Articles

Top 10 Chiropractic Studies of 2013

ChiroNexus recently listed the top 10 chiropractic studies of 2013. In my experience, chiropractic studies tend to be of poor quality. A media report says “study shows chiropractic works for X,” and when I look for the study it turns out to be a single case report or an uncontrolled study. When Simon Singh was sued by the British Chiropractic Association for saying chiropractic treatment for certain childhood ailments was bogus, the BCA responded with a list of 29 studies they said provided evidence for their claims. Steven Novella showed that out of 29 studies on the list, only 17 actually constituted evidence for 4 clinical claims, and those 17 were poor quality, cherry-picked, and too weak to support the claims. I have a copy of a chiropractic textbook entitled Somatovisceral Aspects of Chiropractic: An Evidence-Based Approach and there is nothing in it that would qualify as credible evidence to a science-based thinker. Chiropractic commenters on SBM have told us that modern chiropractic rejects the “subluxation” paradigm and relies on evidence, and I am always willing to look at new evidence and give chiropractors another chance to convince me that a reform movement is really underway, so I looked up the top 10 studies and read them. I was not impressed.

Note: This is a long article with mind-numbing details that will not be of interest to most readers. Feel free to scroll down to the Summary section. You can just read the bold-faced headings describing the claims of each study on the way down.

Also note: For those who want more detail, the “Study #” headings are links to the full text when available online, or to the PubMed citation.

Study #1: Immediate Benefits of Chiropractic Visible on MRI

The full title is “Magnetic Resonance Imaging Zygapophyseal Joint Space Changes (Gapping) in Low Back Pain Patients Following Spinal Manipulation and Side-Posture Positioning: A Randomized Controlled Mechanisms Trial With Blinding.” It was published in the major chiropractic journal, the Journal of Manipulative and Physiological Therapies (JMPT). The authors are from the National University of Health Sciences, a school noted for integrating quackery with medicine. A school that accepts students who don’t even meet their admission requirements and that remedies the lack by teaching them everything they think chiropractors need to know about science in two 8-week sessions of evening classes. Funding was from the NCCAM (in other words, our tax dollars paid for it).

Underlying hypothesis: If the motion of zygapophyseal joints is decreased for any reason (inactivity, repetitive motion, injury), it is hypothesized that they develop adhesions and that both spinal manipulation therapy (SMT) and side-posture positioning (SPP) break the adhesions by “gapping” the joints (separating the articular surfaces, the same process that happens when you crack your knuckles).

Methods: 112 patients with low back pain were randomized to four treatment groups: SMT, SPP, SMT control, SPP control.

First MRI appointment: Patients were placed in a neutral position prior to treatment; the most painful side was always the up side for treatment. An MRI was taken in the neutral position before treatment, then treatment was given followed by a post-treatment MRI.

  1. SPP Group: SPP, remaining in SPP for 2nd MRI
  2. SMT control group: Side-posture SMT, followed by neutral positioning for 2nd MRI
  3. SMT group: side-posture SMT, remaining in side-posture for 2nd MRI
  4. SPP control: brief SPP followed by neutral positioning for 2nd MRI

Groups 2 and 4 served as control groups because previous studies had shown that returning to the neutral position after treatment resulted in no Z joint gapping difference between the 1st and 2nd MRIs.

Treatment phase: All patients received chiropractic care for 2 weeks, including SMT and other modalities.

Second MRI appointment: After 2 weeks of chiropractic treatment, the second MRI appointment was identical to the first with the exception that the groups were switched (1 with 2 and 3 with 4) so that all subjects were in both an intervention and control group and all subjects were in an SPP and an SMT group during the study.

Results: At the first MRI appointment, the SPP group had greater gapping than the other three groups. (SPP .66 +/- .48 mm, SMT .23 +/-.86 mm, controls .18 +/- .71 mm). At the second MRI appointment, SMT followed by SPP was the only group that showed significantly higher increases in gapping from the first MRI appointment. On pain questionnaires, SMT followed by SPP was the only group that showed significant improvement in pain between the first and second MRI appointments.

Conclusion: They speculated that paraspinal muscles may have relaxed more with SPP at the first MRI appointment, whereas SMT might have resulted in transient increased muscle tightness, and that the reversal of findings at the second MRI appointment may have been because the muscles were more relaxed after 2 weeks of SMT. They conclude that SMT is effective in decreasing pain and increasing gapping and that keeping the patient in the side-posture position for several minutes following SMT may have therapeutic benefit.

My thoughts: The research design was complicated, and trying to figure it out gave me a headache. After reading the report several times, I’m still not entirely sure exactly what they did, why they did it, or what the results mean. We already knew that SMT was effective for low back pain, but we didn’t understand the mechanism. This study attempted to show that the improvement is related to increased gapping of the zygoapophyseal joints, but the authors suggest that muscle relaxation may be the mechanism for both increased gapping and decreased pain, raising the question of whether SMT actually accomplishes anything that other muscle relaxing treatments might not do just as well. Basically, before chiropractic treatment, a single SPP treatment increased gapping more than SMT, and after 2 weeks of SMT treatment, a single SMT treatment increased gapping compared to a single SPP treatment. The suggestion of keeping the patient in a side position following SMT is interesting, but this study was not designed to show whether that would improve clinical outcomes. Since the increased gapping disappears as soon as the neutral position is assumed, its clinical importance is questionable. It would be nice to find out if the hypothesized adhesions are real, but the study didn’t address that.

Study # 2: AMA Recommends Chiropractic Before Resorting to Surgery

This is not a study at all. It is a patient information page from the Journal of the American Medical Association. Under the “Treatment” heading it says:

Many treatments are available for low back pain. Often exercises and physical therapy can help. Some people benefit from chiropractic therapy or acupuncture. Sometimes medications are needed, including analgesics (painkillers) or medications that reduce inflammation. Surgery is not usually needed but may be considered if other therapies have failed.

I don’t think this constitutes a recommendation to try chiropractic before resorting to surgery. It mentions acupuncture in the same breath, and specialty organizations like the American Academy of Orthopaedic Surgeons and the American Academy of Family Physicians do not include either chiropractic or acupuncture in their list of treatment options. As a matter of fact, the WHO guidelines for chiropractic specify that disc herniation with progressive neurological deficits is an absolute contraindication to spinal manipulation treatments. It is really a stretch to claim that the AMA recommends chiropractic.

Study # 3: Chiropractic as Effective as Epidural Injections for Lumbar Disc Herniation

This study by Swiss chiropractors, published in the JMPT, was a comparative effectiveness observational study using data from two databases, one of patients who received nerve root injections (NRIs) and the other of patients who received spinal manipulation therapy (SMT) at a single chiropractic practice. Subjects were 51 matched cases of patients who all had MRI-confirmed lumbar disc herniation. (Note: 28% of asymptomatic people also have these same MRI findings.) Two kinds of SMT were given: intraforaminal disk herniation was treated with modified push adjustment with a kick; paramedian disk herniation was treated with pull adjustment with a kick. They did not explain the rationale for when to push and when to pull.

They found no difference in favorable outcomes between the two treatments.

Other studies have found NRI and SMT effective, but the quality of evidence is poor and many studies fail to differentiate between disc herniation and other causes of low back pain. As mentioned under Study #1, chiropractic manipulation is not widely accepted as a treatment option for lumbar disc disease.

They admit some limitations of their study: it was not a randomized clinical trial, so they themselves point out that

the outcomes of these patients cannot be directly attributed to the specific treatments.

(And yet they go right ahead and attribute.) They did not have sufficient demographic information to assess possible confounders. The sample size was small. Outcome data were collected by telephone interview, a method that tends to produce more positive responses than questionnaires. Outcomes were subjective patient reports, not objective measurements. The groups were not comparable: the NRI group had higher pretreatment pain levels. There was an obvious source of bias: patients or referring physicians had chosen which treatment they wanted to try. Also, the NRI was done at a single appointment, while chiropractic patients were seen for multiple treatments. The time spent with the provider is a probable confounder.

