Sometimes you need to help the blind pig.
When people are at the end of their life they like to pass on their life lessons. One thing I have never had a patient say is “Doc, I sure wish I had spent more time at work.”
I try and keep that in mind, but then there are those work commitments that are hard to avoid. I need to have a talk with Drs. Gorski and Novella. No one should have write a blog entry any week their team is in the play-offs. The Blazers were not meant to win more than 25 games, much less be the 5th seed in the West with a chance to make the conference finals. I know. Trailblazers fans are not always grounded in reality. But we are up on the Clippers 3–2 and heading home to close out the series tonight. For the record I wrote the preceding sentence during the game 5 tip-off. I really should not have to do any work this week. Basketball is simply more important.
Take this case report. Anywhere else.
Case reports are a tradition in medicine. Usually they are unique or unusual cases, diseases you are likely to see but once in a career, if that. There are all sorts of medical curiosities that need to be reported. I have a blog over at Medscape devoted to Infectious Disease case reports.
Some case reports, however, inspire eye rolls and sniggers. Why are these even reported? (more…)
My reaction to reading the paper discussed herein, were I a handsome Spaniard.
Bleh. I turned from a short trip to the city of angles with a bad man cold that just isn’t going away. Those who do primary care all tell me that whatever is going around lasts 2-3 weeks. Great. I am not sick enough to get out of work but I am not well enough to have any enthusiasm to do anything. I look at the key board and sigh. I just want to binge watch something mindless.
I know Harriet covered “Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation” last week. But it is one thing to read the evaluation of a paper and quite another to evaluate a paper on your own. It is the latter process where you, and by you I mean me, actually learn something. I write mostly for my edification, not yours. Sorry. It is all about me. I will likely read Harriet’s post this weekend.
The issue at hand is whether chiropractic manipulation can cause a stroke. (more…)
The Integrative Medicine Wheel
“Integrative medicine” (IM) is an ideological movement within medicine driven in large part by those whose livelihoods depend on its continued existence. This includes both those with positions in academic medicine and individual practitioners who use the IM brand to attract patients.
Despite IM and its antecedents (alternative, complementary, alternative and complementary, complementary and integrative) having been around for about a quarter century, we still do not have a working definition of integrative medicine or have any idea whether it positively affects patient outcomes. And, despite the lip service given to IM being evidence-based, or “evidence-informed” or incorporating “appropriate” services into conventional medicine, there does not seem to be any standard for determining which modalities are appropriate for inclusion. We can infer, however, that evidence of effectiveness is not a criterion, as reiki, cranial sacral “therapy”, and homeopathy are standard fare.
In fact, the prospect for actually improving patient outcomes by importing CAM treatments (such as acupuncture) into medical practice would seem to be decreasing over time, as more and more fail to hold up under the scrutiny of well-designed and conducted clinical trials. Perhaps the dearth of evidence for “alternative” treatments is the impetus behind the importation of conventional modalities, such as nutrition and exercise, into the IM fold, treatments that were never viewed as CAM when the whole enterprise started. It has also led to special pleading demanding that research standards be loosened, most recently by the NCCIH, its director’s promise to ensure “rigorous science” notwithstanding.
There is no standard delivery model for integrative medicine or, importantly, an agreed-upon role for the various practitioners who bring the “integrative” to integrative medicine, such as chiropractors, naturopaths and acupuncturists. For example, should they be allowed to practice independently or should the medical doctor have final say on patient care? And, if they differ in their proposed diagnoses and treatments, how are those issues to be resolved? (more…)
NOTE: Today we offer a double feature on the treatment of cervicogenic headache: this post and Dr. Harriet Hall’s post, “When Headaches Are a Pain in the Neck: Spinal Manipulation vs. Mobilization for Cervicogenic Headache.” They complement each other, as well as Dr. Hall’s post from last week on the possible risk of stroke with neck manipulation.
