Unqualified DC's

[Dr. Popalot]

The sole accrediting agency for U.S. chiropractic institutions, the Council on Chiropractic Education, recently admitted to the U.S. Department of Education that thousands of chiropractors were granted degrees from accredited programs that did not meet the minimum requirements for practice; raising patient safety concerns throughout the nation.


http://www.prweb.com/releases/2004/11/prweb178574.htm

[Eos of the Eons]

Considering the quackery most peddle, I would have to wonder if any DC is 'qualified' to touch anybody for anything.

Take into consideration that blood vessels broken when chiros crack necks can and do lead to strokes, then I wonder why they are allowed to be edumacated and granted degrees at all.

I would be thrilled to see the chiroquackery schools vanish from the face of the earth.

[TeaBag420]

Originally posted by Eos of the Eons
Considering the quackery most peddle, I would have to wonder if any DC is 'qualified' to touch anybody for anything.

Take into consideration that blood vessels broken when chiros crack necks can and do lead to strokes, ....



Statistics, please?

[Suezoled]

Well that's good, but there's still a lot of stuff to do.

http://www.newagedirectory.com/amed/degree.htm

[Dr. Imago]

The concept of an "unqualified chiropractor" is a tautology.

-TT

[Suezoled]

Originally posted by TeaBag420
Statistics, please?

Eos isn't quoting stats. Read their philosophy and practice. That makes it downright dangerous.

http://www.quackwatch.org/01QuackeryRelatedTopics/chirostroke.html

[Dr. Imago]

Originally posted by TeaBag420
Statistics, please?

For the 10-year period 1988 to 1997, there were 23 cases of vertebral artery dissection after cervical manipulation reported to the CCPA that represents 85% of practicing chiropractors in Canada. Based on the survey, an estimated 134,466,765 cervical manipulations were performed during this 10-year period. This gave a calculated rate of vertebral artery dissection after manipulation of 1:5,846,381 cervical manipulations. Based on the number of practicing chiropractors and neurologists during the period of this study, 1 of every 48 chiropractors and one of every two neurologists would have been made aware of a vascular complication from cervical manipulation that was reported to the CCPA during their practice lifetime.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14589464

Hey, it happens.

-TT

[Dr. Imago]

To obtain an estimate of how often practicing neurologists in California encounter unexpected strokes, myelopathies, or radiculopathies following chiropractic manipulation, we surveyed each member of the American Academy of Neurology in California and inquired about the number of patients evaluated over the preceding 2 years who suffered a neurologic complication within 24 hours of chiropractic manipulation. Four hundred eighty-six neurologists were surveyed, 177 responded; 55 strokes, 16 myelopathies, and 30 radiculopathies were reported. Patients were between the ages of 21 and 60, and the majority experienced complications following cervical manipulation. Most of the patients continued to have persistent neurologic deficits 3 months after the onset, and about one-half had marked or severe deficits. Nearly all of the strokes involved the posterior circulation and almost one-half were angiographically proven. Patients, physicians, and chiropractors should be aware of the risk of neurologic complications associated with chiropractic manipulation.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7783892

[TeaBag420]

Originally posted by ThirdTwin
The concept of an "unqualified chiropractor" is a tautology.

-TT

The word you're looking for (or should be) is of course "redundancy".

[TeaBag420]

Originally posted by ThirdTwin
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7783892

Yes, of course if you survey chiropractors about their patients, you're going to hear stories about people who have had chiropractic manipulation. Duh. Some of these DCs' patients probably even died. Are you scare yet?

It's backwards. Come back when you have statistics on stroke patients, etc. in general detailing the percentage who went to DCs. And of course controlling for the usual, tobacco use, birth control, overweight, injuries, etc.

Post hoc ergo propter hoc is weak, weak as water, Captain Peacock.

[Benguin]

Originally posted by TeaBag420
The word you're looking for (or should be) is of course "redundancy".

I suspect he was going for plianasm


Hey, it happens.

-TT

The procedures are not risk free, neither is anything in any medical intervention. Your point needs to be supported by evidence that chiros are presenting a greater risk of damage, stroke and death etc than other practitioners mucking about with necks. Such as Osteos, physios, GPs, etc.

And Teabag is right about Post hoc insofaras you'd need to establish what percentage of people visiting the chiros were already exhibiting circulatory problems due to neck trauma.

I'm sorry, but at the moment this not far different to Rouser's "shock horror, thousands have died from taking aspirin, why weren't we told" position.

[anonimouse]

Originally posted by Benguin
The procedures are not risk free, neither is anything in any medical intervention. Your point needs to be supported by evidence that chiros are presenting a greater risk of damage, stroke and death etc than other practitioners mucking about with necks. Such as Osteos, physios, GPs, etc.

And Teabag is right about Post hoc insofaras you'd need to establish what percentage of people visiting the chiros were already exhibiting circulatory problems due to neck trauma.

I'm sorry, but at the moment this not far different to Rouser's "shock horror, thousands have died from taking aspirin, why weren't we told" position. [/B]

Maybe I'm confused here, but is this some kind of argument for the validity of chiropractic as a medical discipline? When their practioners most often espouse the "subluxation theory of disease", doesn't that have the same effect as the homeopath convincing someone to eschew standard medical treatment? Even if what they do doesn't cause immediate harm?

IMO, chiropractors are little more than trained massage therapists with the title of "doctor", space in a strip mall and a supply of bent pens.

[Suezoled]

Originally posted by sodakboy93
Maybe I'm confused here, but is this some kind of argument for the validity of chiropractic as a medical discipline? When their practioners most often espouse the "subluxation theory of disease", doesn't that have the same effect as the homeopath convincing someone to eschew standard medical treatment? Even if what they do doesn't cause immediate harm?

IMO, chiropractors are little more than trained massage therapists with the title of "doctor", space in a strip mall and a supply of bent pens.

...isn't that what I already said?

If the education is wrong or misleadig to begin with, that's the start of something bad, especially when it comes to handling people. Or animals.

http://www.chiroweb.com/ubb/open/Forum1/HTML/000465.html
Pro-chiro

http://chirotalk.proboards3.com/index.cgi?board=excuses&action=display&num=1091736403

Skeptical chiros. Really.

[Benguin]

Originally posted by sodakboy93
Maybe I'm confused here, but is this some kind of argument for the validity of chiropractic as a medical discipline? When their practioners most often espouse the "subluxation theory of disease", doesn't that have the same effect as the homeopath convincing someone to eschew standard medical treatment? Even if what they do doesn't cause immediate harm?

IMO, chiropractors are little more than trained massage therapists with the title of "doctor", space in a strip mall and a supply of bent pens.

No it isn't. Don't confuse efficacy with risk.

The point was related to risks. You are probably right about trained massage therapists and as such, the risks they present should be easily compared. Are you more likely to suffer damage from a masseuse working on your neck or chiropractic? or a GP or a medical Physio? If you want to make a case for them being dangerous that requires comparable statistics.

The same goes for them being useless, there is no evidence they can be of any use for anything other than back pain, but then I never heard of one claiming anything more than that before I stumbled on Randi and Chiro watch. And, by the way, the fact that studies show they manage to be a help for people with spinal pain I think reflects more on the poor showing of the NHS than any particular magic in what chiros do.

We've covered this ground before, it appears what chiros present themselves as and what they believe in (particularly subluxation theory) is somewhat different between the UK and N. America. The Chiros I have quizzed have nothing but contempt for people making claims about cancer or allergies or wishing to practice in isolation from regular medicine.

If it is any consolation after the last time I had this argument with Eos, I decided I'd try and use regular medical channels again next time my neck flares up. I have the advantage now I can actually pay for private help when I hit the NHS dead-end.

[Suezoled]

Originally posted by Benguin
No it isn't. Don't confuse efficacy with risk.