They said SMT was slightly less expensive than NRI, but they admitted that they were only looking at direct procedure costs and could not determine overall cost-effectiveness.

This study was not even randomized. It would have made a lot more sense to have done a prospective randomized study and to have ruled out as many confounders as possible. Because of the flaws in this study, no conclusions can be drawn from it.

Study # 4: Chiropractic Lowers Blood Pressure

This was a study from Sherman College of Chiropractic published in the Journal of Chiropractic Medicine entitled “Blood pressure changes in African American patients receiving chiropractic care in a teaching clinic: a preliminary study.” There were only 24 subjects, all black patients diagnosed with pre-hypertension (120-139/80-89) or hypertension stage 1 (140-159/90-99), with or without medication. There was no control group, and the subjects were not a random or characteristic group of hypertensive patients, but a sample of convenience. Chiropractic did NOT lower blood pressure. The results were negative! BP did not change significantly after chiropractic care. They weren’t happy with that result, so they tried throwing out 4 data points from patients with “outlier” high BMIs, and lo and behold! The remaining data yielded a statistically significant reduction in BP (diastolic pressure only). I don’t think throwing out the outliers was justified; I think it constituted illegitimate data mining. And even for the tweaked dataset, the difference was not clinically significant. The diastolic pressure only dropped from 81.5 to 77.1 and the systolic pressure was unchanged.

Study # 5: Chiropractic Best Option for SI Joint Pain

“Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial” was a single-blinded randomized trial from the Netherlands, published in the European Spine Journal. It was a small trial: a total of 51 patients with leg pain attributed to the SI joint were randomized to one of three treatment groups: physiotherapy (exercise), manual therapy (manipulation with high-velocity thrust technique), and intra-articular steroid injections. They set simple criteria for success and failure: success was complete relief or improved VAS (visual analog scale) pain score; failure was dropping out because of worsening complaints or a VAS score that did not improve. The PT group had 12 failures and 3 successes, the manual therapy group had 5 failures and 13 successes, and the injection group had 9 failures and 9 successes. The magnitude of the improvement was small. On the 10-point VAS of pain, PT improved the score by an average of 0.4 points, manual therapy by 1.9 points, and injection by 0.7 points. In their opinion, a clinically meaningful difference was 1.3-2 points. I’m not sure I agree.

They concluded that manual therapy was the treatment of choice for this select group of patients with SI-related leg pain, but cautioned that the findings may not apply to patients not meeting the specific criteria for inclusion in this study and that because of the small sample size, their results need to be confirmed by a larger study.

The patients were referred by general practitioners with the question whether they had a radiculopathy due to a herniated lumbar disc. It can be difficult to differentiate disc pain from SI pain, and some of the tests have questionable inter-observer reliability.

They mention that they had difficulty recruiting patients willing to be randomized. 23% had an overt favorite. 10 wanted an injection, 5 did not want an injection, 1 wanted manual therapy, and 3 wanted PT.

There is no mention of chiropractors in the study. They did not specify who provided the manual therapy.

The findings of this study contradicted other studies. A 2012 study showed that lumbar manipulation was more effective than SI manipulation. Other studies have shown a greater response to intra-articular injections (67%) than the 50% that this study found. And previous studies have found PT to be effective.

Study # 6: Neck Adjustments Immediately Improve Joint Position Sense

A study from Korea published in the Journal of Physical Therapy Science evaluated 30 normal adults who were divided into two groups (no mention of randomization): the test group was given cervical joint manipulation and massage and the control group got massage only. Reduction in cervical range of motion (ROM) is thought to reduce joint position sense and possibly to be related to dizziness; this study investigated whether increasing ROM in normal volunteers by neck manipulation would improve joint position sense (JPS). Researchers showed patients how to adopt six exact neck positions and then were tested with an inclinometer to see if they could adopt the same positions without instruction. The test group improved significantly on all six tests; the control group didn’t. In a comparison of the test group to the control group, two tests showed a significant difference; the other four didn’t. Errors declined from 2.5 to 3 degrees pre-treatment to 1-1.2 degrees post-treatment. The authors recommend that:

when treating patients with reduced JPS due to decreased ROM, persistent neck pain, or whiplash injuries, the combined application of cervical joint manipulation and massage [be] used.

That conclusion is not supported by the data. A study of JPS on normal volunteers with a normal ROM can’t be used to make clinical recommendations for patients with neck pain and decreased ROM. They didn’t even measure ROM; they just measured people’s ability to assume a previously taught position. The clinical significance of improved JPS is unknown. If they think it is the mechanism by which manipulation works, they need to study JPS in patients with neck pain.

Of concern: neck manipulation carries a small but serious risk of stroke. Question: would gentle mobilization and massage get the same results with less risk?

Study # 7: Chiropractic Better than Medical Care Alone for Back Pain

A randomized controlled trial by American chiropractors entitled “Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients With Acute Low Back Pain: Results of a Pragmatic Randomized Comparative Effectiveness Study.” Subjects were 91 military men and women between 18 and 35 years of age with acute low back pain (LBP). All patients got standard medical care and 45 were randomly assigned to also get chiropractic treatment. Standard medical care (SMC) was a single visit that might include any or all of the following: a focused history and physical exam, diagnostic imaging as indicated, education about self-management including maintaining activity levels as tolerated, pharmacological management with the use of analgesics and anti-inflammatory agents, and physical therapy and modalities such as heat/ice and referral to a pain clinic. Chiropractic treatment (CMT) consisted of 5 visits for high velocity/low amplitude (HVLA) manipulation plus whatever else the chiropractor chose to do (education, exercise, mobilization, etc).

Results: 73% of the SMC + CMT group reported improvement compared to 17% in the SMC-only group. Satisfaction on a 10-point scale was 8.9 and 5.4 respectively. There were two adverse events after chiropractic treatment.

Problems:

  • Followup rates were 85% for the standard care group and 63% for the combined care group.
  • Participants had higher expectation of helpfulness for the combined medical/chiropractic treatment than for standard care alone. This is a clear source of bias.
  • Pain, functional status, and patient satisfaction were measured by subjective answers to questionnaire; no objective measurements were done. They did not even track use of pain medication during the trial or speed of return to full duty.
  • Care was not standardized. Improvement could have been due to some other component of treatment.
  • Multiple visits to chiropractor were compared with a single visit for standard care.
  • This was a select group of healthy young patients; results might not apply to the general patient population.

The design of this trial practically guaranteed that it would favor chiropractic. Pragmatic comparative effectiveness trials of CAM treatments are inherently biased to favor CAM. They allow the nonspecific effects of provider/patient interactions to shine. They are not designed to test whether a CAM treatment is superior to placebo; they are a way of bypassing that essential step.

Study # 8: Spinal Adjustments Relieve Muscle Pain Instantly

From the JMPT. 33 healthy young adults with myofascial trigger points in the gluteus medius and infraspinatus muscles were randomized and treated with SMT targeted to the C5-6 spinal segment or with sham SMT. The pressure pain threshold increased in the treatment group. Chiropractic theory says that SMT relieves pain by improving nerve function. Does increased pressure pain threshold mean the nerves in the infraspinatus muscle are functioning better? We don’t know; the study didn’t address that. Does the finding have any clinical importance for patients with muscle pain? The study didn’t address that either.

Study #9: Cervical Disc Herniation Eased by Chiropractic

A study by Swiss chiropractors published in the JMPT entitled “Outcomes from Magnetic Resonance Imaging-Confirmed Symptomatic Cervical Disk Herniation Patients Treated with High-Velocity, Low-Amplitude Spinal Manipulative Therapy: A Prospective Cohort Study with 3-Month Follow-Up.” This was an uncontrolled study of 50 patients. 55% were “improved” at 2 weeks, 69% at 1 month and 86% at 3 months, according to the patients’ own global impressions; there were no objective measurements. Improvement was greater in patients with acute pain than in those with chronic pain. The treatment is exactly the kind of neck manipulation that has been associated with strokes.

