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Whack em hard/Whack em once and Stroke

There is no satisfaction in hanging a man who does not object to it.
~ George Bernard Shaw

I work in a 5-hospital system and many of us practice at several hospitals. The residents rotate through at least three of the hospitals and the peripatetic nature of health care allows word of curious cases to percolate through the system.  My current resident mentioned that there was a case of a vertebral artery dissection in a young female shortly after chiropractic neck manipulation.

Man, that’s awful. Is she doing OK?

Evidently there were no permanent neurologic sequelae. She dodged that bullet. Or perhaps that noose, as I once calculated that the force of a neck crack is about 40% that of hanging by the neck and it has the same pathologic changes if it goes wrong. Every time I see a death in the movie where the neck is twisted to break it, I think chiropractic, although some tolerate it better than others.

I have not written on CNS events related to chiropractic since 2008, although the topic has been covered by Dr. Hall.  I still suspect that occasionally there is a perfect storm of bad luck, the forces are perfectly aligned in a susceptible patient and they get an embolic stroke or a vertebral artery tear.

It is rare and hard to do. It is very hard to injure people with what the chiropractors refer to as high velocity, low amplitude thrusts. That sounds so much better than whack em hard/whack em once. So the adverse events from a quick partial hanging are rare and proving causality with rare events is not easy.

Many people get the flu vaccine. Many people have heart attacks. A few people will get Guillain–Barré syndrome (GBS). By chance some people will have a heart attack after their vaccine and others will get Guillain–Barré. So did the vaccine cause the heart attack? Or the GBS? Not always a straight forward answer, as the relationship between declining pirate populations and increasing global temperatures demonstrates.

An aphorism we all live by is that association is not causation, although it is, like all aphorisms, lacking in qualifiers. Part of the willingness to assign causality depends in my mind, like much of SBM, upon consideration of prior plausibility.

Some issues are like parachutes. I don’t need extensive trials to realize cause and effect from parachute use and not splatting on the tarmac. Other relationships are more subtle; realizing that azithromycin, in the right situations, increases cardiac deaths. It took an examination of 3 million prescriptions to find that azithromycin leads to 47 to 245 excess cardiac deaths per million prescriptions, depending on the patient risk. There is biologic plausibility, given that some antibiotics can adversely affect the cardiac conduction system. But the average HCW will never give enough prescriptions to kill someone with azithromycin or even recognize it if they did.

In choosing an antibiotic, or any intervention, you have to weigh the risk and benefit from the treatment as well as the risks and benefits of alternative therapies. I am certainly less inclined to give azithromycin to patients with cardiac disease if I have equivalent alternative antibiotics. Since I am aware that I may do harm, even rarely, I need to be circumspect in my use of azithromycin.

As has been the topic of many posts, the efficacy for chiropractic, such as it is, mostly revolves around low back pain. No reason to approach the neck and whack it hard/whack it once. I can find no quality studies that demonstrate efficacy for neck pain. Good studies being those where the treatment is unknown to the patient and provider. Difficult to do in chiropractic, I know. But perhaps possible.

I will take it as written that the benefit from being whacked hard and whacked once to the neck is zero. Those who wish to discuss the issue can refer to other posts.  What then is the risk with a neck whacking?

It depends.

Some practitioners consider it a myth and others find no risk

“The 83 chiropractors administered >5 million career upper cervical adjustments without a reported incidence of serious adverse event.”

although rather than complications they had ‘symptomatic reactions (SRs)’:

“Three hundred thirty-eight (31.0%) patients had SRs meeting the accepted definition. Intense SR (NRS ≥8) occurred in 56 patients (5.1%).”

Symptomatic reactions included

“1) neck pain and/or stiffness/soreness, 2) radiating (arm or leg) pain/discomfort, 3) arm or leg weakness, 4) tiredness/fatigue, 5) headache, 6) dizziness/imbalance, 7) nausea/vomiting, 8) ringing in the ears, 9) blurred or impaired vision, 10) confusion or disorientation, 11) depression or anxiety, 12) fainting, 13) low back discomfort/soreness.”

And what are the symptoms of a vertebral artery transient ischemic attack, the most likely effect of whack em hard/whack em once?

“Dizziness, vertigo, headache, vomiting, double vision, loss of vision, ataxia, numbness, and weakness involving structures on both sides of the body are frequent symptoms in patients with vertebrobasilar-artery occlusive disease. The most common signs are limb weakness, gait and limb ataxia, oculomotor palsies, and oropharyngeal dysfunction.”

Anyone besides me worried when comparing and contrasting the two lists? Remember that these are not recognized as worrisome:

“The 83 chiropractors administered >5 million career upper cervical adjustments without a reported incidence of serious adverse event.”