(snipped)
We've covered this ground before, it appears what chiros present themselves as and what they believe in (particularly subluxation theory) is somewhat different between the UK and N. America. The Chiros I have quizzed have nothing but contempt for people making claims about cancer or allergies or wishing to practice in isolation from regular medicine.
(snipped)


Really? You haven't? I get newsletters all the time from one chiro (among many that I've spoken to) who advocated eating well, exercising, not using things like flu vaccines, and at any age, get yourself adjusted and do it often. In his office. Nevermind if you're 4 years old or 60 years. Avoid sugar, knee surgery, those evil medical drugs, and if you feel unwell, go to your chiropractor first before going to an "allopathic" doctor.

You've never met anyone like that? Well gee... where have you been looking?

[Benguin]

Originally posted by Suezoled
Really? You haven't? I get newsletters all the time from one chiro (among many that I've spoken to) who advocated eating well, exercising, not using things like flu vaccines, and at any age, get yourself adjusted and do it often. In his office. Nevermind if you're 4 years old or 60 years. Avoid sugar, knee surgery, those evil medical drugs, and if you feel unwell, go to your chiropractor first before going to an "allopathic" doctor.

You've never met anyone like that? Well gee... where have you been looking?

As I said, the UK. I think if I lookied a bit harder now I'd find some like you describe, especially with what seems to be a recent surge in woo-med and antivax.

Traditionally, they seem to have put themselves forward as an alternative to physios. Here they have anyway.

I've not exactly done any surveys, but I have visited a few in various towns over the years. If you actually read the stuff on chirowatch you will see there is a conflict between chiros who are woo-ed up to the max and ones who see themselves as people providing some sort of massage plus. The latter being very supportive of the campaigning done by chirowatch.

The debate is about a page down on here (http://www.chirowatch.com/cw-discussions.html)

[Benguin]

In terms of the UK, by law they must be registered with the GCC. Anyone claiming to be able to offer Chiropractic without being registered is liable to prosecution.

I think the only other Alt Med with that kind of system is acupuncture.

Searching the GCC site for hits on "subluxation" produces only two, a boring reading list and this little gem (http://www.gcc-uk.org/files/link_file/Findings_Gage.pdf), which (whilst entertaining) should disabuse you of the notion they are totally without scruples.

[Dr. Imago]

Originally posted by TeaBag420
The word you're looking for (or should be) is of course "redundancy".

tau·tol·o·gy
Pronunciation: to-'tä-l&-jE
Function: noun
Inflected Form(s): plural -gies
Etymology: Late Latin tautologia, from Greek, from tautologos
1 a : needless repetition of an idea, statement, or word b : an instance of tautology
2 : a tautologous statement

tau·tol·o·gous
Pronunciation: to-'tä-l&-g&s
Function: adjective
Etymology: Greek tautologos, from taut- + legein to say -- more at LEGEND
1 : involving or containing rhetorical tautology : REDUNDANT
2 : true by virtue of its logical form alone

It is unnecessary to use the word "unqualified" when describing a chiropractor, Teabag420. Beyond being synonymous or repetitive or redundant, it becomes totally superfluous in describing their practice. To be utterly pedantic (as you demonstrate here) in expand to the full tautology, I could say, "The chiropractor is unqualified. Why? Because he is a chiropractor." Nothing more needs to be said.

I hope that clarifies my usage for you. :)

-TT

[Dr. Imago]

Originally posted by TeaBag420
Yes, of course if you survey chiropractors about their patients, you're going to hear stories about people who have had chiropractic manipulation. Duh. Some of these DCs' patients probably even died. Are you scare yet?

You must not have read very carefully because it was predominately neurologists who were surveyed, after the damage was done. Naturally, when someone strokes out after a manipulation, they don't go back to the chiropractor (at least if the part of their brain that is still functioning is smart enough to tell them not to).

Furthermore, straw man argument about chiropractors patient's dying. Patients die all the time from various causes; we're talking about specifically documented and chiropractic-caused strokes. Whether they represent a significant percentage from all-cause strokes is irrelevant in this discussion.

Nice attempt to try to shift the focus away from the issue at hand, though. :clap:

-TT

[Dr. Imago]

Originally posted by Benguin
I suspect he was going for plianasm.

ple·o·nasm
Pronunciation: 'plE-&-"na-z&m
Function: noun
Etymology: Late Latin pleonasmus, from Greek pleonasmos, from pleonazein to be excessive, from pleiOn, pleOn more -- more at PLUS
1 : the use of more words than those necessary to denote mere sense (as in the man he said) : REDUNDANCY
2 : an instance or example of pleonasm

Nope.

But, thanks for your attempt to help anyway.

:)

-TT

[Dr. Imago]

Originally posted by TeaBag420
It's backwards. Come back when you have statistics on stroke patients, etc. in general detailing the percentage who went to DCs. And of course controlling for the usual, tobacco use, birth control, overweight, injuries, etc.

You are either very confused, or just trying to fight your way out of a corner to save face. I'm going to assume it's the latter, for your sake, because based on many of your previous posts you seem to take pride in a self-perception that you are quite clever. Far be it from me to rob you of that, but I will talk to the relevant facts in this discussion.

Again, no one is arguing that there aren't other causes of stroke. Of course there are! Your point is completely irrelevant. This is what we're talking about here (i.e., more data - and, my bolding and underlining for emphasis):

We analyzed the clinical course and neuroradiological findings of ten patients aged 27-46 years, with ischemic stroke secondary to vertebral artery dissection (VAD; n = 8) or internal carotid artery dissection (CAD; n = 2), all following chiropractic manipulation of the cervical spine. The following observations were made: (a) All patients had uneventful medical histories, no or only mild vascular risk factors, and no predisposing vascular lesions. (b) VAD was unilateral in five patients and bilateral in three. VAD was located close to the atlantoaxial joint in all eight patients and showed additional involvement of lower sections in six, as well as temporary occlusion of one vertebral artery in three. (c) Nine of ten patients had brain infarction documented by magnetic resonance imaging or computed tomography. (d) Onset of symptoms was immediately after the manipulation (n = 5) or within 2 days (n = 5). (e) Progression of neurological deficits occurred within the following hours to a maximum of 3 weeks. (f) Maximum neurological deficits were severe in nine of ten patients. (g) Outcome after 4 weeks-3 years included no or mild neurological deficits in five patients, marked deficits in three, persistent locked-in syndrome in one, and persistent vegetative state in one. (h) Informed consent was obtained in only one of ten patients. Thus, patients at risk for stroke after chiropractic manipulation may not be identified a priori. Neurological deficits may be severely disabling and are potentially life threatening.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10460445

That is scary stuff, man. Chiropractic is dangerous. And, a 10% rate of patient "informed consent" of these risks is beyond abhorrent; it's unconscionable. We'd NEVER get away with this in the non-make-believe world of real medicine.

Furthermore, this study beautifully illustrates - on point - a set of young patients not typically predisposed to stroke. And, these quacks are offering a therapy that has no proven long-term benefit to relieve or treat anything, despite the fact that people swear by it (testimonials are, naturally, irrelevant).

With chiropractic, it's hard to characterize a true risk-to-benefit ratio; you can't divide by zero. But, clearly there are risks. To not tell patients about these risks (or 1 out of 10 attempts, in this case) is appalling. It's wreckless. It's negligent. And, it's self-serving (for the chiropractor). But, sadly, it's par for the course with this illegitmate field of "medical" practice.

Originally posted by TeaBag420
Post hoc ergo propter hoc is weak, weak as water, Captain Peacock.

Please, please, please describe in detail - for my edification, of course - how in any way any argument I've made so far is a post hoc fallacy. Please include references.

-TT

[Dr. Imago]

Originally posted by Benguin
The procedures are not risk free, neither is anything in any medical intervention. Your point needs to be supported by evidence that chiros are presenting a greater risk of damage, stroke and death etc than other practitioners mucking about with necks. Such as Osteos, physios, GPs, etc.