How many of these patients would have improved with no treatment at all, due to the natural course of the disease? The authors say it is virtually impossible to extract reliable figures on the natural history of this condition, so a control group is crucial to interpreting the significance of their findings, and it’s hard to understand why they failed to use one. While double blinding with a credible placebo control would be difficult, they might at least have compared HVLA manipulation to gentle mobilization with exercise and physical therapy modalities like heat.

Study # 10: Chiropractic Thaws Frozen Shoulder Syndrome

From the Journal of Chiropractic Medicine. This was a case series of 50 consecutive patients diagnosed with frozen shoulder syndrome (FSS) and treated with a series of chiropractic manipulation treatments of the cervical and thoracic spine, plus a novel chiropractic method, the OTZ Tension Adjustment, which involves a “skull glide” and an HVLA thrust to correct occipito-atlantal subluxation. There was no control group. The findings:

Many of these patients’ complaints seemed to improve or resolve within 1 month of presentation, whereas, in general, it is thought that FSS symptoms can persist for 2 years or more.

This is junk science.

  • There is no credible mechanism by which anything in the spine could cause FSS.
  • There is no such thing as a chiropractic subluxation.
  • Treating problems elsewhere in the body by adjusting the 1st cervical vertebra doesn’t work and is rejected even by most chiropractors.
  • “Skull glide” is not defined and I couldn’t find anything about it on the Internet. Probably a bogus untested maneuver.
  • The OTZ adjustment has never been tested and there is no reason to think it should work for anything, especially in the shoulder. The founder of the system claims it works for frozen shoulder, migraine, vertigo, insomnia, Bell’s palsy, ADHD, posture, and other conditions.
  • The lead author is the owner and founder of the OTZ system.
  • All patients had been treated by the lead author.
  • No control group.
  • Frozen shoulder usually resolves in a matter of months with physical therapy; even without treatment, it resolves within 24 months.
  • Manual manipulative treatment of the shoulder itself has been tested and found helpful for FSS, but manipulation of the spine has not.

It would have been so simple to use a control group, even if it were only to compare chiropractic treatment with and without OTZ. The lead author invented OTZ and proceeded to treat thousands of patients without bothering to test whether it worked.

This amounts to Tooth Fairy Science squared: it is a study about treating an imaginary subluxation with an imaginary treatment.

Summary

To recap, my evaluation of these “10 best studies” showed:

Study 1. Bewilderingly complicated design, clinical relevance of findings not established.

Study 2. Not a study

Study 3. Small study with numerous limitations and evidence of bias; the authors themselves said outcomes could not be attributed to treatment.

Study 4. Negative study misrepresented as positive

Study 5. Small study with evidence of bias; results incompatible with previous studies

Study 6. Small study of joint position sense in normal people, with questionable clinical relevance. Data do not support conclusions.

Study 7. Pragmatic comparative effectiveness trial designed to guarantee it would favor chiropractic

Study 8. Small study with questionable clinical relevance

Study 9. Uncontrolled study

Study 10. Uncontrolled case series; junk science intended to promote the OTZ System, whose owner and founder is the lead author and treating chiropractor.

Questions remain

Is chiropractic effective? Numerous studies have established that SMT is:

  • Effective for certain kinds of low back pain but not more effective than other treatments.
  • Effective for certain types of neck pain but only when accompanied by exercise, and not more effective than mobilization.
  • Not effective for any other condition.

None of these 10 studies would change those conclusions.

How does chiropractic work? 1,6,and 8 addressed possible mechanisms for effects of SMT. Chiropractic was founded in 1895 and we still don’t know how it works. None of these studies provides a credible answer.

Why aren’t they doing better studies?

How do these studies measure up on Bausell’s 4-point checklist? Not very well:

  1. Subjects randomly assigned to a CAM therapy or a credible placebo control? At best, 1 out of 10 studies.
  2. At least 50 subjects per group? 0 out of 10 studies.
  3. Less than 25% dropout rate? 9 out of 10 studies.
  4. Publication in a high-quality, prestigious, peer-reviewed journal? 0 out of 10 studies.

Standards for conducting well-designed clinical trials are common knowledge today. Why is anyone still doing uncontrolled studies or using inadequate controls? Why is so little research on chiropractic of sufficient quality to merit publication in high quality journals?

Conclusion

If these 10 studies are the best chiropractic research from 2013, that means the quality of chiropractic research is appallingly poor.

Posted in: Chiropractic

Leave a Comment (54) ↓

54 thoughts on “Top 10 Chiropractic Studies of 2013

  1. brat says:

    Picky point: When you mention that a few of the reviewed studies’ research designs were “complicated,” I suspect a better term is “incoherent.” Granted, I’m coming from the social sciences, but a complicated study usually means LARGE N’s. These cats typically use very low N’s, so their research designs SHOULD be fairly straight forward. If the designs are complicated, my BS-meter explodes.

  2. windriven says:

    ” It is really a stretch to claim that the AMA recommends chiropractic.”

    With all due respect AMA does recommend chiropractic as I read the statement. Unfortunately, they do not include any specific guidance on when chiropractic is and is not appropriate for low back pain. Lacking that, the recommendation shouldn’t have been made at all.

    Moreover, the statement includes a recommendation for acupuncture!? What the heck is that about?

    Now we can mince words about when an observation becomes a recommendation. But an average consumer looking for medical acknowledgment that chiropractic – or acupuncture for that matter – might fix their problem is going to find it in that AMA statement.

    What the AMA statement looks like to me is an admission that low back pain has many etiologies and can be devilishly difficult to treat. You aren’t going to die of it and we probably can’t do much more than prescribe anti-inflammatories and analgesics. So dicker around with it yourself. Try some exercise. Try some chiro. Stick a needle in your ear. Whatever, just do it somewhere else.

    I presume that the danger in communicating that attitude to patients isn’t lost on anyone here.

    Low back pain should be managed by a physician. That may include sending a patient for chiropractic care. But that should be based on a solid medical decision, not by aunt Mary to diddling around to see what might work. A primary care physician either is or isn’t the nexus of primary care. Apparently AMA is slouching toward isn’t.

    1. Andrey Pavlov says:

      @windriven:

      I disagree. I read through the whole paper and really the only context is in that one paragraph itself, which Dr. Hall reproduced in it’s entirety.

      Many treatments are available for low back pain. Often exercises and physical therapy can help. Some people benefit from chiropractic therapy or acupuncture. Sometimes medications are needed, including analgesics (painkillers) or medications that reduce inflammation. Surgery is not usually needed but may be considered if other therapies have failed.

      I am personally not a huge fan of the AMA and am not a member myself, but I cannot construe this as a recommendation for chiro or acupuncture in any way let alone “before surgery.” In fact, in the strictest sense, their statement is completely accurate – some people do benefit from chiropractic for lower back pain. That is actually supported by the data. The fact that it is nothing uniquely about chiropractic but rather just the physical therapy aspect makes it an incomplete, but not technically incorrect statement. The same with acupuncture – people do benefit from acupuncture in LBP. Once again, the fact that it is not the actual acupuncture but a combination of placebo plus motivation to mobilize makes it incomplete and more misleading than the chiro statement, but not technically incorrect. The fact that I could also include voodoo rituals along with acupuncture but it isn’t in this statement just means that voodoo rituals to motivate patients to mobilize is less common and hasn’t been studied.

      It is also clear that it is not actually a recommendation to try chiro and acupuncture but a statement that some people do benefit from it.

      Also, there is no assertion as to the order of things, merely that surgery is not very effective and is always a last resort.