And this is not the only study that reported symptoms that could be due to a transient ischemic attack in the vertebral artery distribution

“Adverse events after any of the first 3 treatments were reported by 56%, and 13% of the study population reported these events to be severe in intensity. The most common adverse events affected the musculoskeletal system or were pain related, whereas symptoms such as tiredness, dizziness, nausea, or ringing in the ears were uncommon (<8%).”

In both series the symptoms were brief and mild in most patients.  Like I say, its hard to hurt people. Suggestive and worrisome, especially as the practitioners seem clueless about the potential significance of the symptoms they are apparently inducing. But not a surprise given their lack of real medical training.

I had to snicker when I read Self-reported recognition of undiagnosed life threatening conditions in chiropractic practice: a random survey. It was estimated that a chiropractor would see an undiagnosed serious illness every 2.5 years, noting a variety of illnesses covering everything but the disease they may be inducing.

There are case reports of strokes following whack em hard/whack em once. Seems a very reasonable complication to me given what they are doing to the fragile structure in the neck. But just because it seems reasonable does not necessarily follow that it is true.

There was an interesting report where they evaluated all the case reports of stroke that follow whack em hard/whack em once and they note that the quality of the case reports is poor.

They compared the information provided by case reports and used the Bradford-Hill causality criteria as the standard. Most of the case reports did not provide sufficient causality data from a Bradford-Hill perspective. They point out the need for standardized reporting to provide better information, which is a valid point across the medical literature.

They did find 901 cases of CAD (cervical artery dissection) and 707 incidents of stroke reported to be associated with whack em hard/whack em once. They conclude, as chiropractors might,

As a result, the value of these reports toward informing our understanding of the relation between [cervical spinal manipulation therapy] and CAD is minimal.

I am not so sure. While the case reports may not be perfect, when you read the individual reports they appear compelling given the potential mechanism of injury. Much closer to a parachute evaluation.

There is also a recent systematic review of stroke from whack em hard/whack em once. Being chiropractors, they are understandably reticent to conclude harm.

“Conclusive evidence is lacking for a strong association between neck manipulation and stroke, but is also absent for no association.”

When I read the Cassidy study, the one most often touted as demonstrating a lack of association between strokes and whack em hard/whack em once, I thought it demonstrated an increase in stroke in the young, the group who should not get a stroke.

I think they found the same result:

“Positive associations, especially with cervical and headache related visits, were only observed for chiropractic patients aged < 45 years, with 25 cases (24.5%) and 27 controls (6.6%) within 7 days for general visits. For headache or cervical visits within 7 days, results in the case–control study were OR crude = 3.11 (95% CI = 1.16–8.35) and accelerated bias corrected bootstrap 95% CI = 1.07–9.60, and for visits within 3 days the case-crossover study gave OR crude = 17.7 (95% CI = 2.04–153.3), bootstrap unavailable. However, for the PCP visits similar associations were observed for patients aged < 45 years and ≥ 45 years. For headache or cervical visits within 7 days for patients aged < 45 years, the case–control study resulted in OR crude = 37.60 (95% CI = 4.80–294), and for within 3 days the case-crossover study yielded OR crude = 28.00 (95% CI = 3.44–227.58), and in both cases the bootstrap was unavailable. Sensitivity analysis resulted in attenuation of the estimates towards the null with lower positive predictive values, but the associations remained positive and significant (data not presented)"

Right? Increased strokes in the young?  That is what they are saying?  There are those who have questioned my statistical sophistication and I will say that my continued re-reading of the above paragraph proves them right.

But why do the young have more strokes? In a wild flight of fancy they hypothesize it is due to drinking and infection:

“Cassidy et al. used a case-crossover design to correct for the lower health status of PCP patients, but this design is limited in controlling factors that can change rapidly.  Binge drinking and acute infection may precipitate occlusive strokes, which are capable of causing severe headache before stroke presentation. If PCP patients are more prone to sporadic binge drinking, and acute infection than chiropractic patients, this could lead to baseline elevation of the PCP visit association for the case-crossover analysis.”

More strokes yeah, the young drink, yeah, and they have more venereal diseases, oh yeah, so, it must be the fact they are drunken and infected.  That’s why they had more strokes. Yeah, that’s the ticket.

Weird. Me? I’d have to drink very heavily and have syphilitic dementia before I allowed someone to whack my neck real hard one time.

There may be an opportunity in the future to determine the risk of stroke from whack em hard/whack em once. Many hospitals now have stroke programs where they collect voluminous data about their patients. It would be interesting to graft a questionnaire onto the stroke program evaluation looking for the risk from whack em hard/whack em once and the development of a stroke. There is a research project for someone with the time and expertise.