Well, for one, we inform our patients about the risks involved with procedures. They sign a document, as well, indicating that they have been informed. They are allowed to ask questions and get honest answers. And, they can refuse treatment if they wish without any pressure, often tantamount to salesmanship, to keep coming back and coming back and coming back...

Secondly, we utilize evidence-based data that demonstrates that there is a sound rationale in the therapy we are offering.

Originally posted by Benguin
And Teabag is right about Post hoc insofaras you'd need to establish what percentage of people visiting the chiros were already exhibiting circulatory problems due to neck trauma.

No he's not. And, now I've shown data that demonstrates otherwise. We're not talking about whiplash or car accident patients. We're talking about otherwise healthy patients who go to a chiropractor, for whatever reason (e.g., stiff neck, headaches, what have you), and are offered a treatment with (1) no long-term proven benefit, (2) little good science to back it up, and (3) little to no discussion of the risks involved.

Originally posted by Benguin
I'm sorry, but at the moment this not far different to Rouser's "shock horror, thousands have died from taking aspirin, why weren't we told" position.

It's quite different. Here we have proven cases of damage, with no real discussion of benefit or relief. I would argue that all of medicine, and anything that falls under the aegis of medical care, should adequately document a risk-to-benefit ratio that weighs ethically in the favor of treatment before that treatment is offered. Chiropractic is not now, nor has it ever been or likely will be in the future, the standard of care for any type of problem with the neck. That is evidence-based. That's how real medicine works. If you (or anyone else) wants to argue otherwise, show me the data. We can debate it here.

-TT

[anonimouse]

The American Chiropractic Association considers themselves the largest chiropractice organization in the world. This is some of the stuff I saw on their website:

http://www.acatoday.com/media/releases/vaccinations.shtml

Also check out some of the things they say chiropractic treatment can help. (including ADHD and asthma)

http://www.acatoday.com/media/tips/adhd.shtml

And check out what they consider the "scope of chiropractic" to be:

http://www.acatoday.com/media/whatis/history_chiro.shtml

Doctors of Chiropractic frequently treat individuals with neuromusculoskeletal complaints, such as headaches, joint pain, neck pain, low back pain and sciatica. Chiropractors also treat patients with osteoarthritis, spinal disk conditions, carpal tunnel syndrome, tendonitis, sprains, and strains. However, the scope of conditions that Doctors of Chiropractic manage or provide care for is not limited to neuromusculoskeletal disorders. Chiropractors have the training to treat a variety of non-neuromusculoskeletal conditions such as: allergies, asthma, digestive disorders, otitis media (non-suppurative) and other disorders as new research is developed.

Considering chiropractic care has yet to be shown to be effective in ANY of those conditions, I find it interesting that the ACA would assume it's "under their scope".

And the ICA - they're the ones that actually supported baby murderer/grieving father Alan Yurko. Their stance on vaccination is also well-known.

http://www.chiropractic.org

I mention these two links because if you look up "chiropractic" on Yahoo's health site, they're the two mentioned to go to for information about the subject. So I assume they're reasonably "credible" sources within the profession.

I'm sure that there's a group of chiropractors who are committed to limiting the scope of the profession to treatment of back pain - but considering what I've seen from two prominent organizations, I'd assume they're in the minority.

[Benguin]

Originally posted by sodakboy93
I'm sure that there's a group of chiropractors who are committed to limiting the scope of the profession to treatment of back pain - but considering what I've seen from two prominent organizations, I'd assume they're in the minority.

I get the distinct impression you are very probably correct. Although what seems odd is that the American ones primarily adhere to the model you describe and British ones to a more rational model. Odd that.

Well, for one, we inform our patients about the risks involved with procedures. They sign a document, as well, indicating that they have been informed.

Yes. Same here with the Chiros. It's a legal requirement.

They also have to get xrays and check with the patient's GP by law, though I'm not sure what that counts for.

I'd have thought the risks of spinal cord damage are self evident, though maybe not the stroke risks. I'm at least equally concerned by the tendency of completely untrained GPs to attempt neck manipulation on injured patients.

Secondly, we utilize evidence-based data that demonstrates that there is a sound rationale in the therapy we are offering.

Well they would claim that too, it's a question of the quality of evidence you consider acceptable. I suspect Homeos would answer 'yes' to such a question sighting a whole plethora of anecdotes in support.

And, now I've shown data that demonstrates otherwise.

Not quite, you've only requoted the original. The Chiro sites point out that data does not indicate the sample size of their patients and extrapolate that to say you are looking at data of all of canada. boiling down to 1 in 3 million patients at the most conservative. The one you yourself quoted was 1 in 6 mill.

It's quite different. Here we have proven cases of damage, with no real discussion of benefit or relief. I would argue that all of medicine, and anything that falls under the aegis of medical care, should adequately document a risk-to-benefit ratio that weighs ethically in the favor of treatment before that treatment is offered. Chiropractic is not now, nor has it ever been or likely will be in the future, the standard of care for any type of problem with the neck. That is evidence-based. That's how real medicine works. If you (or anyone else) wants to argue otherwise, show me the data. We can debate it here.

Indeed, very true on the lack of data. And you are right about the neck thing, chiros claim few studies have been done but I don't know if that is true. A lack of studies doesn't indicate it doesn't work, only that it hasn't been studied.

I went to chiros because a succession of GPs had nothing to offer, especially gaulling when my problems resulted largely from a GP intervention. Now I do believe conventional medicine does have decent treatments on offer ... but I'm only going to find that out now I've got the money to push it. Or maybe I'll waste a ton of money.

My (largely positive) experiences are t=1 and therefore not much use. At the time I originally turned to them I had no idea of their woo-origins. In my more informed position I think I would be more forceful in insisting that my GP actually help with my neck problems. As it is, it was entirely down to a Chiro that I got referred to an MF surgeon and diagnosed with a TMJ disorder. The very best of ten years of regular GPs was diazepam, a dangerous, marginal and unsuccessful treatment.

Risk-Benefit is the right approach, I'm not going to dispute that. And the idea that back clicks can help with allergies, asthma and digestive orders is pretty counter intuitive.

Should Chiro (or parts of it) ever manage to prove efficacy properly then those parts would cease being CAM and be happily assimilated into regular medicine. The reason for their relative success (in the UK at least) is the incredibly poor show by the NHS on back pain. People turn to other things, most of which have no help on offer.

This really depends on whether we are saying that at the present time there is no decent help for people with spinal pain. I'm a self-confessed wimp with pain, and I will try things that have some hope on offer.

[Dr. Imago]

Originally posted by Benguin
Yes. Same here with the Chiros. It's a legal requirement.

They also have to get xrays and check with the patient's GP by law, though I'm not sure what that counts for.

But, they are not doing it! That's the point. I presented data on the 10 vertebral artery dissections that showed only one patient had given his informed consent.

Think about it: if you tell a patient that there is a risk of verterbral artery dissection and stroke with neck manipulation, there's a chance they'll say "no thank you" to the chiropractor. These quacks then know that they've potentially lost someone than can bill for numerous follow-up visits. There is a self-serving incentive not to inform the patient of such risks, if one were to be utterly and completely cynical about their practice. My thoughts are that the "science" and collegial communication is so tainted, denial-laden, and just generally bad between medical doctors and chiropractors that the chiropractors themselves do not either know there is a risk and/or refuse to think their treatment caused it! Therefore, they feel (wrongfully) that they don't have to, ethically or otherwise, inform their patients. And, they aren't.

Originally posted by Benguin
I'd have thought the risks of spinal cord damage are self evident, though maybe not the stroke risks. I'm at least equally concerned by the tendency of completely untrained GPs to attempt neck manipulation on injured patients.