      I agree that we should have a higher standard in what we write and delve more deeply into things. I certainly would have written it differently and I agree that lay people and medicos with a pro-CAM bias could view that as a recommendation, but that is why I would write it differently – to prevent ambiguous interpretations. We are mincing words here, as you say, and there is obviously some bias in the writers (otherwise why not mention massage for LBP? sure helps me out), but I don’t think I can technically call that a recommendation.

      And no, the danger of the misinterpretation is not lost upon me. Which is why I am content being clear as to what it is – a single sentence in a small paragraph outlining what people do rather than what physicians recommend. And then lambaste the AMA for being so dumb in their statements (amongst other things).

      1. windriven says:

        We’ll agree to disagree about this Andrey. To my mind the endorsement is implicit. But the most troubling to me is not what the paragraph says but what it doesn’t say. The final sentence should have been something on the order of:

        Your physician can rule out potentially serious diseases that may present as back pain and prescribe appropriate treatment which might include physical therapy or chiropractic.

        As to acupuncture, if there is quality research demonstrating efficacy greater than placebo, I must have slept through that class.

        1. Andrey Pavlov says:

          I’ll agree that there is an implicit endorsement and as such I do have a problem with that. However, I just can’t bring myself to read it as an actual recommendation. Of course, as I said above, I am not a fan of the AMA in general but that is a whole different can of worms, though the reasons why dovetail with this sort of thing as well.

          As for the acupuncture, in my reading of the literature, the acupuncture itself doesn’t have benefit beyond placebo, but the people who go there gain additional benefit from motivation for mobilization which does actually help. In other words, what we find is that “standard of care” actually does work, but standard of care involved movement and restoration of activity levels sooner rather than later. The analgesics are used in the acute phase and to allow for mobilization which can be painful at first. People who have failed “standard care” fall into chronicity because they do not move as a result of the pain which worsens their symptoms in a vicious cycle. By thinking something else is helping relieve their pain or otherwise empowering them to move, they then actually do what they are supposed to and alleviate their lower back pain.

          How does this relate to chiro and acupuncture? Because both of them work through this placebo motivational effect. If you’ll notice in the literature chiro is effective for back pain but only chronic back pain – and that is why. It has no effect for acute back pain. In that case you are taking a self-selected group of people and giving them an “excuse” to mobilize, which is why I included the comment about voodoo spells. As such, I find chiro and acupuncture to be entirely equivalent although chiro is more well studied for chronic LBP than acupuncture which is why the conclusion is more obvious there.

          1. windriven says:

            Andrey, We talk in these pages all the time about the ethics of prescribing placebos. If the only effect of chiropractic is placebo then how is this different from prescribing a sugar pill for aunt Mildred? How is it different even from prescribing an antipsychotic and telling aunt Phyllis it will cure her Morgellon’s? In most cases it will “cure” the Morgellon’s and do it without aunt Phyllis having to confront the reality of her mental disease. So what’s the harm?

            Slippery slope, no?

          2. Charlie says:

            Anyone care to debate Dr. Raymond Damadian MD, on the benefit of Chiropractic? He invented the MRI, and knows a thing or two about objectivity and seeing pre-post MRIs and X-rays. He just came out and said he thinks Chiropractors help people with Neurodegenerative diseases quite well and he says so based on hundreds on case studies of patients suffering with MS, Dementia, Alzheimers, epilepsy, etc.

            How come none of your colored “scientific pills” get as good of results as Upper Cervical Chiropractors?

            http://www.youtube.com/watch?v=I8KGFUlPGLE

            this should be amusing to see your reactions to his presentation of scientific proof that these patients are really improving. Luckily technology is finally able to validate it.

            http://www.youtube.com/watch?v=7ENXw4ECwPg

            Here he dives into a little more explanation of how good of results he and a chiropractor are getting for patients once their biomechanics of their neck are aligned back to normal. Pre-post X-rays and MRIs don’t lie.

            1. Sawyer says:

              Please provide some evidence besides crappy youtube videos. I’m not even asking for a peer-reviewed paper, just something in writing to pin down the guy’s claims.

              And forgive me if I’m being unfair to Dr. Damadian, but I don’t place any confidence in his ability to evaluate the overall effectiveness of a complex therapy. Engineering achievements aside, he’s apparently pretty keen on young earth creationism. Is this really the person chiropractors want to hitch their wagon to?

              1. Charlie says:

                I anticipated arrogance, but not quite that narrow. How is that youtube video crappy? apparently you didn’t watch it so it is a presumptuous and ignorant (quite literally so) response to make. Its a video of a Medical conference, something i can only imagine you’ve been to. Dr. Damadian presents research with pre-post CSF flow videos so you can visualize what he is talking about. I heard the technology for reading CSF flow is less than a decade old so it might be interesting for you to see the pre/post with your eyes.

                per your interest, here is some ‘written’ information that lays it out. http://www.fonar.com/pdf/PCP41_damadian.pdf

                From the onset, it should seem logical that structure can have an effect on function and that if the structure or biomechanics of the Atlas and cervical spine is altered – following injury or poor posture – that the function could possibly be altered too.

                Please watch the video i first posted, its quite interesting or since you enjoy reading, please read the link above.

                Although you may cringe at an anecdotal story, a formal NFL quarterback, Jim Macmahon, gained immediate relief from an atlas adjustment thanks to Dr. Damadian contacting him and getting him under care. Jim was suffering with crippling pain after years of bashing his head around. Since there wasn’t s surgery or a voodoo pharmaceutical drug to sweep his pain under a rug, he even considered suicide as some of his friends had done. Dr. Scott Rosa and Dr. Damadian measured precisely how his atlas had shifted out of place and then showed objectively how it corrected following adjustment. They recorded that CSF flow was improved and any and all other objective proof they check. The doctor said of Macmahon, “he could tell an immediate difference in his speech. Mac said he felt like a toilet bowl had been flushed in his head and everything came out.” http://www.deseretnews.com/article/865587776/The-fighter-Former-BYU-NFL-quarterback-Jim-McMahon-aims-to-win-the-toughest-challenge-of-his-life.html?pg=all

                and from your throne of omniscience, you sneered, “And forgive me if I’m being unfair to Dr. Damadian, but I don’t place any confidence in his ability to evaluate the overall effectiveness of a complex therapy… he’s apparently pretty keen on young earth creationism.”

                No, I will not forgive you for that unwarranted and unfair comment. what does that have to do with his knowledge of MRI creation and diagnostic skills? so he is automatically discredited for a harmless unrelated belief? Do you ignore the works of your colleagues who believe in the bible too? Do you mock a practitioner’s contributions if they dont agree with you on a completely unrelated topic such as that?!?! If your child had a brain trauma and was the knife of Dr. Benjamin Carson (the top child neurosurgeon in the country), would you even consider searching for a new doctor, out of fear that he believes in God and the creation? I just can’t accept that you would believe for 1 second that either Dr. Ben Carson or Damadian are incompetent to read a flippin MRI because they separately believe in the creation. wow, you are something else

                You might need your head screwed on straight by an Upper Cervical chiropractor and then check yourself into a atheist-only emergency room to have them check to see if you have a heart.

                And yes, my brother’s chronic high blood pressure resolved, the his doctor’s surprise because he went to an Upper Cervical Chiropractor. His moderate mid and low back pain, and headaches vanished too. Its sad his GP’s voodoo organ-compromising meds didn’t have the same placebo effect as his objective assessment by his chiropractor. think of this, the GP checked his symptoms, and gave him some meds for his severe headaches, back pain, and switched him over to new blood pressure pills…. based on what science??!?!?! a pressure cuff reading and my brother’s subjective symptoms? Hows that for science based medicine.

                then his Chiropractor, takes pre-post xrays, and shows us exactly how much his neck bones were out. the post xray shows his neck curve and such is much better! thats more objective than the GP.