If you are a preponderance of data kind of gal, as I am (preponderance of data, not a gal) there is more data to support the risk of stroke after whack em hard/whack em once to the neck to give one pause. We get black box warnings for less frequent drug complications. I doubt I will see a journal article entitled “The Myth of Azithromycin Death.” But then, I pay attention to the data and am not invested in an intervention with no basis in reality that offers only harm without benefit. It must be tough if your raison d’etre only causes harm. I kind of feel pity.

Hanging is too good for a man who makes puns; he should be drawn and quoted.
~ Fred Allen

Posted in: Chiropractic, Clinical Trials

Leave a Comment (49) ↓

49 thoughts on “Whack em hard/Whack em once and Stroke

  1. I am not very well versed in Chiropractic : what is the neck twisting supposed to do?

  2. elburto says:

    I’m almost impressed by the sheer gall of “Adverse events? Nope, not one. We had a few events that were pretty adverse though, we call them ‘Symptomatic Reactions’”.

    Delightfully brazen.

  3. tgobbi says:

    Once again I draw upon my 3 decades of fascination with the bizarre world of “mondo chiropractico” for a couple of anecdotes:

    2 friends, both medical professionals (1 emergency physician, 1 ER nurse) have each reported 2 cases of stroke victims in the ER directly following chiropractic neck manipulation. As in straight from the chiro office to the hospital!

    I’ve been told by DCs that there’s a greater possibility of stroke from bending back for a shampoo at a hair salon or from glancing in the rear-view car mirror than there is from a chiropractic neck manipulation.

  4. Scott says:

    @ FBA:

    Supposedly, it realigns “subluxations” (displacements of vertebrae that nobody but chiropractors can detect, and no two chiropractors detect the same ones) which are impeding the flow of the body’s “innate intelligence” (i.e. qi, soul, insert name for vitalism here) and causing all disease. Complete fiction.

    Just like naturopathy and homeopathy.

  5. Jeff Rubinoff says:

    Courtesy of ZDoggMD, a video advertisement of a chiropractor performing neck manipulations: https://www.youtube.com/watch?feature=player_embedded&v=BJQfT9C5Adc

  6. tgobbi says:

    Jeff supplies this link: Courtesy of ZDoggMD, a video advertisement of a chiropractor performing neck manipulations: https://www.youtube.com/watch?feature=player_embedded&v=BJQfT9C5Adc

    Well, if that isn’t enough to scare the s**t out of you!

    This video is supposed to entice people to submit themselves to chiropractic??? I think it’s more of a deterrent!

    Gentle? Not hardly.

  7. DevoutCatalyst says:

    Wow, add a little Foley to that video and you’ve got quite a send up of chiropractic. The expressions on their faces ! Uh, what’s he doing inside her mouth ?

  8. Blue Wode says:

    Mark Crislip wrote: “…the efficacy for chiropractic, such as it is, mostly revolves around low back pain. No reason to approach the neck and whack it hard/whack it once.”

    Unfortunately, chiropractors believe they have plenty of reason to manipulate the necks of patients who are suffering from back pain only:

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

    Reference (11) in the above quote is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62. Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and gives the reference Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.

  9. Blue Wode says:

    @ Jeff Rubinoff

    Note that the chiropractor in that video is also a high level Scientology cult member who’s reached the state of “clear”. It was pointed out, and discussed, on the skeptical chiropractic forum, Chirotalk, yesterday:
    http://chirotalk.proboards.com/index.cgi?action=display&board=summaries&thread=5965&page=1#48480

  10. Eugenie Mielczarek says:

    From 2001 to 2012 NCCAM has spent over $27 million to test spinal manipulation.

  11. mattyp says:

    Mark Crislip wrote: “They did find 901 cases of CAD (cervical artery dissection) and 707 incidents of stroke reported to be associated with whack em hard/whack em once. They conclude, as chiropractors might,

    “As a result, the value of these reports toward informing our understanding of the relation between [cervical spinal manipulation therapy] and CAD is minimal.“ ”

    Well, yeah, it is miminal. Minimal doesn’t equal zero. It’s a material risk that must be brought up during informed consent with the patient.

    “But then, I pay attention to the data and am not invested in an intervention with no basis in reality that offers only harm without benefit.”

    Was the Bronfort review into chiropractic (http://www.biomedcentral.com/1746-1340/18/3) not up to standard? I thought it did a pretty good job, and cut through a lot of the BS that many chiropractors claim, especially with “type-O” conditions. It concluded there appears to be benefit from manipulation migraine and cervicogenic headache & cervicogenic dizziness, with better quality studies required (I know the line about better and better quality studies showing less and less benefit, I listen to the Quackcasts…) . I will concede that what many chiropractors still “adjust” for, reduction of subluxations, has no basis in reality, but to say there is only harm without any benefit is a stretch. But the risk, while small, is material, and it is why informed consent is important.