A cervicogenic headache has been defined as a secondary headache (beginning in the suboccipital area) caused by nerve pain referred from a source in the upper cervical spine. According to the American Migraine Foundation, “To confirm the diagnosis of cervicogenic headache, the headache must be relieved by nerve blocks….Treatment includes nerve blocks, physical therapy, exercise, Botox injections, and medication. Physical therapy and an ongoing exercise regime often produce the best outcomes.”1
There are a number of published studies advocating use of upper cervical manipulation as a treatment for cervicogenic headache,2 often without adequate consideration of the danger of such treatment. While upper neck manipulation might sometimes be an effective treatment for a cervicogenic headache, care must be taken to avoid upper cervical manipulative techniques that may pose risk of stroke by damaging vertebral and internal carotid arteries.
Most headaches are of the tension-type variety, often originating in the myofascial structures of the head and neck. There are many other types of headache, some of which can be life-threatening or unbearably painful, none of which are neck related. Headache caused by a leaking brain aneurysm may portend possible rupture of a swollen blood vessel. A migraine or a cluster headache is less serious but can cause agonizing pain. Sudden appearance of neck pain with headache can be a symptom of spontaneous vertebral artery dissection, which can result in a full-blown stroke if aggravated by neck manipulation. When a headache is sudden, severe, or persistent, it is important to have a medical evaluation before concluding that you have a neck-related headache or before submitting to neck manipulation, especially upper cervical manipulation that involves rotation of the atlas on the axis. (more…)
NOTE: Today we offer a double feature on the treatment of cervicogenic headache. My article is about a study that compared manipulation to mobilization; it is followed by retired chiropractor Sam Homola’s guest article on manipulation for cervicogenic headache. The two posts complement each other and also complement my post from last week on the possible risk of stroke with neck manipulation.
If a headache originates in the neck, does manipulation provide more relief than mobilization?
Cervicogenic headache (CGH) refers to headaches that are caused by problems in the neck, as opposed to headaches of non-neck etiology that may be accompanied by neck pain. There is controversy over whether CGH is even a valid diagnosis. Diagnostic criteria usually include unilateral headache triggered by head/neck movement or by pressure on the neck, headache that spreads to the neck, shoulder or arm; and often limited range of motion in the neck. If a nerve block in the neck relieves the headache, that would confirm that the pain originates in the neck, but nerve blocks are not routinely done and are not required for diagnosis.
Is manipulation effective for CGH?
There is controversy over whether spinal manipulation is an effective treatment for CGH. A 2005 systematic review concluded that “A greater number of well-designed, randomized, controlled trials are required to confirm or refute the effectiveness of spinal manipulation.” (more…)
Can neck manipulation (by chiropractors or by other practitioners) cause strokes? Many of us think it can, but definitive proof is lacking. A recently published study looked at the available evidence. A systematic review found a small association between stroke and chiropractic care but concluded that the association was spurious and that there was no evidence for causation. My colleagues and I have written about this subject several times; some of the links are listed here. I certainly agree that there is no definitive evidence for causation, but I think there is evidence to support a strong enough probability of causation to constitute a good reason to avoid neck manipulation. (more…)
CAM proponents view National Health Interview Surveys recording the supposed popularity of CAM, an amorphous conflation of anything from conventional medical advice to mythical methods, as an invitation to unleash even more unproven remedies on the public. My interpretation is quite different. I see the same figures as proof that we are doing too little to protect the public from pseudoscience.
In fact, state and federal governments are acting as handmaidens to the CAM industry by legalizing practices and products that have insufficient proof of safety and efficacy and, in some cases, are so scientifically implausible that they can never meet that standard. The federal government keeps “integrative” medicine centers at major academic institutions and private foundations afloat with taxpayer money by funding research that has failed to improve public health or the treatment of disease, despite seemingly endless trials, because “more research is needed”.
As we shall see, Australia has a more effective regulatory system for dealing with CAM. And the advocacy group Friends of Science in Medicine (FSM), an organization with goals similar to our own Society for Science-Based Medicine, is keeping the government on its toes, investigating violations of the law on its own and reporting them. We in the US could learn something from their two recent successful campaigns attacking misleading health claims. (more…)
I was looking over a recent class catalog from my alma mater, University of Oregon. I see the Astronomy Department is having a day devoted to astrology, inviting astrologers to talk about their profession. And the Chemistry department is having alchemists give an overview on how to change base metals into gold. And, to green our energy, the Physics Department, where I acquired my undergraduate degree, is having a symposium on perpetual motion machines. I am so proud.