                My mom sent her annoying friend to the same Upper Cervical doctor cause she’s always in bed with migraines, er at least she was until she got her neck and head straightened out. She describes, walking on clouds, for the first time in a decade.

                If only the MD years of prescribing pills based on subjective proof had the same placebo effect as this chiropractor.

                while your house may be full of many leather-bound books and a smell of rich mahogany, I haven’t heard your long l

              2. Charlie says:

                Once again, your ignorant and petty observation, “forgive me if I’m being unfair to Dr. Damadian, but I don’t place any confidence in his ability to evaluate the overall effectiveness of a complex therapy. Engineering achievements aside, he’s apparently pretty keen on young earth creationism.”

                Dr. Damadian is an expert at reading MRI’s and reading medical literature. you discredit him because you sneered that neurodegenerative diseases are too complex of a theory for him. hmmmmm. well, at the same symposium many other MD’s were present and involved. Neurosurgeons, PhD’s, MD’s, and well over one hundred of them. They all share a similar perspective.

                for example

                “William G. Bradley, MD., PhD, FACR, Professor & Chair, The Department of Radiology at the University of California, San Diego speaking about “CSF Physiology and Its Role in Neurologic Disease” at FONAR’s Cranio-Cervical Syndrome Symposium http://www.youtube.com/watch?v=8VPJHXePgw8

                “Neurosurgeon Joel Franck, MD., from Bay Neurosurgical and Spine Institute, Panama City, Florida, speaking at The FONAR’s Cranio-Cervical Syndrome Symposium held on April 6, 2013, New York, NY.” http://www.youtube.com/watch?v=spMkX3XAWjs

                Dr. Franck, Does what you probably would enjoy more, he digs into the neck with a knife and then with a pair of pliers pulls the C2 back inline with C1 and then screws them together, which results in improved symptoms of the patient, and improved CSF flow. What would be more scientific is if he sent that patient to an UC chiropractor first, and then if that didn’t work, he could do the invasive expensive approach.

                Its a lot simpler to adjust the atlas back into place but the medial profession prefers the expensive and invasive route.

                So look, Dr. Damadian isn’t alone in the theory about CSF flow being involved in Neurodegenerative diseases. There’s all sorts of experts and talk in the community about that. thousands of CSF flows and MRI readings conclude the same. Its not difficult to check the Chiropractor’s post adjustment. reading the MRI for an expert seems pretty easy.

                All the doctors at this medical conference can make sense of it, why can’t you?

                is it really because a chiropractor, was able to get such good results? does it bother you that the specialists in medicine via this conference and elsewhere are referring so many patients to Dr Scott Rosa, and many are resolving? Does it hurt you that a pain killer isn’t doing as good a job at fixing the root problem?

                you should watch all of the videos. I did, they were really interesting. maybe there is something to it all.

                Tell me what you think from these videos. im interested in your perspective, after all you dont believe in the creation so you MUST be brilliant beyond your years when it comes to processing analytical information.

                oh and just for fun, my brother’s improved hypertension wasn’t a fluke after all. http://www.webmd.com/hypertension-high-blood-pressure/news/20070316/chiropractic-cuts-blood-pressure

                might want to double check to see if that hypertension expert, Dr. Bakris is a creationist, then you can discredit him altogether .

              3. Andrey Pavlov says:

                @charlie:

                No, I will not forgive you for that unwarranted and unfair comment. what does that have to do with his knowledge of MRI creation and diagnostic skills? so he is automatically discredited for a harmless unrelated belief

                No, he is discredited because that particular belief is so astoundingly wrong, so incredibly, profoundly, ineffably, and unequivocally incorrect that the fact that he can hold such ideas speaks deeply to his ability to use motivated reasoning and lack of ability to critically think. It is even more damning in that the very technology that he is supposed to be expert on disproves YEC in and of itself.

                You cannot be a scientist of any kind and accept YEC. And considering what the political, ideological, and evidentiary state of chiropractic is he disqualifies himself from the discussion because it is beyond clear that when a conclusion is important to him, he will literally ignore everything we know in order to continue to hold it.

                Do you ignore the works of your colleagues who believe in the bible too? Do you mock a practitioner’s contributions if they dont agree with you on a completely unrelated topic such as that?!?!

                Not as much, because a “belief in the bible” is a vastly different beast than a belief in YEC. The amount of cognitive dissonance and ability to ignore evidence, cherry pick data, and persevere in motivated reasoning is leagues apart between “belief in the bible” and YEC. But yes, I echo Neil de Grasse Tyson’s sentiment when he said (and I paraphrase):
                “It is not strange that 85% of the National Academy of Sciences is atheist. It is strange that 15% aren’t.”

                And yes, when someone has ideas as incredibly and profoundly absurd as YEC, it deserves nothing less than mockery. I’m not about to trust a scientist who dabbles in alchemy or astrology either. If you can publicly acknowledge that you genuinely believe in something so mind bogglingly stupid, then I cannot trust the rest of the efflux from you is smart.

                f your child had a brain trauma and was the knife of Dr. Benjamin Carson (the top child neurosurgeon in the country), would you even consider searching for a new doctor, out of fear that he believes in God and the creation?

                In such a circumstance anyone would be hard pressed to even care to think about it. But, given the hypothetical opportunity to consider it and if there was a different practitioner available, yes, I would rather have that person do the surgery than Carson. However, in this case it is still rather different. Technical skills such as surgery in an acute setting are very different than scientific skills in taking the time and effort to put together data and synthesize a report on it. A YEC belief doesn’t influence technical skill as much as it would critical thinking in synthesizing data and presenting it in an unbiased way. Particularly when it comes to a field with politicoideological controversy.

                I just can’t accept that you would believe for 1 second that either Dr. Ben Carson or Damadian are incompetent to read a flippin MRI because they separately believe in the creation. wow, you are something else

                You might need your head screwed on straight by an Upper Cervical chiropractor and then check yourself into a atheist-only emergency room to have them check to see if you have a heart.

                So no, it is not an emotional response that “we don’t like religious people” or something ridiculous like that. It is a dispassionate assessment of the sort of thinking, introspection, bias, and to what level a person can be subject to each of those. A YEC (or even just old earth creationist) belief demonstrates how the person is willing to think when the conclusion is more important than the truth. When it comes to trusting someone to look at MRI’s in an unbiased way and present data in an unbiased way, holding out a positive belief in YEC tells me that they cannot be trusted to be unbiased. It would be slightly different if it was some waffley agnostic position: “I don’t know enough to say one way or another, but I think creation makes more sense than evolution” is different to saying “I’ve examined the evidence and feel it takes too much faith to believe in evolution and there is evidence for creation.”

                The former is just ignorance with a cultural bias (though in consideration of how heated a topic this is in our country, even that is somewhat hard to excuse). The latter – which is what Damadian and Carson believe – shows unequivocally that when a conclusion is already held, they can be amazingly bad at looking at evidence to come to a conclusion.

                That will affect the ability to present data, particularly on controversial topics. It doesn’t really affect the ability to cut through a cranium and do some technical work nearly as much.

            2. weing says:

              Why do you think that the information from the videos you linked to is trustworthy and valid? Do you trust the reports from a drug company that their medication is the best thing since sliced bread? Why or why not? Do you think such reports should be verified independently? Why or why not?

        2. PMoran says:

          “Some people benefit from chiropractic therapy or acupuncture.”

          I suppose the AMA statement can be supported as advice to patients on the grounds that the studies don’t totally preclude that. Though I am a little surprised that they have not been more cautious e.g. “some people may benefit”.

          As Andrey says the benefits may be from placebo and other incidental influences rather than from any overriding physiological characteristics of the interventions, as applies in most mainstream medical interventions, but from the patient’s viewpoint that hardly matters.

          A different question altogether is “what should doctors be recommending as routine care?” That brings into play questions of cost/risk/effectiveness, individual patient receptiveness to different forms of medicine, our duty to maintain a body of secure medical knowledge, and who is footing the bill.