  12. Blue Wode says:

    mattyp wrote: “Minimal doesn’t equal zero. It’s a material risk that must be brought up during informed consent with the patient.”

    It’s just a pity that informed consent procedures are often ignored by chiropractors:

    Quote

    “Results from this survey suggest a patient’s autonomy and right to self-determination may be compromised when seeking chiropractic care. Difficulties and omissions in the implementation of valid consent processes appear common, particularly in relation to risk.”

    Ref: Consent: its practices and implications in United kingdom and United States chiropractic practice
    http://tinyurl.com/a9jorhl

    Indeed, the Association of Chiropractic Colleges suggests informed consent but does not mandate it…
    http://www.ebm-first.com/chiropractic/various-concerns/2154-chiropractic-strokes-again-an-update.html

    Hardly reassuring, is it?

  13. Blue Wode says:

    mattyp wrote: “Was the Bronfort review into chiropractic (http://www.biomedcentral.com/1746-1340/18/3) not up to standard?”

    No. It had very little to do with ‘chiropractic’, and the UK General Chiropractic Council, who commissioned the review, were caught out by it. See:
    http://www.zenosblog.com/2010/11/where-the-evidence-leads/

    For a quick summary, see here
    http://edzardernst.com/2012/11/the-risk-of-neck-manipulation/#comment-1368

  14. goodnightirene says:

    I just had houseguests (nursing students from Chicago) who are very eager to graduate so they can move to Seattle and attend Bastyr for “advanced medical training” and move into the “wonderful world of alternative medicine”. Apparently not a single thing in the nursing curriculum has given them the slightest pause–and that gives me a lot of pause.

    Actually, they are motivated by the trend of “all the best places are offering it now”; ergo, “there must be something to it”. They felt it was “rude” of me to refer to all this as so much quackery. The worst thing was that I had to back off, bite my tongue (it’s still bleeding), and pretend to be a shruggie because they were PAYING guests (reviews are everything on the WWW).

    I bet I could double the rates if I could find the time to get that Reiki Master certificate, add some incense pots, strew around a few copies of “Natural News”, and offer super-organic-all natural vitamins in place of the bowl of fruit. And “free consultation” coupons to the local whack ‘em hard/whack ‘em once, of course.

    I know I’ve written this before, but I DESPAIR. (I do think I will print out the new e-books, though and leave those somewhere discreet–like on the toilet lid or the pillow).

  15. windriven says:

    @irene

    “Actually, they are motivated by the trend of “all the best places are offering it now”; ergo, “there must be something to it”.

    Oh how I share your concern about this. And it isn’t just nurses. There are plenty of MDs who walk with them hand-in-hand. I have no statistics to demonstrate this but I suspect that science based medicine is losing ground. We haven’t heard from nygbrus for a while. I’d love to hear his thoughts on the prevalence of woo in his cohort.

  16. windriven says:

    @tgobbi and DevoutCatalyst

    I thought the video was satire. Apparently I was wrong. I don’t know whether to laugh or cry.

  17. mattyp says:

    @ Blue Wode: No, it’s not reassuring at all. I had the minor misfortune of having appendicitis a couple of years ago. The resident was the fella asked to come get my informed consent for the surgery. It was awkward and it was bumbled, but he did it. You wouldn’t want to imagine surgery being done without informed consent, indeed I think it’s a criminal offence, or certainly a deregisterable offence (mitigating circumstances allowing).
    Why should we be any different?

  18. mho says:

    @goodnight irene

    why bother with a certificate? make one up. . .

  19. mattyp says:

    Blue Wode wrote: “It had very little to do with ‘chiropractic’, and the UK General Chiropractic Council, who commissioned the review, were caught out by it. See:
    http://www.zenosblog.com/2010/11/where-the-evidence-leads/

    I found this quote interesting:
    “Chiropractors can’t have it both ways: chiropractors can’t claim to be unique amongst the manual therapists because of their techniques, yet claim any evidence for their particular ‘art’ from the studies that were not about chiropractic manipulations. The GCC has made this perfectly clear.”

    I think as time drags on, the uniqueness will disappear and we’ll be mainstream therapists but for another name (hopefully). I don’t hold my breath though. I was in a chiropractic group the other day and they were banging on about philosophy, and the question was: “what’s the difference between a manipulation by a physio or doctor and an adjustment by a chiropractor? The intent.” Gimme a break.

  20. @windriven

    Oh how I share your concern about this. And it isn’t just nurses. There are plenty of MDs who walk with them hand-in-hand. I have no statistics to demonstrate this but I suspect that science based medicine is losing ground.