But not when it comes to SCAM (Supplements, Complementary and Alternative Medicine). Medicine is strange in that has no issues embracing pseudo-science. My medical school, OHSU, had an afternoon devoted to Integrative Medicine for the third year medical students, with lectures by a chiropractor, a traditional Chinese pseudomedicine practitioner, a naturopath and an integrative medicine practitioner. They also had a small group discussion of a case of irritable bowel syndrome where one of the discussion leaders was a……Qi……….Gong………..master. Really. I would be so pissed if I was going $166,000 in medical school debt and I was being taught about the approach to ANYTHING by a Qi Gong Master. It was a day to ignore that whole ‘science’ thing in the name of the school. (more…)
I had the pleasure of speaking on the topic of chiropractic and the newborn baby earlier this week at a meeting of the Boston Skeptics. There is a video of the talk online for anyone interested in learning more. And if you haven’t yet, please read yesterday’s post on chiropractic and babies by Sam Homola.
My introduction to pediatric chiropractic
Although I was aware of the existence of chiropractic well before beginning my medical training, I was blissfully ignorant of the full scope of what many chiropractors actually do on a daily basis. My belief that they practiced solely as “doctors of the back” was shattered early in my pediatric training at Vanderbilt while on a pulmonary medicine rotation when I was asked to consult on the child of a well-known musician who lived in the area. The patient, perhaps only hours from respiratory failure, had been brought to our emergency department only after chiropractic treatments had failed to manage a severe asthma exacerbation.
That encounter, as well as another around the same time involving a child with a throat abscess being treated with acupuncture, inspired me to dig deeper into the general concept of alternative medicine. I even went so far as to approach a local chiropractor who had set up a table at a Nashville YMCA to promote chiropractic prevention and treatment of the flu. Dr. Fakename happily allowed me to spend a day in his office, and even brought in his own child to demonstrate his approach pediatric care.
Needless to say, Dr. Fakename failed to convince me of the benefits or need for chiropractic involvement in pediatric healthcare. When the discussion turned to routine childhood vaccines, I heard the party line on the subject for the first of many times. Dr. Fakename was not against vaccines, he was in favor of giving families all of the facts. He gave me some reading material, and a book suggestion or two, which provided nothing but potential and unproven risks with no mention of the well-established benefits and proven safety of immunizations. I’ll never forget what his wife, who had brought their child in for the demonstration, whispered to me during a moment of distraction: “Don’t worry, we vaccinate our kids. I make sure.”
By the end of my residency I was a full blown skeptic of a variety of alternative medical modalities in addition to chiropractic, and had built a reputation as someone interested in and knowledgeable on the subject of quackery. I even gave a grand rounds on pediatric CAM with a focus on chiropractic which I’m proud to say drew a standing room only crowd that included folks from the community interested in alternative medicine as well as from the brand new integrative medicine center at Vanderbilt. I had even been asked to serve as a resident representative, however that invitation was quickly rescinded after my skeptical talk. (more…)
My article “Pediatric Chiropractic Care: The Subluxation Question and Referral Risk” was published in the 2016 February issue of the journal Bioethics. The abstract summarizes the message of the article:
Chiropractors commonly treat children for a variety of ailments by manipulating the spine to correct a “vertebral subluxation” or a “vertebral subluxation complex” alleged to be a cause of disease. Such treatment might begin soon after a child is born. Both major American chiropractic associations─the International Chiropractic Association and the American Chiropractic Association─support chiropractic care for children, care that includes subluxation correction as a treatment or preventive measure. I do not know of any credible evidence to support chiropractic subluxation theory. Any attempt to manipulate the immature, cartilaginous spine of a neonate or a small child to correct a putative chiropractic subluxation should be regarded as dangerous and unnecessary. Referral of a child to a chiropractor for such treatment should not be considered lest a bad outcome harms the child or leads to a charge of negligence or malpractice.1
The first objection to my article came in a January 30 Facebook posting by Milehighchiro, a subluxation-based group: (more…)