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Pushback on Chiropractic

Daniel David Palmer, creator of the nebulous subluxation and father of chiropractic.

Daniel David Palmer, creator of the nebulous subluxation and father of chiropractic.

From time to time we respond directly to reader comments or e-mails in an article, when it seems that doing so would be a useful teachable moment. One of the strengths of social media is that it is interactive, which can be didactic.

I feel it is very important to respond to what people actual believe and say, because otherwise we may tend to get lost in our own narrative, as legitimate as it might be. That is the essence of ivory tower syndrome, academics talking to themselves without a reasonable sense of what is happening in society. Part of our mission is to interact with society, not just our colleagues, and to engage in a serious conversation about the nature of science and medicine.

To that end, I recently received an e-mail responding to an interview I had done previously about chiropractic. The e-mail is full of pro-chiropractic propaganda and misconceptions, and so it provides an opportunity to address some of these claims. (more…)

Posted in: Chiropractic

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Australian Chiropractor Ian Rossborough Promises to Stop Treating Children…for Twenty Days

kangaroochiro

An Australian chiropractor treating a baby kangaroo makes as much sense as treating a human child

Before I begin this brief update to my recent post on Australian baby chiropractor Ian Rossborough’s “crack heard round the world,” I want to give a quick thanks to Jann Bellamy for organizing our day of Science-Based Medicine at NECSS last week. It was an amazing experience sharing the stage with the SBM crew for my first public presentation, and finally getting to meet Scott, John, and Saul. I’ve given hundreds of lectures to residents and students, and even a grand rounds or two, but this was orders of magnitude more exciting and stressful. I may be biased, but I think we nailed it.

With NECSS prep taking up a significant percentage of my time and a rough current work week making up for days off, my post today is a little shorter than usual. My overall average word count still gives Gorski a run for his money however. Well, that’s not actually true. Gorski is in another league.

Rossborough provides an undertaking?

Chiropractor Ian Rossborough, who I recently discussed in a post on the backlash against pediatric chiropractic in Australia, has received the slap on the wrist I sadly expected. According to the Australian Health Practitioner Regulation Agency website, which has jurisdiction over the Chiropractic Board of Australia when it comes to “professional conduct, performance or health of registered health practitioners,” Rossborough has promised to leave them kids alone:
(more…)

Posted in: Chiropractic, Science and Medicine

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The Crack Heard Round the World

Chiropractor Ian Rossborough mid-rationalization

Chiropractor Ian Rossborough shown here mid-rationalization

In January, Melbourne chiropractor Ian Rossborough uploaded a video to YouTube of himself treating a 4-day-old premature infant. The video, one of many that can be found on his “Chiropractic Excellence” channel, is for educational purposes only, intended to teach the world about the miraculous benefits of chiropractic care for a wide variety of conditions. Although the cynical among us may proclaim that his videos are just more examples of chiropractic practice building shenanigans, Rossborough claims that he simply wants to “enable natural healthy living, without resorting to drugs or surgery.”

Australian physicians respond

Well, there are apparently a lot of angry and cynical Australians, particularly journalists and physicians. In late April, the video, which features Rossborough manipulating the newborn’s thoracic spine hard enough to cause a loud cracking sound and a cry of pain went viral after it was featured in a story on Australian Broadcasting Corporation Radio National. Rossborough, and the treatment of children by chiropractors, has since come under intense scrutiny.

According to the Australian press, “doctors have declared war on chiropractors” in response to the realization that newborns and young infants are undergoing unnecessary spinal manipulation for problems such as colic, acid reflux, and excessive crying as well as for nebulous benefits like boosting the immune system and improved growth and development. The Royal Australian College of General Practitioners, the largest medical college in Australia with a membership of over 30,000 rural and urban primary care physicians, has even requested that members refrain from referring patients to chiropractors. They want the federal government and private insurers to stop paying for nonsense such as infant chiropractic.

Frank Jones MD, president of the RACGP, has made the media rounds, describing infant and toddler adjustments as “seemingly almost cruel” and lacking any supporting evidence. He has also called for the Chiropractic Board of Australia to shape up in order to have any chance of being accepted as a legitimate scientific discipline. Jones thinks that chiropractors like Rossborough and his ilk don’t know what they are doing and are putting patients at risk. He reminds the public that a physician’s job is to advocate for patients and to try to reduce exposure to practices where the risk far exceeds any potential benefit. I like this guy.

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Posted in: Chiropractic, Science and Medicine

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Chiropractors, Blind Pigs, and Acorns

Sometimes you need to help the blind pig.

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…)

Posted in: Chiropractic, Clinical Trials, Humor

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Chiropractic- Ignoring the Precautionary Principle Since 1895

My reaction to reading the paper discussed herein, were I a handsome Spaniard.

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…)

Posted in: Chiropractic, Clinical Trials, Critical Thinking

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Academic Consortium plan: force medical residents to practice integrative medicine

The Integrative Medicine Wheel

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…)

Posted in: Acupuncture, Chiropractic, Ethics, Medical Academia, Medical Ethics, Naturopathy

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Cervicogenic Headache and Cervical Spine Manipulation

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…)

Posted in: Chiropractic

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When Headaches Are a Pain in the Neck: Spinal Manipulation vs. Mobilization for Cervicogenic Headache

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?

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…)

Posted in: Chiropractic

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Chiropractic and Stroke: No Evidence for Causation But Still Reason for Concern

neck adjustment
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…)

Posted in: Chiropractic

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Regulating CAM Aussie Style

640px-Flag_of_Australia.svg
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…)

Posted in: Chiropractic, Diagnostic tests & procedures, Guidelines, Legal, Naturopathy, Politics and Regulation

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