    The “us vs them” mentality of you and your religious cultists is sickening.
    Newsflash.. there is no “jihad” between conventional and alternative medical practitioners.

    We happily work together in real clinical practice. I work with MDs, radiologists, pathologists, and refer patients to them and MDs refer patients to me. Nobody is losing and Integrative Medicine is winning.

  21. EbmOD says:

    Well timed. A friend of mine (who is also in his early thirties) went to his chiropractor just 10 days ago for a stiff neck. He then developed what he thought was sciatica. Only it worsened until he was physically incapable of lifting himself off of the floor due to excruciating pain. He had to be admitted to the hospital where he was diagnosed with a pinched nerve. Guess it could have been worse . . .

  22. BillyJoe7 says:

    Apparently, science based medicine is a cult, and inanities pulled out of the nether regions are real clinical practice.
    And, apparently, patients don’t matter as long as the altmed practitioners and the ignorant and opportunistic MDs who give them oxygen live happily together making fast bucks.

  23. MTDoc says:

    @FBA
    Speak for yourself about our embrace of CAM. I’m with Windriven on this one.

    @Windriven
    Gee, I didn’t realize you were a religious cultist. Hard to equate that with SBM!

  24. harv says:

    The only benefit of chiropractic is that it provides the patient with something to focus upon during the healing process. It serves as a placebo activity, minimizing pharmaceutical hazards.

  25. goodnightirene says:

    @windriven

    So now we are “religious cultists”–pot, kettle, black. I’m pretty sure most of us are atheists and what could be more cultish than something like homeopathy, acupuncture, naturopathy, ayurvedic, reiki, or any of the others that originated with a maverick thinker (or eastern mysticism) and are slavishly followed by dedicated believers?

    I want to state this again (as I did to the nurses), it’s fine to offer support services to people who may feel that their experience with doctors and hospitals is not warm or personal enough, but it is not all right to claim that making them feel better “spiritually”, or because of a placebo effect, is a different type of medicine than can cure or treat disease beyond that placebo effect. Nor is it moral or ethical to take their money for it when the claims are not supported by science. If they want to make a donation (as people do to a church) for your assistance, that’s fine, but when you call supportive services “medicine” and charge “fees”, that is fraud.

    I have yet to find a CAM believer (including a few MD’s) who can define “scientific method” for me. Those who try usually get it wrong from the outset by declaring it to be “another way of thinking”.

  26. BillyJoe7 says:

    1984

  27. mattyp says:

    Fast Buck Artist said: “”Integrative Medicine” is winning?”
    That’s an alarming attitude. The only people who should win should be patients. Not an industry.

  28. @mattyp

    You are right, patients wellbeing comes first.
    Patient satisfaction surveys consistently favor integrative medical clinics. Teams of MDs and NDs work together to bring non-toxic non-invasive natural alternatives to clinical care.

    Evaluation of Interative Medicine for mitigation of chronic insomnia and constipation in inpatient settings has found that naturopathic treatment has reduced the need for sleep medication from 55% to 11% for inpatients with eating disorders.

    Studies by National Institute of CAM show that holistic medical use is growing and nearly 40% of adults now use alternative medicine treatments and products and it’s growing further.

    Thats the reality. There is no war between CAM and DBM, we work together, the patients benefit, the clinics benefit, the medicare budget benefits. Its a win-win-win situation.

  29. BillyJoe7 says:

    Apparently our fast bucking CAM artist believes that patient self-reports are a reliable form of evidence, that popularity is a useful argument, that the plural of anecdotes is data, and that cherry picking is a fulfilling occupation.

    And we are all invited to dance arm in arm, cheek to jowl, blissfully, ignorantly to the end of the rainbow.

  30. BillyJoe7 says:

    Dr. Strangelove.

  31. windriven says:

    @BillyJoe

    Your literary and cinematic allusions are particularly apt, I think. Lies and distortions repeated often enough become indistinguishable from truth. In embracing that distorted reality we become, eventually, our own persecutors.

    Which scourge of humanity has been conquered by homeopathy or acupuncture or colonic irrigation or naturopathy? Was it polio? Rickets? Smallpox? Acute appendicitis? Renal failure? What deep insights into human physiology have been elucidated by these shamans and poseurs?

    Nothing. They are empty boxes with plastered with colorful graphics promising unimaginable goodness within.

  32. tgobbi says:

    mattyp states: “The only people who should win should be patients. Not an industry.”

    At least in the United States it seems to me that this isn’t the philosophy of the chiropractic industry. The associations and most of the individual DCs I’ve had contact with are struggling to keep the business alive without regard to proving the efficacy of their claims. My contention, as I have expressed before, is that chiropractic is an elaborate marketing scheme, not a healthcare profession. For anyone who needs corroboration of this I recommend searching the SBM site, the Respectful Insolence site and the Quackwatch site. You’ll see countless egregious affronts to science-based medicine on all of them. Random checks of individual chiropractors’ websites also offer tons of testimony for the pseudoscientific nature of the business.