          I don’t regard the above as “endorsement” in that sense.

          1. windriven says:

            Peter,

            Does the ‘patient information’ under discussion tell the patient to see her doctor to rule out serious medical conditions that might present as back pain?

            Is it ethical or unethical to prescribe placebos?

            Is science based medicine a paradigm or is it just a situational construct to be rolled out and put away as is convenient?

            1. irenegoodnight says:

              I think Andrey and PM are correct and you are over reading the AMA statement. There–now that’s settled :-)

              (I don’t DISagree with you–it’s just a matter of degree).

      2. WilliamLawrenceUtridge says:

        For me the issue is – if that’s the sole mention of chiropractic in that entire paper, then calling it an “endorsement” is deceptive.

        The actual statement seems like the weasel-word-way out of saying “this is politically touchy and we don’t want to look at the actual evidence or piss off any stakeholders”. The DSM took a similar approach to the issue of childhood abuse and dissociative identity/multiple personality disorder – “some people claim”, totally ignoring the fact that “the evidence isn’t very good”. Not surprising to me regards the AMA and chiropractors considering they lost the suit against chiropractors several decades ago.

        1. windriven says:

          “The actual statement seems like the weasel-word-way out”

          Precisely, William. This appears on the “patient information page.” Tell me with a straight face that your forklift operator uncle Louie with lower back pain isn’t going to read this and think – huh, if its OK by the AMA then it must be OK for me.

          We talk incessantly about science based medicine and about changing people’s attitudes toward quackery. The line has become quite sharp in my mind. There is medicine and there is not-medicine. Acupuncture is not-medicine. Chiropractic, with the possible exception of LBP, is not-medicine.

          What is the difference between condoning acupuncture and condoning coffee enemas? BS is BS whether in this pasture or that.

          1. Andrey Pavlov says:

            Now that I have had some sleep and some coffee, you are indeed swaying me a bit more your way windriven. But I think what I wrote last night still stands. The AMA is a professional organization not a scientific one. It isn’t even a professional organization that grants certifications or sets any standards for our profession, like the American College of Physicians (of which I am a member). To me this is just yet another example of why I will never be a member of the AMA. I guess it all boils down to the fact that I already didn’t like them and this doesn’t add much grist to that. But I agree that for Uncle Louie he doesn’t – and shouldn’t be expected – to know the difference. In that sense, I can view this as any other piece of tripe coming out of the NCCAM or Dr. Oz. A tiny turd on top of a steaming pile of….

            But I still do think it is more useful to point out – accurately – that it is sad and pitiful that the chiros would use something as paltry as this from an organization like the AMA as any sort of evidence or endorsement in their favor.

            1. windriven says:

              And yes, you are correct. AMA is not a scientific organization though I’d like to believe that science informed its positions. As I noted to Madison, I get worked up when institutions that should know better espouse nonsense because it is easier than drawing a hard line. It would be like the (entirely fictional) National Association of Biology Teachers condoning the teaching of Intelligent Design on grounds of intellectual freedom.

              In any event this has become a tempest in a teapot.

              1. David Gorski says:

                Also, since it lost the lawsuit by chiropractors, the AMA has been very gun shy about criticizing CAM or taking action to try to block CAM practitioners from winning extended scope of practice from various states, unfortunately. This has led to its being mostly ineffectual in this effort.

              2. Andrey Pavlov says:

                Windriven: agreed

                Dr. Gorski – also a good point.

            2. irenegoodnight says:

              Now, WD, you’ve swayed me a bit as well–so I still agree with Andrey.:-)

    2. MadisonMD says:

      It is really a stretch to claim that the AMA recommends chiropractic.

      I agree with Harriet here. True this patient information page does recommend chiropractic. However, it does not claim to be the official position of the AMA. Such a position would seem to require a positive action of the association or its elected leadership. Instead, this text is a patient handout penned by a pediatric critical care physician working as the Morris Fishbein Fellow in Medical Editing at JAMA and two coauthors who are providing content for the journal.

      The only official guidance on chiropractic from AMA seems to be this:

      It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient. A physician may refer a patient for diagnostic or therapeutic services to a chiropractor permitted by law to furnish such services whenever the physician believes that this may benefit his or her patient. Physicians may also ethically teach in recognized schools of chiropractic.

      This guidance emanates from permanent injunction issued against the AMA after a prolonged lawsuit. The injunction requires this language in place of prior AMA ethics guidelines (circa 1965) that said it is unethical for physicians to associate professionally with chiropractors.

      So the AMA position on ethics of physicians who endorse chiropractic, insofar as it appears favorable, is legally mandated. It does not necessarily reflect the actual views of the leaders or membership of the AMA.

      1. windriven says:

        “True this patient information page does recommend chiropractic. However, it does not claim to be the official position of the AMA.”

        Madison, you are, in my opinion, splitting hairs. This page is intended for patients – generally non-professionals. I think that any general reader would assume this paragraph to mean that chiropractic and acupuncture are OK to try. If that is the case and if we’re all OK with that, why do we bother with science based medicine? Why insist that patients use an MD as a PCP? Let’s just have everybody do their own thing.

        -There should have been – at a dead minimum – a statement that the patient’s physician should rule out potentially serious medical conditions that might present as back pain and could then recommend treatment as appropriate. I will note that the paragraph that you cite specifically says “A physician may refer.”

        I won’t argue the ethical points other than to note that the position of several bloggers here is that the use of placebos is unethical. Ethics exist independent of the AMA. The AMA or its lawyers might call a steaming blob of bovine excrement pumpkin pie but you and I both know its a cow flop.

        IMHO this is exactly the reasoning that leads to quackademic medicine, to Ted Kaptchuk, to the Osher Center for Complementary and Integrative Medical Therapies, and to $100 million pissed away every year by NCCAM.

        So Madison, if this is OK where exactly do we draw the line?

        1. MadisonMD says:

          There should have been – at a dead minimum – a statement that the patient’s physician should rule out potentially serious medical conditions that might present as back pain and could then recommend treatment as appropriate.

          Agreed. In fact, here’s what it says at the bottom of the JAMA patient information page quoted by Harriet (I linked above):

          The JAMA Patient Page is a public service of JAMA. The information and recommendations appearing on this page are appropriate in most instances, but they are not a substitute for medical diagnosis. For specific information concerning your personal medical condition, JAMA suggests that you consult your physician.

          windriven says:

          I won’t argue the ethical points other than to note that the position of several bloggers here is that the use of placebos is unethical.

          I agree with this sentiment as well. I am not really trying to defend AMA or this patient handout. In fact I am disappointed that this handout published in JAMA recommends acupuncture/placebo. However, it can only be purported to be the recommendation of the authors and endorsed by the editors of JAMA. Perhaps it is splitting hairs since it could be misinterpreted by the public as an official AMA recommendation. Yet It is overmuch for a chiropractor association to use it to claim that AMA recommends chiropractic. I think this was Harriet’s point.

          So Madison, if this is OK where exactly do we draw the line?

          I draw the line at truth/dishonesty. This line tells me that the recommendation of Goodman et al. for acupuncture is not OK. In case of placebo, honesty would require one to tell the patient that it is placebo yet carries rare but serious risks. This (rare risk)/(zero benefit) ratio cannot support a favorable recommendation.

          I believe that most physicians (“shruggies”) have a more muddled view of this situation. This is why we need more physicians to read SBM, join SSBM, and become more aware of the dangers of new age postmodernism that is creeping into medicine.

          1. windriven says:

            “This is why we need more physicians to read SBM, join SSBM, and become more aware of the dangers of new age postmodernism that is creeping into medicine.”

            Why? Everyone seems to be OK with AMA condoning (I’m tired of arguing the point of what constitutes a recommendation) acupuncture and chiropractic. I guess I missed the post when the decision was taken that these were science based modalities after all.