(1) Nothing in medicine is self-evident. Patients (and even some caregivers) are incredibly stupid and need to have everything - and I mean EVERYTHING - explained to them at a 5th grade level.

(2) Believe it or not, there's actually not that much true risk to the actually cord which is well protected within the bony spine and surrounded by a nice cushion of fluid. It's pretty damn hard to transect a spinal cord short of major sheer-force or penetrating (etc.) trauma (so much for your 'self-evident' theory). The vertebral arteries, on the other hand, are a different story - especially if you stretch the neck beyond the range of what it's normally supposed to be stretch.

(3) GP's do not manipulate spines. I've never met a Family Practice (or any medically trained doctor), aside from DO's in the U.S., who do manipulations. And, if they do manipulations (as in the DO's case), they have received extensive training in how to do so. No one screws around with the spine in a cavalier manner.

Originally posted by Benguin
Well they would claim that too, it's a question of the quality of evidence you consider acceptable. I suspect Homeos would answer 'yes' to such a question sighting a whole plethora of anecdotes in support.

This is exactly it. Our evidence-base comes from adequate and well-controlled studies where confounders and limitations of design are openly discussed as well as the overly risk-to-benefit ratio and alternate therapies. Safer, equally effective therapies will always be chosen over those with greater risks. And, extremely risky therapies would only be chosen in instances where the patient would otherwise suffer severe, permanent injury without an intervention and/or die. It's all about risk-to-benefit, and we have good documentation.


Originally posted by Benguin
Not quite, you've only requoted the original. The Chiro sites point out that data does not indicate the sample size of their patients and extrapolate that to say you are looking at data of all of canada. boiling down to 1 in 3 million patients at the most conservative. The one you yourself quoted was 1 in 6 mill.

I slightly disagree. First off, the study is referencing total manipulations, not patients. So, the total number of patients is far less than 6 million. Likewise, you're only looking at the clearly documented cases where patients admitted that they'd received these manipulations. Many patients do not share this info with their "real" doctor. Secondly, I would argue that there is little - if any - documented long-term benefit to chiropractic that demonstrates, above all else, even what the treatment actually does. Sodakboy93 already mentioned the flawed premise (namely the "subluxation theory" of disease) that chiropractic is predominately based on.

Remember, we're talking about a practice that often involves violent jerking of the spine and other body parts, not gentle manipulation. It can be quite a brutal. And, the studies that these chiropractors present cannot be well-controlled. Nonetheless, a lot of the ailments they claim they are GOOD at treating (e.g., lower back pain) have a naturally short and spontaneously remitting course on their own.

Originally posted by Benguin
Indeed, very true on the lack of data. And you are right about the neck thing, chiros claim few studies have been done but I don't know if that is true. A lack of studies doesn't indicate it doesn't work, only that it hasn't been studied.

I went to chiros because a succession of GPs had nothing to offer, especially gaulling when my problems resulted largely from a GP intervention. Now I do believe conventional medicine does have decent treatments on offer ... but I'm only going to find that out now I've got the money to push it. Or maybe I'll waste a ton of money.

My (largely positive) experiences are t=1 and therefore not much use. At the time I originally turned to them I had no idea of their woo-origins. In my more informed position I think I would be more forceful in insisting that my GP actually help with my neck problems. As it is, it was entirely down to a Chiro that I got referred to an MF surgeon and diagnosed with a TMJ disorder. The very best of ten years of regular GPs was diazepam, a dangerous, marginal and unsuccessful treatment.

Risk-Benefit is the right approach, I'm not going to dispute that. And the idea that back clicks can help with allergies, asthma and digestive orders is pretty counter intuitive.

Should Chiro (or parts of it) ever manage to prove efficacy properly then those parts would cease being CAM and be happily assimilated into regular medicine. The reason for their relative success (in the UK at least) is the incredibly poor show by the NHS on back pain. People turn to other things, most of which have no help on offer.

This really depends on whether we are saying that at the present time there is no decent help for people with spinal pain. I'm a self-confessed wimp with pain, and I will try things that have some hope on offer.

It depends specifically on the problem. Most neck pain is musculoskeletal. Some of it is spinal in origin. Sometimes it requires surgery to get relief. Often it takes months to feel back to normal.

I think a large part of the problem is that people often expect to feel better immediately. Jerking the neck and paraspinal muscles around probably does break-up tissue and stretch out aching muscles. I'm not sure that, in the short run, this is a good idea or, in the long run, really benefits the patient. Numerous studies have shown that chronic pain is almost always neurological and actually involves damage to the nerves. Other studies show that those who are going to get better are going to do so mostly on their own. I'm not sure how chiropractic can help, other than temporarily averting the patient's attention away from their pain.

Again, I'm happy to look at any data. Any data - good or bad that attempts to show how chiropractic works. Anyone who's up to the challenge can start with trying to definitively show what exactly is making that "cracking" sound when the joints are manipulated. (HINT: no one knows)

-TT

[Suezoled]

Originally posted by Benguin
In terms of the UK, by law they must be registered with the GCC. Anyone claiming to be able to offer Chiropractic without being registered is liable to prosecution.

I think the only other Alt Med with that kind of system is acupuncture.

Searching the GCC site for hits on "subluxation" produces only two, a boring reading list and this little gem (http://www.gcc-uk.org/files/link_file/Findings_Gage.pdf), which (whilst entertaining) should disabuse you of the notion they are totally without scruples.

Erm, I never said chiros are totally without scruples (did ?) The Skeptical Chiropractic Chat site has wonderful discussions about the education, limitations, benefits, etc and horror/shame that ethical chiro practioners feel about the (American anyway) chiros who are loudly peddling their wares.

And yes, I do read the Quackwatch website, and check up on it often. It's how I found JREF in the first place.

*sighs* I can't seem to download that file. My machine isn't letting me.

Hey, when did chiros (in the US anyway) start trying to sub-specialize? For example, there are Orthopaedic Chiros (Kitty and I saw that sign once while walking into town), and there are Dental Chiros (they treat TMJ among other things), Cardiac Chiros, etc etc. There are even Chiros who think they can prevent SIDS in babies by adjusting them.

Originally posted by Benguin
Yes. Same here with the Chiros. It's a legal requirement.

They also have to get xrays and check with the patient's GP by law, though I'm not sure what that counts for.

Sadly, I find that is often the case with Chiros; they might say they work with one's GP, but consulting the patient's GP, the GP has said more often than not "oh I didn't know he was going to one" or "I didn't reccomend he see one." Too, GP's have no idea what that Chiro is doing on the patient, as they are in fact NOT informed by the Chiro.
Well, believe that or not as you like. I work in health insurance and deal with hundreds of major contracts, covering clients from 50 states and Puerto Rico. Follow-up has consistenly show the lack of consultation with one's medical doctor. This also goes for Chiros not keeping or sending info to OBGYN's, Oncologists, neurologists... but on the other hand, you might choose to dismiss this, as I am not allowed to share actual statistics or reveal detailed client information (I can tell general stories, but that isn't exactly evidence or stats).

[Suezoled]

Originally posted by ThirdTwin

(1) Nothing in medicine is self-evident. Patients (and even some caregivers) are incredibly stupid and need to have everything - and I mean EVERYTHING - explained to them at a 5th grade level.
Hey! I resemble that remark!


(2) Believe it or not, there's actually not that much true risk to the actually cord which is well protected within the bony spine and surrounded by a nice cushion of fluid. It's pretty damn hard to transect a spinal cord short of major sheer-force or penetrating (etc.) trauma (so much for your 'self-evident' theory). The vertebral arteries, on the other hand, are a different story - especially if you stretch the neck beyond the range of what it's normally supposed to be stretch.
I just want to mention here that about 4 chiros I visisted personally did not recognize the signs of a common heart attack in women (in my description I had mentioned heartburn, nausea, fatigue, cold sweaty skin, pain the jaw and chest).
Not that it has anything to do with vertebral arteries directly, but it's something else that chiros should know and do not.