  33. EbmOD says:

    Gotta love when people’s arguments are taken down how they run to the ‘Alamo’ of primacy of consciousness and repeat their little mantras . . .

  34. WilliamLawrenceUtridge says:

    So I think I found the study. The interventions section is the most interesting:

    The IMED program brought a number of changes to the ED program previously in place at the hospital. Specific to insomnia, patients on the ED program were treated pharmaceutically, mainly with Trazodone (a serotonin reuptake inhibitor/antagonist). On the IMED program, insomnia was treated first via instructions on sleep hygiene, and then, if needed, an herbal product (containing Valerian root extract, Rhodiola rosea root extract, Hops strobiles extract, Passion flower aerial parts extract, and German chamomile flower extract) and/or 5-hydroxytryptophan (the metabolic precursor to serotonin) were prescribed. If these approaches were not successful, patients were prescribed conventional medications for sleep.

    So, the regular care group got pills to help people sleep (and sleeping pills are recognized as both effective and risky) meanwhile the CAM group got instruction on sleep hygiene, a bunch of herbs, and the same medications as the regular care group. So, much like the study on naturopathy discussed by Dr. Gorski earlier in the week, there are two groups and their treatments are not remotely equivalent. The inclusion of sleep hygiene alone both misrepresents conventional care (which would include sleep hygiene) and is a tremendous confound. What improved sleep quality here, was it a herbal medicine blend, sleep hygiene or the fact that eventually they got actual pharmaceuticals if none of the other types worked? This isn’t a test of naturopathy, this is an advertisement that first assumes a proprietary herbal blend works, then gloms so many other treatments you never know what actually was responsible for the improvement in the patients.

    CAM “researchers” are either terrible researchers, or aware that their nostrums are unlikely to be effective and deliberately design their tests to be scientifically meaningful – but marketable.

    I hope we get another lecture about how unethical researchers and the FDA are, that’s always amusing.

  35. EbmOD says:

    “CAM “researchers” are either terrible researchers, or aware that their nostrums are unlikely to be effective and deliberately design their tests to be scientifically meaningful – but marketable.”

    Ding ding ding. Many of those who push CAM I think are quite aware it is bunk, but because it is bringing home the bacon, they just want to preserve the golden goose.

  36. tgobbi says:

    EbmOD states: “Ding ding ding. Many of those who push CAM I think are quite aware it is bunk, but because it is bringing home the bacon, they just want to preserve the golden goose.”

    This hasn’t been my experience. Over the years most of the alternative practitioners I’ve been in contact with (DCs and NDs mostly) really believe in what they do. Of course it’s possible that they’ve sold themselves a bill of goods and have come to regard their disciplines as legitimate and efficacious.

  37. WilliamLawrenceUtridge says:

    The thing is, doctors who bled their patients, priests who chanted to Hermes Trigemester or Hathor, Chinese alchemists who dosed their emperors with mercury to achieve immortality, cavemen who trepanned the skulls of their patients – they all also really believed in what they did. Doc Spock, recommending babies sleep on their stomachs, really believed in what they did. Knee debridement, milk for ulcers, whole cell pertussis vaccines – lots of people believed very strongly in what they did.

    Believing in what you do, believing and practicing with the best of intentions, doesn’t mean you’re actually helping people or practicing efficient and effective medicine. Testing, and the willingness to abandon what doesn’t work, is what ensures you are actually improving the health of people.

  38. EbmOD says:

    “This hasn’t been my experience. Over the years most of the alternative practitioners I’ve been in contact with (DCs and NDs mostly) really believe in what they do. Of course it’s possible that they’ve sold themselves a bill of goods and have come to regard their disciplines as legitimate and efficacious.”

    I agree that the majority are that way, and that an even greater majority started that way, but I have long had my suspicions that many of those who push the CAM are secretly disillusioned or flat don’t believe but realize it is a good scam with regards to their own finances. For example, look at Mike Adams at Natural News. When I read his stuff, I don’t get the feeling that I am reading the report of someone who truly believes, but rather of someone who is a master manipulator who knows how to line his own pockets.

    Even if Mike Adams truly does believe, I think it stands to reason that just like many who are raised in religion, have a crisis of faith and can’t quite pull the trigger on letting go of it despite the fact that deep down they know it is an unlikely proposition, there are many who have realized that they are practicing modern day voodoo.

  39. pmoran says:

    EbmOD states: “Ding ding ding. Many of those who push CAM I think are quite aware it is bunk, but because it is bringing home the bacon, they just want to preserve the golden goose.”

