2 wks by the time the come see us.

  54. Cowy1 says:

    @ Dr Hall,

    “I was talking about what works. Cost effectiveness is a different subject altogether. Chiropractors have claimed that their treatments are more cost-effective; but I question that, especially considering that patients are often persuaded to return for maintenance adjustments and for conditions where manipulation is not effective. The most effective treatments are usually cost-effective in the long term”.

    We’re in agreement here; the cost-effectiveness part is just kind of interesting.

    For example, the best-case scenario here is that, if you spin the data just right and ignore crappy study design, a “trial” of SMT is roughly equivalent to a $4 bottle of Tylenol for uncomplicated LBP. Not superior, probably not any safer and it can’t possibly be any cheaper. Certainly, if I had a 3-year post-undergrad degree I’d want a little more bang for my buck, at least for my own self-respect.

    Considering the majority of chiropractors still believe in the subluxation (or whatever new name they thought up for it) so they will treat pretty much anyone with anything while ignoring the quasi-legitimate uses for SMT why should we refer to them at all? Gives most of the legitimacy they don’t deserve, at least based on their practices.

    Predictably, the chiros here will probably start screaming about how deadly Tylenol is after this post.

  55. Blue Wode says:

    @ jhawk

    You are failing to address the real problem. Even if you were correct about Ernst’s alleged bias, you’d still have to get past the lack of evidence-based standardisation in chiropractic (the topic of Dr Homola’s blog post above):

    Quote
    “Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them. And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.”
    http://tinyurl.com/6b6nkzg

    What’s being done to ensure that chiropractic patients aren’t ensnared by chiropractic quackery?

  56. Harriet Hall says:

    I think something has been missed in the criticism of Ernst’s studies, and it speaks to the purpose of this blog. Evidence can be found to support any CAM treatment, but most of that evidence is compatible with what you would expect to find when an ineffective treatment is tested. Ernst is looking for strong, credible, convincing evidence, and he’s not finding much.

  57. DrRobert says:

    Personally, I don’t take a chiropractor’s criticism of a MD PhD’s reaearch with over 600 (or is it 700?) publications very seriously. Especially when said research shows that chiropractic care is …. underwhelming.

  58. rwk says:

    Anyone who has LBP that would respond to a $ 4 bottle of tylenol like Cowy1 states is unlikely to be in any of our offices anyway.

  59. DrRobert says:

    This is the only systematic review I could find for “myofascial release”:

    http://biblio.physiotek.com/sites/biblio.physiotek.com/files/myofascial.pdf

    Conclusions: We are unable to reach any conclusion on the diagnostic criteria and methods or on any efficacy of myofascial release. We recommend strongly that reliability studies be performed on diagnostic tests for myofascial dysfunction (tightness/looseness), so that efficacy studies can be performed on a more solid diagnostic foundation.

  60. DrRobert says:

    @rwk, @jhawk:

    This is M.D.s are so critical of chiropractors:

    http://www.youtube.com/watch?v=0zRhUmgnIQM

  61. arufa says:

    Looks like this conversation has taken a turn towards the unproductive. My better judgement is telling me to stay out of it, but I have never been a very good listener.

    First I just want to point out that many on this site seem to be so bias against chiro that they loose their ability to argue convincingly and effectively. The arguments seem to degrade into “I am going to disagree with anything a chiro supporter says because I don’t like them.” This leads to an unproductive conversation and the valid, well supported, concerns of those who question the tenants of chiro get lost in these non-scientific arguments.

    There are some chiros who attempt to be science and evidence based and they treat very similar to PTs (this includes SMT). If we are going to have a productive conversation about a specific topic like SMT, then we need to drop our biases against a profession and talk scientifically and objectively about SMT.

    My reading of the literature is that using SMT for long term chronic management of low back pain is poor practice. However, one can make a convincing argument that SMT is effective for short term treatment of acute and subacute low back pain. No other intervention that I have as a PT can give me such drastic results in such a short period of time. By drastic I mean at least a 50% reduction is disability after 1-3 sessions. And yes, there is evidence to back that up.

    Now it is justified to ask about cost effectiveness and comparison to other treatments. But bottom line we don’t know what the best treatment is and SMT used wisely seems to be a logical choice.