          2. MadisonMD says:

            Everyone seems to be OK with AMA condoning (I’m tired of arguing the point of what constitutes a recommendation) acupuncture and chiropractic.

            Windriven, I’m not really understanding. I’m NOT OK with AMA or doctors condoning acupuncture.
            I am OK with AMA or doctors condoning chiropractic for very limited musculoskeletal low back pain, although I would not support referral to chiropractor that does all the nonsensical stuff. I’d actually prefer referral to PT.

            So, I think we are in agreement.

            1. windriven says:

              I apologize, Madison. The issue of a bright line between science and not is a hot button for me and I’ve felt a bit at odds with a handful of the commenters whom I hold in highest esteem – so I confess to being irrationally defensive.

              Mea culpa.

              1. Andrey Pavlov says:

                It is late and I am tired after a long drive (I just had a meeting presentation, and then coffee with an astronaut :-D yay science!) and so I don’t have time for a full response. I also may be misreading this but felt at least part of it was directed at me.

                I guess part of it for me is that I don’t view the AMA as a scientific organization. They are a professional organization and, IMHO, kind of a crappy one at that. They are much more interested (historically anyways) with the financial bottom line of physicians than actually providing good science based medicine and recommendation. Many times those two goals align, but not always. Just like how free markets select for whatever makes the most money and sometimes that aligns with a good quality product that is at a competitive price.

                This also seems like a very small “condoning” if you will. A single line, in a non-committal way, that at best tacitly condones and maybe indirectly recommends something which superficially does have more truth to it than the vast majority of CAM claims in a patient guide, not a study or peer reviewed article. Maybe it is just a quirk of my own psyche here but I am having trouble getting my knickers in a twist over it. Maybe it has to do with the idea that the chiros are taking this as being meaningful and I don’t want it to actually be meaningful (because it really isn’t to them, and it makes them look foolish for listing it as anything more than how I would casually mention “granola” on my shopping list). Maybe that is a post hoc rationalization.

                But you’re right – if I had anything to do with the publication of it I would not have let it stand, regardless. It is still not as rigorous and precise as we should be. Just seems to me, for whatever reason, that it is so incredibly trivial that it makes more sense to laugh at the chiros touting it as an endorsement than to get all in a huff about how we as physicians should not have even tacitly endorsed it. Plus the AMA only represents (IIRC off the top of my head) ~30% of physicians

  3. goodnightirene says:

    I read the whole thing straight through and was mostly appalled that any of this could be called a “study” or that any of the “journals” are credible.

    I mostly commend you for taking the time to expose this baloney, when you could have been knitting. :-)

    1. Andrey Pavlov says:

      GNI:

      Agreed. This wouldn’t have passed muster in my high school science classes. Granted my high school was a nationally award winning school in a rich area with lots of resources, but still, these are supposed to be legitimate peer reviewed scientific studies and my high school science teachers would have failed me for them.

  4. Jann Bellamy says:

    Integrative medicine proponent Dr. Wayne Jonas testified before Congress that Study # 7 (funded by the U.S. Military) demonstrates that chiropractic added on to usual care significantly improved back pain in active duty populations. He was promoting the expansion of integrative medicine in the military. I wrote about his unwarranted exuberance over this and 2 other questionable studies in Integrative Medicine Invades the Military: Part One. http://www.sciencebasedmedicine.org/integrative-medicine-invades-the-u-s-military-part-one/. Unfortunately, Dr. Jonas’s testimony is but one example of how these poorly done studies are misrepresented to the public in support of chiropractic treatment and engender further questionable studies, as this one has. (It’s also funded by the military.) Your review is a much needed antidote to that misrepresentation.

  5. All in all a pretty piss poor effort that. To me, there were far more useful studies published about chiropractic or by chiropractors in 2013. They might not have had the “rock-star” or promotional catchiness about them but they were more clinically useful than this list.

    Sigh.

    1. That miniature rant was directed at those that compiled the list, not Harriet.

      1. Andrey Pavlov says:

        I’ll second AdamG request… what would have been on your list?

        1. Andrey,

          For starters I’d have led with this:
          http://www.ncbi.nlm.nih.gov/pubmed/23778372

          Essentially as it was aimed at recognising adverse events and their frequency with chiropractic care.

          I’ll shoot through the rest of my list on Papers over the weekend.

          RC

        2. *irony alert*

          This one was published in the Chiropractic Journal of Australia. The journal published by the Chiropractors Association of Australia. Just fabulous.

          http://www.chiro.org/pediatrics/ABSTRACTS/Medical_Management_of_Pediatric.shtml

          1. WilliamLawrenceUtridge says:

            I’m sorry to point this out, but you seem to be proud of two rather dubious studies.

            The first is basically a tiny preliminary survey of the safety and efficacy of chiropractic care. I agree, it’s a decent first step. Don’t you think your profession should have taken it 100+ years ago?

            The second appears to be* a tu quoque criticism essentially saying “not all of medicine is proven to work”. That may be true, but it’s irrelevant. The essence of its argument seems to be “chiropractic doesn’t need to prove it works until all medical interventions are proven to work“. First, that’s irrelevant – chiropractic damned well should test its interventions in properly controlled trials. Second, what would your reaction be if this were reversed? “Pfizer says it doesn’t need to test the safety and efficacy of its drugs, and should be able to freely sell them to whoever will buy them, until chiropractors prove that spinal manipulation is safe and effective.” Put that way, your whole argument kinda looks like a pile of dogshit, doesn’t it?

            Why does chiropractic continually insist that its identity and effectiveness is wrapped up with the scientific status of real medicine? Why does real medicine have to be perfect chiropractic care can be challeneged?

            *Not positive, I only gave it a very quick skim.

            1. The first article, yes. Damned well should have been done 100+ years ago. But, it wasn’t. So yes it’s a start but ppl are finally making starts.
              As for the second, you missed the irony alert… It was a horrible bit of bogshite that I’m horrified made it to print in a journal. It’s a “logical fallicy salad”. Perhaps I should have been clearer on how I felt about it…

    2. AdamG says:

      Care to share any citations?

  6. am says:

    Had a very stiff and sore neck a couple of weeks ago. Went to a chiropractor, received manipulation, was able to sleep better that night, and felt virtually no pain the next day.

    Am I the victim of some kind of sneaky hypnotic suggestion by my chiropractor or did the manipulation actually help?

    My bet is on the second. Fortunately I don’t have the religious fervor/blinders the corporate shills/drug pushers running this site seem to have.

    It seems the primary interest of this site is to protect the financial interests of Big Pharma and corporate medicine.

    1. Andrey Pavlov says:

      Many chiropractors also do massage, either intentionally or inadvertently, as part of their manipulations (or even in lieu of manipulations). Massage has therapeutic benefit.

      A sore stiff neck is also amenable to time – regression to the mean.

      Such feelings are also highly suggestable and affected by both placebo effects and responses, no “hypnosis” necessary.

      We are also well known to rewrite memories when we access them such that salient details change in telling the story – in other words you may have felt better a day or two later but link it to the chiropractor visit as a part of confirmation bias. Or it may have seemed to helped based on massage and placebo but not fully resolve till a few days later and your memory shortens the time frame to fit a narrative since the chiro is the only thing you “did” in order to address the problem of the stiff neck.

      We also tend to defend things we have done, particularly if we made an effort or paid money to have them done. Nobody likes to have paid money for something utterly useless, so we rationalize that it did help or helped more than it actually did.

      So, you get some kind of massage on a stiff neck, it gets better on its own roughly around the same time, plus some expectancy bias, some unconscious pressure for it to have worked, else you wasted your money, a bit of placebo effect and response, and some confirmation bias with a little memory tweaking and suddenly the chiro is the one that definitively “fixed” your neck.