    Tgobbi: This hasn’t been my experience. Over the years most of the alternative practitioners I’ve been in contact with (DCs and NDs mostly) really believe in what they do. Of course it’s possible that they’ve sold themselves a bill of goods and have come to regard their disciplines as legitimate and efficacious.

    This is my experience too, at least with those who engage in such discussions. Outright frauds exist, but they are not likely to run the risk of being shown up.

    Financial investments in CAM will have some influence on belief, and I believe that mankind has considerable ability to kind of “half-believe”, for selected purposes. Yet none of this is necessary for CAM’s existence.

    We spend a lot of time here discussing the illusions of therapeutic efficacy that dominate everyday medical practice: placebo responses, non-specific influences, the natural progress of diseases, coincidence, various areas of bias etc.

    We have often observed their influence upon our own esteemed professors in relation to some scarcely plausible treatments. So powerful are these illusions that we are still learning how to exclude their influence in already highly technical and formidably expensive clinical studies, in order that we can really know what “works” (meaning “has intrinsic efficacy”). So powerful are they that even in the present century we can acknowledge their ongoing influence by partially accepting the viewpoint that “most published medical research is wrong”.

    Moreover, virtually every CAM supporter that speaks up provides examples of their influence.

    So how come some of us balk at allowing that CAM practitioners and supporters may be acting in good faith, and simply because of these powerful influences!!!

    Science has been able to partially insulate itself from them only by rather extreme application of the null hypothesis (more or less, “nothing is true until —” ) reinforced when necessary by plausibility considerations. That is a sound approach for medical science, but we should acknowledge that as physicians we have a competing obligation that might lead us to sometimes give methods a provisional benefit of the doubt where individual patient benefits are at all possible. That is all that some CAM supporters are trying to suggest.

    BTW, even cancer quacks convince themselves they are helping, by sparing their clients the evil effects of conventional methods. They sincerely believe (or permit themselves to be convinced ) that those methods hardly ever work, but simply poison those receiving them.

  40. goodnightirene says:

    @pmoran

    “BTW, even cancer quacks convince themselves they are helping, by sparing their clients the evil effects of conventional methods. They sincerely believe (or permit themselves to be convinced ) that those methods hardly ever work, but simply poison those receiving them.”

    This is almost verbatim what my houseguests were spouting. I think they are sincere. They are nice people. Sadly, they are hideously ill-informed and do not have a clue about the history of science or how it operates today. Good intentions are not enough. Quacks are entitled to offer comfort and support, but not to take money from the equally ill-informed. I really think this is the bottom line. But then, churches take money, so the precedent is there–unfortunately.

  41. @tgobbi and pmoran

    Outright fraud is rare in our industry. There is a lot of grey area though – practices where profits are the primary concern and patient wellbeing is an afterthought (this goes for both conventional and alternative medicine practices).

    A prime example in CAM that comes to mind is Herbalife, a publicly listed company selling diet supplements. Going through their materials, one quickly realises that therapeutic benefit of the products is not even a remote consideration in the business operations. Is Herbalife Cell-U-Loss an effective treatment for cellulite? Nobody knows or cares. The company is not even concerned how many of these mystery pills they sell. It’s not what brings in the bacon. The business is basically a pyramid scheme making money from membership fees of new recruits.

    If you think conventional medicine is much more concerned about patient wellbeing than profits, please stop fooling yourselves. Merck has covered up for years that their blockbuster drug Vioxx relieves the pain and stiffness in joints by killing the patient. Roche has covered up for 30 years their blockbuster product Accutane prescribed for self-limiting teenage skin problems is an extremely toxic chemotherapy drug, causing inflammatory bowel disease, depression, severe birth defects, dryness of mucus membranes and a whole basket of other wonders. They finally withdrew it in 2009, not due to safety concerns mind you, but calculated that cost of lawsuits and competition from generics outweigh the profits.

  42. BrewandFerment says:

    My mom suffered from incapacitating migraines for most of her 40s. I suspect, without any real proof, that they may have been connected to the emergency hysterectomy that she had 3 or 4 days after the (induced due to MD schedule conflicts at 37 wks) birth of my youngest sibling, when the post-partum uterine repairs failed. Apparently something related to the induction either caused a rupture or my sibling went into some sort of spasm, not sure what. Not surprising, given that it was her 5th child in 6 years at the age of 39. At the age of 7, I as the eldest child was cooking (burning) dinner several days a week while she was down for the count. Someone suggested a chiropractor and mom became completely sucked in by the whole chiro and much of the alternative medicine world. There were weird dietary interventions, etc. all because she had become convinced that the chiro helped stave off or mitigate the migraines.