It depends specifically on the problem. Most neck pain is musculoskeletal. Some of it is spinal in origin. Sometimes it requires surgery to get relief. Often it takes months to feel back to normal.

I think a large part of the problem is that people often expect to feel better immediately. Jerking the neck and paraspinal muscles around probably does break-up tissue and stretch out aching muscles. I'm not sure that, in the short run, this is a good idea or, in the long run, really benefits the patient. Numerous studies have shown that chronic pain is almost always neurological and actually involves damage to the nerves. Other studies show that those who are going to get better are going to do so mostly on their own. I'm not sure how chiropractic can help, other than temporarily averting the patient's attention away from their pain. Hey, I'm going to bring up yet another anecdote: I did go in for a manipulation (best to get hands-on experience about this, ne?) I told the guy not to adjust my neck. He reaches out and adjusts my neck. I hear the pop, my vision gets very dark. I sit up, and I'm dizzy, my neck hurts, and the dark spots are only very slowly going away. When I tell the chiro this, he says "well it happens sometimes." No re-examining me, no checking of pulse or heart rate (no stethascope in the office, and I suspect no training to use one anyway), no mention of maybe, just maybe, talking to my real doctor about it. Just sent on my merry way. I spend the day with a sore neck and the feeling of being choked.

Again, I'm happy to look at any data. Any data - good or bad that attempts to show how chiropractic works. Anyone who's up to the challenge can start with trying to definitively show what exactly is making that "cracking" sound when the joints are manipulated. (HINT: no one knows)

-TT

I have rather thought that the cracking sound was at least partially due to the snapping of tendons over the joints of bones, the movement aided in the joint by the synovial fluid. Or maybe the stretching of the tendons is coincidental to the actual sharp movement made on the joint, in which case I had originally thought it was the release of a small vaccuum in the joint itself, that is pressed out by the joint closing on the vaccuum so that the synovial fluid fills the gap or a new vaccuum is created.

On the other hand, that's a rather lay-person's guess, and I admit to my ignorance in the end.

ps: ThirdTwin: I love you man!

[TeaBag420]

Originally posted by Suezoled
Hey! I resemble that remark!


I just want to mention here that about 4 chiros I visisted personally did not recognize the signs of a common heart attack in women (in my description I had mentioned heartburn, nausea, fatigue, cold sweaty skin, pain the jaw and chest).
Not that it has anything to do with vertebral arteries directly, but it's something else that chiros should know and do not.
Hey, I'm going to bring up yet another anecdote: I did go in for a manipulation (best to get hands-on experience about this, ne?) I told the guy not to adjust my neck. He reaches out and adjusts my neck. I hear the pop, my vision gets very dark. I sit up, and I'm dizzy, my neck hurts, and the dark spots are only very slowly going away. When I tell the chiro this, he says "well it happens sometimes." No re-examining me, no checking of pulse or heart rate (no stethascope in the office, and I suspect no training to use one anyway), no mention of maybe, just maybe, talking to my real doctor about it. Just sent on my merry way. I spend the day with a sore neck and the feeling of being choked.

I have rather thought that the cracking sound was at least partially due to the snapping of tendons over the joints of bones, the movement aided in the joint by the synovial fluid. Or maybe the stretching of the tendons is coincidental to the actual sharp movement made on the joint, in which case I had originally thought it was the release of a small vaccuum in the joint itself, that is pressed out by the joint closing on the vaccuum so that the synovial fluid fills the gap or a new vaccuum is created.

On the other hand, that's a rather lay-person's guess, and I admit to my ignorance in the end.

ps: ThirdTwin: I love you man!

How did it end up when you sued him and reported him to the state licensing authority? Oh, what's that? You didn't?

Couldn't have been too serious, then.

[Benguin]

Originally posted by ThirdTwin
But, they are not doing it! That's the point. I presented data on the 10 vertebral artery dissections that showed only one patient had given his informed consent.


I think we are comparing eggs with apples here. I don't know anything about the North American system. I was commenting on the UK practice. Although I don't know if anyone has properly audited how well the UK practitioners follow their own CoP.


Think about it: if you tell a patient that <<snip>>


Well patients should always have risks explained. This was where my comment about Rouser came from .... as (from your correcting me below) the risk would be 1 in 3 mill manipulations, the risk from having a cortisone injection is x, from an operation is y. You (the patient) need to just balance that against the likely benefit and the inconvenience of putting up with the problem. I think that is what I understand by informed choice.

Trouble is, many peoples' grasp of evidence and risk and benefit is insufficient. I admit mine was before I started to look into this a bit more. Probably still is to some extent.


(3) GP's do not manipulate spines. I've never met a Family Practice (or any medically trained doctor), aside from DO's in the U.S., who do manipulations. And, if they do manipulations (as in the DO's case), they have received extensive training in how to do so. No one screws around with the spine in a cavalier manner.


I've had two GPs do this to me, and I don't believe I would be the only patient they'd try it on. I subsequently found out one (who left me with problems) had been kicked out of his job in geriatrics at a local hospital for playing that trick. I suspect a more letigous atmosphere has probably cut the practice down. I wouldn't assert it is (or ever was) widespread, but 'never' is not correct. I'd agree they shouldn't be doing that, why they would is beyond me.


Nonetheless, a lot of the ailments they claim they are GOOD at treating (e.g., lower back pain) have a naturally short and spontaneously remitting course on their own.


I think you are underestimating the number of people who give up on their GPs for saying precisely that and expecting people to put up with medium to long term pain.


It depends specifically on the problem. Most neck pain is musculoskeletal. Some of it is spinal in origin. Sometimes it requires surgery to get relief. Often it takes months to feel back to normal.


And sometimes there is nothing that can be done except pain relief and lifestyle adaptation.


I'm not sure that, in the short run, this is a good idea or, in the long run, really benefits the patient.


In the short term there is pain relief, I'm not sure that the idea of massage providing some short term alleviation from sore muscles is that controversial. The claim that needs testing is whther that (or chiro in general) actually improves the longer term prognosis. AFAIK they've a few marginal studies on lower back pain in their favour, but that's all.


Again, I'm happy to look at any data. Any data - good or bad that attempts to show how chiropractic works. Anyone who's up to the challenge can start with trying to definitively show what exactly is making that "cracking" sound when the joints are manipulated. (HINT: no one knows)

-TT

Here is the BMJ (http://bmj.bmjjournals.com/cgi/content/abstract/311/7001/349?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=Meade&andorexactfulltext=and&searchid=1100855559498_1396&stored_search=&FIRSTINDEX=0&sortspec=relevance&volume=311&resourcetype=1) article on the back pain thing. Help yourself.

I'm curious what the cracking noise is, I know what the common chiro explanation is, but it doesn't make a massive amount of sense. Surely someone knows?

[Benguin]

Originally posted by Suezoled
Erm, I never said chiros are totally without scruples (did ?) The Skeptical Chiropractic Chat site has wonderful discussions about the education, limitations, benefits, etc and horror/shame that ethical chiro practioners feel about the (American anyway) chiros who are loudly peddling their wares.

No, sorry, I didn't mean to strawman you with that one!

I was just surprised myself at how clearly they seemed to rule out certain claims and practices. Compared to other woo, say, homeopathy where they seem incapable of agreeing anything is beyond the pale.

[Terry]

Originally posted by ThirdTwin
[...]
(1) Nothing in medicine is self-evident. Patients (and even some caregivers) are incredibly stupid and need to have everything - and I mean EVERYTHING - explained to them at a 5th grade level.
[...]