      Of course the other option is that the manipulation actually helped. Nobody likes being fooled, particularly by their own minds, but what I wrote (or some combination thereof) has a lot more evidence to support it than the manipulation actually working. Particularly considering that your bias is blatantly evident by calling us “corporate shills/drug pushers.” I mean, really, you think there isn’t bias in your approach to that one?

      The fact that you believe the conclusion with much less evidence to be correct doesn’t actually make it so. Particularly considering that I, as a “corporate shill/drug pusher” medical doctor would have recommended some stretches, a nice massage, perhaps a warm compress, and, if necessary, an ibuprofen or possibly a muscle relaxer if you really complained it was that bad. After having ruled out more sinister concerns based on a good history and a focused physical exam, of course.

    2. Harriet Hall says:

      You have no way of knowing how your neck would have felt the next day if you did nothing. I know someone who made an appointment to see a chiropractor on Monday for his back pain and on Saturday his pain vanished. How do you reconcile your experience with the fact that in multiple studies, when large groups of people with your symptoms are treated with manipulation and compared to a control group, manipulation is no more effective than gentle mobilization, and neither is effective unless exercise is also used? Are you at all concerned about the possibility of stroke from neck manipulation? Admittedly it’s rare, but devastating when it happens.

      Your accusation of us being corporate shills is false, laughable, mean-spirited, and can’t be supported by any evidence.
      We do have a religious fervor – for the truth.

    3. WilliamLawrenceUtridge says:

      am, I used to see a chiropractor regularly. He was one of the better ones – he didn’t think he could cure cancer, but did think he could help with musculoskeletal pain and dysfunction (and thus, was basically a physiotherapist). I lived and worked close enough that I could walk there in less than five minutes. I would routinely make appointments when I had a stiff neck. He would adjust my neck, it would hurt transitorily (which he explained as the nerves and blood vessels re-adjusting to reduced impingement, sure, whatever) but the next day it would feel better. I started reading SBM, and on that basis, stopped seeing the chiropractor (a combination of fear of stroke and intellectual honesty).

      Now when my neck hurts, I just tolerate it or perhaps take an advil. In most circumstances, my neck no longer hurts the next day.

      Did neck manipulation help either of us?

      Also, I’m not sure how recommendations or suggestions of “gentle stretching or exercises” is protecting the financial interests of Big Pharma and corporate medicine. Could you explain how easily-found exercises add to the bottom line of Pfizer or GSK? Thanks!

  7. irenegoodnight says:

    My neighbor has rotator cuff surgery just after Christmas. The anesthesiologist “forgot to give [her] the pain block that goes with the pump” (for pain relief) so she has been in what she feels is extreme pain (she is not the delicate type at all). She ended up telling him off big time and he “yelled at her” in return. She is particularly angry that he “treated [her] like a drug addict” because she called him at 5 am after a hellish night with no pain relief at all due to the pump failure.

    Today she is going to see her chiropractor (whom she has seen for years for back pain and trusts implicitly in spire of my prodding) to get some “manipulation” for the arm as she “can’t take it anymore”. Following my protestations, she assures me that her chiro is also a PT. I’m not so sure, my guess is that he uses some of those techniques.

    I’m thinking he’ll do most of the things Andrey mentions above and give her a lot of sympathy. She will credit any improvement (real or perceived) to the chiro and I will have no credible rebuttal.

    Point of this story? Glad you asked. The doctor has treated her dismissively from the outset and it ended in real confrontation. The chiro is going to be all ears and very soothing. There must be a lesson here somewhere, but its just another loss for reason because (generalization alert!) doctors at least often appear to be quite uncaring. And yes, I real not have much to offer my friend in rebuttal.

    1. windriven says:

      ” The doctor has treated her dismissively from the outset and it ended in real confrontation. ”

      Sadly enough most patients don’t have much choice when it comes to the anesthesiologist. Your friend would perhaps be better served by reading out her orthopedic surgeon. The anesthesiologist may well be dismissive of your patient but s/he would not likely be dismissive of the surgeon. It won’t matter a bit if the anesthesiologist never sees your friend again. But s/he will see the surgeon often and will only work with the surgeon with the surgeon’s consent.

    2. mousethatroared says:

      IreneGoodNight, you are right, probably not much you can do to resolve the situation for the immediate future. If there is anything you can do to help your friend feel more empowered (okay, everyone hates that word, but…) in seeing this doctor or finding another one, it might help in the long run.

      I’m unclear whether it was the surgeon or the anesthesiologist who was dismissive, but your friend will have to see someone for follow-up, I assume, at the minimum, maybe sooner if her pain continues to be unmanageable or if she has a complication. It seems a long shot that even a good PT could help surgical pain.

      Maybe you could offer to go to the next visit with her and stand up for her if needed, help her find a new surgeon, or navigate who to call to get a prescription for her pain (maybe her internist?).

      This might not give her more faith in the medical system, but it might confirm that you have her best interest at heart and keep the door open for future conversation.

      Sorry, If that’s stating the obvious and off your point. Clearly the best thing for your friend and for generating patient confidence would have been for the doctor to do his job properly and/or for him to rectify the situation immediately with an sincere apology once he found out about the mistake.

      1. Andrey Pavlov says:

        If there is anything you can do to help your friend feel more empowered (okay, everyone hates that word, but…)

        I don’t. I use it regularly. I view my role as empowering my patients as much as possible to make adequately informed decisions and take control of their own health as much as possible. I’m the expert telling them what will and won’t work (to put it simplistically) but they are the only ones with the power to actually effect those things. Hence, I empower them.

        1. mousethatroared says:

          I know, it’s a fine word when it’s not being prostituted by disingenuous company management “Our goal is to empower employees to optimize company goals through the use of incentivized payment systems.”

          Unfortunately, some people who have worked corporate jobs have a visceral reaction to the word.

      2. irenegoodnight says:

        Thanks Mouse–nice to hear from you. Sorry if I wasn’t clear that the problem was entirely with the anesthetist, who my neighbor chose to ream out. Not sure how she feels about the orthopedist at this point. It was the anesthetist (anesthesiologist?) who “forgot the pain block”.

        At any rate, the real issue between me and this neighbor is that she has been seeing a chiro for years and I’ve been trying to get her to see that as a lot of money down a rat hole of placebo effect. Now she’s going to the chiro instead of talking to the ortho about the anesthesiologist, which I find so very dumb. But the neighbor is a bit dim to begin with so I don’t know why I bother. o-o

        Update: Said neighbor is well enough to shovel the snow with one arm! Saw her out there and was amazed. She is a tough bird. We are at minus 9 degrees as of this morning (01/28) and she’s out there in her Green Bay Packer jacket pushing the damn snow around with one arm. Even the wiener dog had better sense and crapped on the porch before dashing back inside.

  8. Joseph Iannelli says:

    Where does science exist ? Is there one organization , one profession, or one discipline that has sole claim for science studies ?
    where is unbiased science , with unbiased conclusions ?
    Can any competing industry conduct research or analyze research in an unbiased manner ? Preformed conclusions will certainly sway cursory analysis and insert bias into study formulation. The scientist , the organization , the person and most importantly the motive must be examined to determine the value of any information observed.

    1. WilliamLawrenceUtridge says:

      Joseph, science and research are human enterprises. There are always caveats, biases (far more then monetary – people have intellectual, national, personal and institutional biases, monetary just happens to be the easiest one to point out, or smear one’s opponents with) and limitations. It renders scientific conclusions problematic and tentative, it doesn’t render all research results illusory and it doesn’t magically make any other form of decision making superior, or even equal. Ultimately the data wins out as the questions and controls get more precise. The community is self-policing, relying on honesty, mutual criticism (even axe-grinding), peer review, replication and extension to clarify their questions and data. Unbiased conclusions, in absolute terms, will never be a reality, but that is why it is so important for science to be a public, collaborative, iterative and community-based. One person will rarely get everything right, but as a whole it’s pretty good, and far superior to pretty much every other type of inquiry (within specific domains, of course).

Comments are closed.