    Fortunately we had all had our vaccinations before she started taking us to the chiro, because for all practical purposes we got much more face time with him than our regular family doctor. (scary thought!) I had a few (vicious) migraines in my early teens, aura, nausea and the whole nine yards. I remember feeling much despair that if mine were starting so early, how was life going to be worth living??? So it’s probably to be expected that I also bought into the whole chiro rationale; believe me, at a rather vulnerable time of my life I got the full range of sCAM argumentation. Fortunately the migraines stopped quickly and I only had one other one 18 years ago when my eldest was 8 months old.

    Over the next 20 odd years, I did have sporadic chiropractic treatments (to my husband’s disgust) although most were for lower back issues, and were limited in frequency due to availability of time and funds. And in the interim I had started hearing Dr. Dean Edell on the radio and discovered Quackwatch so was starting to get disillusioned with the whole sCAM world, yet hadn’t completely cut it loose.

    But then about 10 years ago, I went for an adjustment due to some upper back muscle tension/pain that ibuprofen didn’t fix. The chiro I’d usually seen was pretty low key and had fixed this particular issue before, but he was away for several weeks and had a relief chiro. I might have waited except that I couldn’t fully expand my lungs due to the pain in my upper back, so I went to him. I got the adjustment and relief but he also “adjusted” my neck and it was tight and hurt a lot more than I expected. The next morning before breakfast I started getting a migraine aura–the first that I had had since that single one 18 years ago, so I called up a chiro that was open on Sat and took some OTC analgesic before I left. I was sitting in the treatment room and realized that the aura was gone and my head had never started to hurt. The chiro came in and insisted on giving me the whole chiro spiel about subluxations and so forth. I told him the headache was gone. I think I did get an “adjustment” but that was the last time I ever set foot in a chiro office, and since then I’ve come to believe I may have had a rather narrow escape.

  43. Davdoodles says:

    “Outright fraud is rare in our industry.”

    Good. Grief.

    And sand is “rare” on a beach.
    .

  44. DugganSC says:

    Truth be told, most alt med practitioners I know truly believe in their work. It’s no more fraud than your mother telling you that your eyes will stay crossed if you don’t uncross them, or that swimming within an hour after leads to devastating cramps. Since they truly believe it, it’s not fraud, just not true.

    Now some of the companies that sell supplements and the like on the other hand, they’ve been caught doing everything from “supplementing” with pharmaceuticals to substituting filler instead of the vitamins they claim.

  45. mattyp says:

    tGobbi wrote: “At least in the United States it seems to me that this isn’t the philosophy of the chiropractic industry. The associations and most of the individual DCs I’ve had contact with are struggling to keep the business alive without regard to proving the efficacy of their claims. My contention, as I have expressed before, is that chiropractic is an elaborate marketing scheme, not a healthcare profession.”

    There are certainly large elements of the profession that would back up your claim.

    “For anyone who needs corroboration of this I recommend searching the SBM site, the Respectful Insolence site and the Quackwatch site. You’ll see countless egregious affronts to science-based medicine on all of them. Random checks of individual chiropractors’ websites also offer tons of testimony for the pseudoscientific nature of the business.”

    This seems like a conversation we’ve had before…

  46. pkkoop says:

    My wife (works in a stroke rehab centre) has also noticed this apparent correlation anecdotally, as I discovered after I sent her this link:

    “We have seen a number of vertebral and basilar artery dissections [following] suspiciously after chiropractic appointments. “

  47. Scott says:

    Truth be told, most alt med practitioners I know truly believe in their work. It’s no more fraud than your mother telling you that your eyes will stay crossed if you don’t uncross them, or that swimming within an hour after leads to devastating cramps. Since they truly believe it, it’s not fraud, just not true.

    I disagree – the fact that they believe it doesn’t render it not fraud. Because they are holding themselves out to be medical professionals, and taking money for those services, and the evidence is clear that said services do not work, they should know that their work is bogus.

    IANAL, so I can’t speak to whether the legal terminology allows a “should have known” standard for fraud charges, but IMO the ethical standard certainly does.

  48. jhawk says:

    Mark Crislip,

    In regards to the Cassidy study, positive associations were found in those under 45 for the chiro group but these same positive associations were found for the PCP group. This is in part why the authors come to their conclusion.

    “But why do the young have more strokes? In a wild flight of fancy they hypothesize it is due to drinking and infection:” “More strokes yeah, the young drink, yeah, and they have more venereal diseases, oh yeah, so, it must be the fact they are drunken and infected. That’s why they had more strokes. Yeah, that’s the ticket.”

    Here they are trying to give a possible reason for why the PCP group under 45 had the same association with stroke as the chiro group. This possible reason being that the PCP group was less healthy for reasons listed.

    This is how I read it anyway!

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