I find this remark disturbing. I'm glad that, as a soon-to-be-qualified doctor, you seem to have a commitment to explaining things. As someone who hasn't studied medicine myself, I find it a great help when my doctor takes the time to explain the meaning of (for instance) test results, and the likely course of diseases and so on. However, my doctor doesn't act like he thinks I'm stupid. (Matter of fact, I had a G.P. once who did that. I changed doctors.) In my opinion, this attitude will not be helpful to you in your medical practice. It is my belief that you will encounter patients of a wide range of intellectual abilities, and to regard them all as "incredibly stupid" would be a mistake.

&lt;/rant about one tiny part of a good post&gt;
--Terry.

[anonimouse]

Originally posted by Terry
I find this remark disturbing. I'm glad that, as a soon-to-be-qualified doctor, you seem to have a commitment to explaining things. As someone who hasn't studied medicine myself, I find it a great help when my doctor takes the time to explain the meaning of (for instance) test results, and the likely course of diseases and so on. However, my doctor doesn't act like he thinks I'm stupid. (Matter of fact, I had a G.P. once who did that. I changed doctors.) In my opinion, this attitude will not be helpful to you in your medical practice. It is my belief that you will encounter patients of a wide range of intellectual abilities, and to regard them all as "incredibly stupid" would be a mistake.

&lt;/rant about one tiny part of a good post&gt;
--Terry.

FWIW, I agree with TT for the most part - even intelligent, educated people turn into nitwits when it comes to medical issues. That's why you see so many people turn to useless "alternative" medical practices, even those that you'd think SHOULD know better. I believe part of the problem is that people are generally not educated enough on the basics of science and physiology. Well, that and common sense.

[Dr. Imago]

Originally posted by Terry
I find this remark disturbing. I'm glad that, as a soon-to-be-qualified doctor, you seem to have a commitment to explaining things. As someone who hasn't studied medicine myself, I find it a great help when my doctor takes the time to explain the meaning of (for instance) test results, and the likely course of diseases and so on. However, my doctor doesn't act like he thinks I'm stupid. (Matter of fact, I had a G.P. once who did that. I changed doctors.) In my opinion, this attitude will not be helpful to you in your medical practice. It is my belief that you will encounter patients of a wide range of intellectual abilities, and to regard them all as "incredibly stupid" would be a mistake.

&lt;/rant about one tiny part of a good post&gt;
--Terry.

You're right, Terry. I should've qualified my original statement with the word "many". Simple omission in typing the original response on my part, and not indicative at all about how I feel about nor approach my patients. There are instances when the patient, to be completely candid, knows more than the doctor about his/her particular condition.

-TT

[Dr. Imago]

Originally posted by sodakboy93
FWIW, I agree with TT for the most part - even intelligent, educated people turn into nitwits when it comes to medical issues. That's why you see so many people turn to useless "alternative" medical practices, even those that you'd think SHOULD know better. I believe part of the problem is that people are generally not educated enough on the basics of science and physiology. Well, that and common sense.

I've also seen instances where patients think they have a particular medical condition based on particular symptoms they have, research the heck out of it using the Internet and other resources like the Merck manual, come to the clinic telling you what they have, and then require exhaustive "re-education" about what their problem actually is. This phenomemon seems to correlate extremely well with their education level. And, the recalcitrance in trying to convince them otherwise can be astounding.

-TT

[Terry]

Originally posted by ThirdTwin
I've also seen instances where patients think they have a particular medical condition based on particular symptoms they have, research the heck out of it using the Internet and other resources like the Merck manual, come to the clinic telling you what they have, and then require exhaustive "re-education" about what their problem actually is. This phenomemon seems to correlate extremely well with their education level. And, the recalcitrance in trying to convince them otherwise can be astounding.

-TT

Interesting. I've twice gone to the doctor fairly convinced I knew what the problem was, and twice been correct. Normally I don't have any idea, and I just describe my symptoms. But I feel like it's useful to my doctor if I say "I think I've got X, because I have these symptoms, and had contact with a know infected person recently", assuming that I have that information. Would you guys prefer I kept my speculation to myself if I were your patient?

--Terry.

[Dr. Imago]

Originally posted by Terry
Interesting. I've twice gone to the doctor fairly convinced I knew what the problem was, and twice been correct. Normally I don't have any idea, and I just describe my symptoms. But I feel like it's useful to my doctor if I say "I think I've got X, because I have these symptoms, and had contact with a know infected person recently", assuming that I have that information. Would you guys prefer I kept my speculation to myself if I were your patient?

--Terry.

No, that's fine. Please continue to communicate openly with your doctor. This is also one of the ways we gauge how "involved" you are with your own care. If you don't have "X", then the doctor will figure that out. It's not like you're going to lead him/her down the wrong path. The only thing that may happen is that you may overemphasize certain symptoms that you know are associated with "X" and not be as clear about your recollection of other symptoms. But, a good clinician will ask you other questions that may uncover things that you may not think are important or have under emphasized.

I'm trying on a daily basis not to become TOO jaded about medicine this early in my career. But, after you see your 9,723,256th obese diabetic on dialysis who hasn't checked her blood sugar in the last month and is on her tenth admission this year for complications related to her non-adherence to treatment, you start to become a little cynical. ;) You have to consciously remind yourself that everyone is different. Just the other day, I got a consult for an 84-year-old woman with ascites (I'm on the GI service in the hospital now). I assumed the worst before I went to see her... e.g., cirrhotic alcoholic vs. end-stage metastatic cancer vs. Ed-knows-what. I was actually pleasantly surprised when I met her. She actually suffered from a very interesting case of myelodysplastic disorder (something to that point I'd yet to see "live" and in person), and she was one of the unfotunate ones who develops ascites secondary to hepatic congestion related to the condition. She was very "with it", pleasant, well-informed, responsive, easy to educate (look up the etymology of "doctor"), and understood what was going on. So, I'd expected some alcoholic who was beyond hope, as is often the case, and was grateful for what I'd found. And, these are the patients you tend to always remember...

-TT

[Eos of the Eons]

Originally posted by Benguin

I've had two GPs do this to me, and I don't believe I would be the only patient they'd try it on. I subsequently found out one (who left me with problems) had been kicked out of his job in geriatrics at a local hospital for playing that trick. I suspect a more letigous atmosphere has probably cut the practice down. I wouldn't assert it is (or ever was) widespread, but 'never' is not correct. I'd agree they shouldn't be doing that, why they would is beyond me.




Noting that GPs get punished for that, but DCs do not. Rather a double standard.

[Dr. Imago]

Originally posted by Benguin
Here is the BMJ (http://bmj.bmjjournals.com/cgi/content/abstract/311/7001/349?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=Meade&andorexactfulltext=and&searchid=1100855559498_1396&stored_search=&FIRSTINDEX=0&sortspec=relevance&volume=311&resourcetype=1) article on the back pain thing. Help yourself.

Thanks, Benguin. This is something we can discuss. Although it focuses on low back pain, a topic different than what we have been concerned with, I think it's germane.

The conclusion from the study (in the abstract):

Conclusions: At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals.

I am interested to know what treatments were offered in "hospital management" of the back pain. I think that is critical to understand how these patient's treatment was stratified (e.g., who got more "aggressive" therapy, who was deemed "untreatable", etc.) and what interventions were used.

From the full article:

Follow up Oswestry questionnaires were returned by a consistently higher proportion of patients allocated to chiropractic than to hospital treatment. At six weeks, for example, they were returned by 95% and 89% of chiropractic and hospital patients, respectively and at three years by 77% and 70%.

This would point to both reporting bias and Hawthorne effect, as I've previously discussed on other threads. Patients more likely to receive intervention are more likely to report improvement by the mere fact that they are being studied (Hawthorne). Also, if you get a greater response from an active treatment group, you will tend to have a greater degree of fidelity in reporting (reporting). These are potential study confounders. Nonetheless...