    We spend billions of dollars on low back pain a year and a very small percentage of it is from SMT. In fact, there is good data to suggest that high quality PT treatment (which includes SMT) can save a lot of money. If I provide SMT and get a patient better 3 days faster, that is 3 days less out of work and they are less likely to see there MD and get an xray/MRI or get sent to a surgeon. The large cost of low back pain treatment comes from imaging, long term use of medication (which makes as much sense as long term use of SMT) and surgery. The kicker is many of these medical interventions (especially complex spinal fusions) are unneeded and don’t lead to better outcomes.

  62. DrRobert says:

    @arufa: I’m ignoring most of what you wrote because I don’t have time to be involved in another argument on the internet, but: would you say that you can treat back pain just as well, if not better, than chiropractors, without ever having to utilize X-ray?

  63. DrRobert says:

    @arufa, I 100% agree with you.

  64. rwk says:

    Dr Robert says
    @arufa: I’m ignoring most of what you wrote because I don’t have time to be involved in another argument on the internet, but: would you say that you can treat back pain just as well, if not better, than chiropractors, without ever having to utilize X-ray?

    arufa says

    Yup!

    Dr Robert says

    @arufa, I 100% agree with you.

    Well I guess that settles it,you both win.
    And for some more childishness- I’ll bet my dad can beat up both your dads.

    This is scientific based medicine.

  65. rwk says:

    DrRobert
    What is your point with the URL?

  66. arufa says:

    rwk?

    Not sure what part of DrRobert’s and my exchange was childish. I made a statement (a lot of which was expressing my opinion, anyone is welcome to agree or disagree) and then he asked me a simple question and I answered it.

    He maybe could have asked the question in more neutral language like “can patients with low back pain be treated with SMT or by a PT effectively without x-rays”. I think it is pretty well established that best practice is to only perform imaging on those patients (with LBP) who are at an elevated risk for nasty things (or maybe to help guide surgery). In no way do findings on an x-ray or MRI help guide the interventions we can provide as PTs and Chiros. They may help with referral decisions but beyond that imaging does not improve outcomes and it does not predict which conservative interventions are most likely to help a patient. This statement is not simply my opinion it is support by the evidence.

    And for the record, is the bet that your dad can beat up both our dads at the same time or in separate altercations? j/k

  67. rwk says:

    @arufa
    The childishness bit was mainly directed at DrRobert,the anti-chiropractic militant. You said exactly what he was looking for. He’s trying to pit PTs against DCs whom can be rivals. You’ve likely given him fodder for his next blog article.
    I’m starting to suspect if he actually is a MD, he’s not a very busy one( or is retired ) to devote his life to the extinction of chiropractic. When does he see patients, make hospital rounds,etc? Most MDs I know don’t have time to do such things.
    X-rays and other imaging have their place,there are guidelines. I’d rather be able to take or order them on my own
    when I think they are clinically necessary than to have to convince DrRobert to do it for me.

    If I said my interventions were better than PTs,that would be just as silly to you,right?

    Don’t forget to look at DrRobert’s latest blog on Myofascial Release and Rolfing. A grade school student couldn’t have done much worse at investigative journalism.
    Myofascial Release is not Rolfing and vice-versa. Not even close. I’d bet there are way more OTs and PTs than DCs doing Barnes’ ( who as you know is a PT ) Myofascial Release. Yet he only mentions DCs and NDs.

  68. jhawk says:

    @ Blue Wode

    ” Thus many, if not most back pain patients receive upper spinal manipulations.”

    Is there any evidence behind this comment?

    “It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.”

    This would only be the case if there is solid evidence for the above comment.

    “What’s being done to ensure that chiropractic patients aren’t ensnared by chiropractic quackery?”

    Many of the schools have added research departments, evidence based practice courses and are teaching the quackery from a historical perspective. UWS being a prime example. Hopefully this will continue and seep into every chiro school.

    @DrRobert

    “Personally, I don’t take a chiropractor’s criticism of a MD PhD’s reaearch with over 600 (or is it 700?) publications very seriously. ”

    Ahhh, the old argument from authority game. It is not just my criticism of the Ernst review, did you read the critique of his review I posted earlier? It includes an MD, PhD (I matched your authority) and will trump it with multiple other PhD’s. Their conclusion: The conclusions by Ernst and Canter were definitely not based on an acceptable quality review of systematic reviews and should be interpreted very critically by the scientific community, clinicians, patients, and health policy makers. Their conclusions are certainly not valid enough to discredit the large body of professionals utilizing spinal manipulation.