As in the first report those with short current episodes, a history of back pain, and initially high Oswestry scores tended to derive most benefit from chiropractic. Those referred by chiropractors consistently derived more benefit from chiropractic than those referred by hospitals.
...
As with the results based on the full Oswestry score the improvement due to chiropractic was greatest in those initially referred by chiropractors, although there was also a non-significant improvement (ranging from 9% at six months to 34% at three years) due to chiropractic at each follow up interval in those referred by hospitals.

Two points here: First, we know from numerous other studies that short current episodic back pain with high pain levels is also more prone to spontaneous remission. These types of patients are also more likely to be the sedentary with poor conditioning (I can post references, if necessary). Secondly, the fact that chiropractor referred patients fared better indicates some sort of pre-study bias that that cohort of patients came to the therapy anticipating relief. Subjectively, these patients will do better than those referred from hospital, and they will also intuitively likely report higher pain scores and more relief given the pre-conception that chiropractic will help them. Conversely, those with severe pain that has required hospital care are less likely to believe that anything will help them (which may be true). They may have more "true", chronic pain that is not responsive to any therapy. So, when referred to a chiropractor, they are naturally less likely to receive benefit. This is my speculation based on experience; and I'm not sure that I can defend it with data. Continuing on...

The considerably larger numbers of patients with data now available at two and three years show smaller benefits at these intervals than previously, though these still significantly favour chiropractic.

As the 'N' goes up, the treatment effect goes down. This is to be expected when there is a nominal effect and better sampling. If a true effect were seen, the larger the 'N' gets the wider the treatment vs. non-treatment gap should get if there is a true effect.

We believe there is now more support for the need for "fastidious" trials focusing on specific components of management and on their feasibility.

Still, in this study, I think it is fairly safe to conclude that 3 out of 10 people who did not respond to traditional "hospital" therapy benefitted from chiropractic for long-term lower back pain. These patients were enrolled if provided they had "low back pain in whom manipulation was not contraindicated", which I also think is important. How many chiropractors, if you were to walk into their office with low back pain, would turn you away if you had what a medical doctor deemed some sort of contraindication to manipulation (e.g., sciatica, osteoporosis, etc.)? That's a serious question. Also, what other treatments could be offered, aside from chiropractic and it's flawed theory, to the patient if it was determined that a particular patient was not benefitting from "standard" therapy? I think these are the important questions to ask.

To that end, here's a more "fastidious" trial. I offer the following from the New England Journal of medicine, also on low back pain, published in 1998 as a sort of follow-up study to the one you reference and I discuss above. I can link to the full article through my school's subscription, but others (who don't have a subscription or don't want to pay) can look at the abstract, which is posted here and from which I excerpt the conclusion:

Conclusions For patients with low back pain, the McKenzie method of physical therapy and chiropractic manipulation had similar effects and costs, and patients receiving these treatments had only marginally better outcomes than those receiving the minimal intervention of an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question.

http://content.nejm.org/cgi/content/abstract/339/15/1021?hits=20&where=fulltext&andorexactfulltext=and&searchterm=chiropractic&sortspec=Score%2Bdesc%2BPUBDATE_SORTDATE%2Bdesc&excludeflag=TWEEK_element&searchid=1100971768680_4493&FIRSTINDEX=0&journalcode=nejm

Why this study is important (which again happens to reference the study you posted), especially given that they are specifically talking about lower back back pain and not vertebral artery dissection, is that it highlights a comparison and, along with that, the lack of meaningful distinction between physical therapy (as might be offered through a physical therapist or physiatrist referred by a GP), chiropractic, and minimal intervention all while underscoring the additional costs. With this particular study, there was no meaningful difference in outcome between the methodologies offered.

Now, coupled with the woo-woo premises under which chiropractic is offered and the divisive nature of many chiropractors "alternative" (vs. complementary) stance with regards to the traditional Western medicine model, they see their therapy as equivalent, separate, and perhaps better than what regular doctors have to offer. This is simply not the case, and numerous studies (including this one) show it, at best, to be marginally better than doing nothing at all and equivalent to physical therapy that does not involve "cracking" the spinal joints.

Furthermore, there is (as we've also discussed to this point) evidence that chiropractic may be dangerous. Again, we get back to the risk-to-benefit ratio of the treament, which is paramount when there exists equivalent yet safer treatments available to pain sufferers. This tips the balance away from offering chiropractic manipulation as a viable therapy. Now, coupled with the fact that many chiropractioners (at least in the study I referenced above) are not even discussing these risks and/or allowing their patients to make informed consent, my belief is that this becomes a dangerous, systematic practice that patients are agreeing to without full disclosure or understanding of the risks involved. This is a far cry from the type of argument that Rouser2 makes, namely that the risk of taking any medicine always outweighs the benefit.

We haven't even discussed the additional costs to the patient nor the other completely unproven claims (e.g., asthma, etc.) that chiropractors asserts they are able to effectively treat.

I'm yet to be convinced that chiropractic is any more beneficial than regular physical therapy or deep massage. But, what's worse is chiropractors cloak their treatments in unproven theories of disease and, in some cases, do not inform patients of the substantial risks of manipulation. That's what makes it a dangerous practice.

Originally posted by Benguin
I'm curious what the cracking noise is, I know what the common chiro explanation is, but it doesn't make a massive amount of sense. Surely someone knows?

Nope. No one knows. There's a lot of speculation, but nothing proven.

-TT

[Benguin]

Originally posted by ThirdTwin
Thanks, Benguin. This is something we can discuss. Although it focuses on low back pain, a topic different than what we have been concerned with, I think it's germane.


True. But given chiropractic doesn't seem to have a worthwhile study to its name beyond this continuing any other discussion would be a bit pointless.


How many chiropractors, if you were to walk into their office with low back pain, would turn you away if you had what a medical doctor deemed some sort of contraindication to manipulation (e.g., sciatica, osteoporosis, etc.)? That's a serious question.


It is a serious and relevant question, unfortunately I have the impression the answer rather depends on whether we are in the UK or the US. The UK ones operate in a regulatory framework which dictates a proper assessment of contraindications. I'm not aware of widespread disregard for that ... but I'm not aware of anyone studying it. Still, on balance the burden of proof is shifted. As for the US and Canadian ones .... are they regulated at all? I don't know.



Now, coupled with the woo-woo premises under which chiropractic is offered and the divisive nature of many chiropractors "alternative" (vs. complementary) stance with regards to the traditional Western medicine model, they see their therapy as equivalent, separate, and perhaps better than what regular doctors have to offer.


Well some do, and some see themselves as complementary. A distinction worth drawing, as any of these treatment claiming themselves 'alternative' are unquestionably dangerous. The so called complementary ones deserve slightly closer scrutiny.


This is simply not the case, and numerous studies (including this one) show it, at best, to be marginally better than doing nothing at all and equivalent to physical therapy that does not involve "cracking" the spinal joints.

Furthermore, there is (as we've also discussed to this point) evidence that chiropractic may be dangerous. Again, we get back to the risk-to-benefit ratio of the treament, which is paramount when there exists equivalent yet safer treatments available to pain sufferers. This tips the balance away from offering chiropractic manipulation as a viable therapy. Now, coupled with the fact that many chiropractioners (at least in the study I referenced above) are not even discussing these risks and/or allowing their patients to make informed consent, my belief is that this becomes a dangerous, systematic practice that patients are agreeing to without full disclosure or understanding of the risks involved. This is a far cry from the type of argument that Rouser2 makes, namely that the risk of taking any medicine always outweighs the benefit.

Fair point. But it does require proving that patients are not giving informed consent. Again, I get the impression that the answer to that is largely dependent on the regulatory framework the chiros operate within.


We haven't even discussed the additional costs to the patient nor the other completely unproven claims (e.g., asthma, etc.) that chiropractors asserts they are able to effectively treat.


Again, they don't do that here. Here is one having his license to practice withdrawal underscored (http://www.gcc-uk.org/files/page_file/Press_Release_GageHC.pdf?CFID=2496014&CFTOKEN=14199928) for claiming, amongst other things, a cure to parkinsons.