    @HH

    “Ernst is looking for strong, credible, convincing evidence, and he’s not finding much.”

    Does any treatment for LBP and neck pain have “convincing” evidence? I think we both understand why there is not any robust evidence so I will not belabor these points again.

  69. Harriet Hall says:

    @jhawk,
    “Does any treatment for LBP and neck pain have “convincing” evidence?”

    When I said Ernst was looking for convincing evidence and not finding much, I was referring to all of his CAM investigations, not specifically to manipulation, but…

    Yes. There is convincing evidence for analgesics, exercise, avoidance of bedrest, etc. There is convincing evidence that manipulation is equivalent to other treatments for certain limited circumstances, but some people are less convinced than others because of the difficulties in separating the specific from non-specific effects of treatment and because of other factors affecting the quality of the evidence.

    There is no convincing evidence that manipulation is superior, and there are legitimate concerns about safety, time commitment, and pseudoscientific adjuncts frequently found in chiropractic offices. There is no convincing evidence that “subluxations” exist.

  70. Blue Wode says:

    @ jhawk

    Re the evidence behind this Ernst comment:

    Quote
    “Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment.”

    Reference (11) is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62.
    http://tinyurl.com/7gknxhy

    Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and references Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.

  71. Blue Wode says:

    @ jhawk

    I don’t have access to the Coulter et al paper, but here’s what Dr Homola said about it in a previous blog post:

    Quote

    “When the RAND (Research and Development) organization published its review of the literature on cervical spine manipulation and mobilization in 1996, it concluded that only about 11.1% of reported indications for cervical spine manipulation were appropriate…Since about 90% of manipulation in the United States is done by chiropractors (1) who use spinal manipulation as a primary treatment for a variety of health problems, neck manipulation is more problematic among chiropractors than among physical therapists and other practitioners who use manipulation only occasionally in the treatment of selected musculoskeletal problems…A physical therapist trained in the use of both manipulation and mobilization for musculoskeletal problems would be less likely to use manipulation inappropriately than a chiropractor who routinely manipulates the spine for “the preservation and restoration of health.”(15)…According to the Association of Chiropractic Colleges (ACC), “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.” (15) Chiropractors who are guided by this vague paradigm (more of a belief than a theory) often manipulate *the full spine of every patient* for “subluxation correction”. Few chiropractors specialize in the care of back pain and other musculoskeletal problems, and only a few have renounced the chiropractic vertebral subluxation theory…Whatever the incidence of stroke per number of neck manipulations might be, this risk is greater per patient among chiropractic patients who may be manipulated many times for “health reasons” and who may be manipulated regularly for ‘maintenance care’.”

    http://www.sciencebasedmedicine.org/?p=1037

  72. Blue Wode says:

    @ jhawk

    Also, it’s worth noting what Dr Homola has to say here:

    Quote
    “There is good reason to believe that most chiropractors are adjusting the spine to correct vertebral “subluxations.” According to Job Analysis of Chiropractic (National Board of Chiropractic Examiners,2005), 96.2% of chiropractors in the United States use a diversified technique that includes an average of six different techniques for full-spine adjusting. About 26% of chiropractors include the Palmer upper cervical/HIO technique among their adjustive procedures. A small percent–1.2%–specialize exclusively in upper cervical techniques, adjusting the atlas as a primary method of treatment. A survey published by Ohio Northern University, How Chiropractors Think and Practice (2003), 88.1% of North American chiropractors believe that the term “vertebral subluxation complex” should be retained in defining the practice of chiropractic; 89.9% believe that a chiropractic spinal adjustment should not be limited to musculoskeletal conditions. The “Chiropractic Paradigm” formulated by the Association of Chiropractic Colleges in North America states that “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.” Most state laws, in keeping with the consensus of chiropractic colleges, define chiropractic as a method of correcting vertebral subluxations to restore and maintain health. Since surveys indicate that most chiropractors are using a diversified or specialized technique to adjust subluxations in the spine, and since most chiropractors believe that vertebral subluxations can affect general health, it’s logical to assume that most chiropractors routinely adjust the spine to “restore and maintain health.”… Many chiropractors dance around the [subluxation] theory, saying one thing and doing another, that is, they do not treat disease; they simply make spinal corrections to relieve interference with the body’s healing powers. The patient might be led to believe that a chiropractic adjustment for neck or back pain might also provide an inadvertent or indirect cure for an organic ailment, thus baiting the patient for spinal care that might help whatever ails them.”

    See http://tinyurl.com/6wjq9f9

    By the way, in the UK around 60-70% of chiropractors admit to chiropractic philosophy (subluxation theory) being important to their practices, and I understand that the figure is higher in Australia and New Zealand.

  73. Blue Wode says:

    @ jhawk

    Re my asking what’s being done to ensure that chiropractic patients aren’t ensnared by chiropractic quackery, you wrote: “Many of the schools have added research departments, evidence based practice courses and are teaching the quackery from a historical perspective. UWS being a prime example. Hopefully this will continue and seep into every chiro school.”

    Teaching the quackery from a historical perspective despite the Association of Chiropractic Colleges claiming “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation”?

    I’m not convinced. Besides, my question was in the present tense and addressed an enormous, problem with current chiropractic practices – i.e. how are the patients of licensed chiropractors in the 30-60 age group, of whom 60-90% (as noted above) operate practices rooted in pseudoscience, being protected from risking their time, money and lives on chiropractic quackery?

  74. Cowy1 says:

    Re: chiropractors abandoning the subluxation.

    Got the hard-sales push from one of Chicagoland’s larger chiropractic practice-management firms, ChiroOne, while picking up some Goose Island after clinic at the local grocer.

    DC – “Want to get your spine checked for nerve interference?”.
    Me – “Not really”.
    DC – “We’ve got a great deal right now to keep your spine healthy”.
    Me – “Not interested”.
    DC – “When did you last get your spine checked?”.
    Me – “A long time ago”.
    DC – “More than a year?”.
    Me – “Yes”.
    DC – “You should really get it checked to make sure you don’t have any subluxations that could cause all kinds of bad things to happen to you”.
    Me – “I’ll be fine, thanks”.

    He then proceeded to start bugging the next guy in line. I was polite but these things are irritatingly frequent in my neck of the woods.

    These people have 50+ “clinics” in the greater Chicago area alone, many of them filled with young grads. The chiropractor hassling me couldn’t have been 30. Sort of blows a hole in the “us new science-based grads don’t believe in the subluxation” theory.

  75. rwk says:

    @cowy1
    1.Why didn’t you tell him off and embarrass him? It’s your duty to SBM
    2.What does Goose Island have to do with it ?
    3.after Clinic as in “Student Clinic”?

    BTW It’s embarrassing to me. The owners of Health Source make all the money not the grunt doing the canvassing.
    The medical counterpart happens at corporate health screenings, hospitals and “clinics” that are basically doing the same thing: Looking for more patients. Your future salary will depend on it.

    http://www.comhs.org/community/screenings.asp

  76. rwk says:

    I meant ChiroOne not Health Source

  77. Cowy1 says:

    @rwk

    #1
    Not my place, not in the middle of the grocery store. Besides, as you admit, standing there in front of the discount pastries and harassing people to get your spine checked is probably embarrassing enough for someone with a “doctoral” degree.

    #2
    It had been a long, crappy day and I needed a drink. It was on sale so I bought that instead of Guinness.

    #3
    Sort-of; I’m an M3 on a core rotation of which the clinic blows terribly, at least from my perspective.

    There is no medical counterpart to “subluxation” screening at a grocery store.

    Besides, and this should be obvious to you, checking for hypertension or hyperlipidemia has a proven mortality benefit; checking for invisible spinal lesions does not. In case you missed it, they were offering a “deal” (reduced rate) where you pre-pay for some number of visits to get your back whacked back into line.

    Re HealthSource,
    Looks like the exact same scam as ChiroOne except the cancer has spread across the entire country. The fact that the state chiropractic boards aren’t investigating these con-artists for out-and-out fraud is unbelievable.

  78. Cowy1 says:

    @rwk

    “your future salary will depend on (health screenings)”.

    LOL, I have yet to see any MD hurting for patients so badly that they feel the need to stand next to the deli counter at a grocery store trolling for business.

  79. marcus welby says:

    Perhaps we need to consider legislation like has evidently been passed in Mexico:

    http://hosted.ap.org/dynamic/stories/L/LT_MEXICO_FAKE_MEDICINES?SITE=FLPET&SECTION=HOME

  80. noahs900 says:

    Anyone know how much a Chiropractor’s malpractice insurance is?

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