I'm yet to be convinced that chiropractic is any more beneficial than regular physical therapy or deep massage. But, what's worse is chiropractors cloak their treatments in unproven theories of disease and, in some cases, do not inform patients of the substantial risks of manipulation. That's what makes it a dangerous practice.


I agree with you on that. I think regular physio therapy or deep massage probably is as beneficial (unless proved otherwise). It is damned near inaccessible in the NHS, and hence people turn to woo-med for help. Doesn't mean the woo-med works, but it does give it a distinct artificial market advantage.


On the issue of cost benefit, a very recent study has just looked into this. BMJ article (http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38282.669225.AEv1).

[Rolfe]

It seems to me you're at slight cross purposes here. In the UK nobody sees chiropractors as doctors. They don't call themselves doctors and their training is nothing like medical training. They're seen, and I think most of them see themselves, as a branch of physiotherapy. They inhabit the fringes of the woo world in private "orthopaedic" clinics and fitness centres. Now how much of what they do is woo is hard to say, and it probably varies, but the whole idea of the subluxations and the flow of energy through the nerves and the life-long prophylactic adjustments just doesn't seem to get on the radar screen to any significant extent. People go to them for relief of musculoskeletal pain, especially lower back pain, and either find the manipulation helpful or not. That's about it.

It was quite a shock to me to find out that chiropractors in the US are called "doctor" and see themselves as somehow on a par with doctors and claim to be able to treat other things than back pain. Also the whole subluxations and lifelong adjustments stuff.

I think it's hard to conduct a transatlantic conversation about chiropractic and make any real sense. We seem to be talking about two almost completely different things.

Rolfe.

[flume]

In the yellow pages section of the phone book for my town (in the US) which lists chiropractors, there are about 30 of the larger ads (rather than the normal small phone listings). Of those thirty, six include applied kinesiology among their special skills. Several also mention nutritional counseling, one lists NAET, and one lists 'eternity medicine'. So not all US chiropractors may go in for those things, but there is a fraction which does.
So about 20% of the chiropractors who pay for the larger ads are in the woo-woo zone. I don't know what the percent is for all the chiropractors in town; it could be much lower. Since they don't provide information in the small listings I can't tell, and I didn't count the small listings.)

[Dr. Imago]

Originally posted by Rolfe
It was quite a shock to me to find out that chiropractors in the US are called "doctor" and see themselves as somehow on a par with doctors and claim to be able to treat other things than back pain. Also the whole subluxations and lifelong adjustments stuff.

The thing is, here they receive very similar medical training in the first two years (of a four-year program) of school, except they don't get training in pharmacology, for obvious reasons. Therefore, how they arrive at such a bizarre, controversial, and unsupported (at least scientifically) theory of disease is beyond me. It's like they get the training in physiology, anatomy, histology, biochemistry, and pathology - just like their MD counterparts - and then forget everything they learn in the clinic when the whole "subluxation" theory gets pounded into their heads.

Nonetheless, I still believe that it is a dangerous practice for some. That is the core of my argument. And most chiropractors are ill-equipped to make a differentiation upon whom they should or should not practice their manipulations. Likewise, we are not talking about gentle stretching and passive motion of extremities and areas of the body like one would find in regular physiotherapy. They position the body then violently wrench the spine so it "pops". Now, imagine doing this in someone who has spinal stenosis with compressed nerves and have sciatica or some other neurologic condition. Good chiropractors should know better than to mess with that - it is a surgical condition. However, I think we can cite examples (at least I can) when they "go there" anyway and make these problems worse, if not permanently injure the patient. All of this happens in the face of little evidence that their practice, when studied comparitively, is substantially better than regular medical management and/or physical rehab.

That's one of my bigger beefs with the practice, which is separate from all the other truly "woo" stuff like claiming to cure asthma, migraine, etc. that has absolutely NO foundation in reality. And, yes, there are a lot of chiroquacks in the U.S. that advise you against seeing a regular doctor first... if at all.

-TT

[Eos of the Eons]

One name: Tim Bolen

Must go wash my hands for typing that now, and my eyes for looking upon it. Meh.

[Suezoled]

Originally posted by Rolfe
(snipped)

It was quite a shock to me to find out that chiropractors in the US are called "doctor" and see themselves as somehow on a par with doctors and claim to be able to treat other things than back pain. Also the whole subluxations and lifelong adjustments stuff.

(snipped)
Rolfe.

Hmf. And don't I know it.



Caller: Hi, I'm DOCTOR backquacker.
Me: oh. you're a chiro
Caller: yes, I'm a DOCTOR of chiropractics.
Me: yeah I heard you. You're a chiro. What do you want?

(and variations of the same for the most part)

[Eos of the Eons]

:D

I often wonder if chiroquacks (DOCTOR backquacker-ROFLMAO!) get at all insecure when people don't give them the respect they think they are due.

There was a chiro at a woman's show I went to. He held daily "talks" to small groups of people. There was a time schedule for when to show up for one. So I ambled into one. He went on about "vitality" and "energy" and "wellness" blah blah blah...some of the audience really got into it, excitedly yelling yes or putting their hand in the air when he asked them something like wanting more vitality.

I was rolling my eyes. He kept looking at me, kinda puzzled like. Then he finally got to his point after going on and on and on about his book he had written on "vitality" and "health" blah blah blah. The book wasn't published yet though... he finally reveals.

BUT it is the most pre-ordered book ever!! I thought this was it. People buying his book in advance. I thought that wasn't too bad, kinda weird...

BUT THEN! Good deal! You can get the book for FREE!! YES, if you pay $150 to put your finger in his machine and get your vitality measured!! Just $150.00!! And after you get your vitality measured (energy, blah blah), then he can suggest how best to be at your optimum vitality level with whatever quack treatment!

That's when I got up and left. I managed to make it out of the seating area without saying anything.

Later he came walking near the booth I was at (I was manning it for the financial planner I worked for at the time), he kept walking, kinda looked at me for a second as I glowered at him.

Oh, if only I had some kind of witty remark, or cool sarcasm I could have shot at him at some time!

Any suggestions for next time?

[anonimouse]

Originally posted by Eos of the Eons Oh, if only I had some kind of witty remark, or cool sarcasm I could have shot at him at some time!

Any suggestions for next time?

I was going to suggest something in the vein of a different place to stick one's finger to measure "vitality", but that would be hopelessly inappropriate.

The few times I'm unfortunate enough to meet up with a chiropractor, I ask them for a free bent pen.

[Suezoled]

Originally posted by sodakboy93
I was going to suggest something in the vein of a different place to stick one's finger to measure "vitality", but that would be hopelessly inappropriate.

The few times I'm unfortunate enough to meet up with a chiropractor, I ask them for a free bent pen.

indeed. Chiros talk about vitality and circular reasoning and curves of spines and adjustments and then you just realized that the beautiful curve and the circular reasoning and the bend of vitality in the body is, quite simply, bent.

[HopkinsMedStudent]

Originally posted by ThirdTwin
The thing is, here they receive very similar medical training in the first two years (of a four-year program) of school, except they don't get training in pharmacology, for obvious reasons. Therefore, how they arrive at such a bizarre, controversial, and unsupported (at least scientifically) theory of disease is beyond me. It's like they get the training in physiology, anatomy, histology, biochemistry, and pathology - just like their MD counterparts - and then forget everything they learn in the clinic when the whole "subluxation" theory gets pounded into their heads.

This is exactly right. The first couple of years are fairly legit. They study alot of the same material as medical students. In fact, many of the basic science professors at chiro schools are legit PhDs who also have experinece teaching at bona fide medical schools.

However, as ThirdTwin alluded to, there is an ENORMOUS disconnect between the first 2 years and the last 2 years. All of a sudden everything goes from science-based to quackery. The shift in tone and education is absolutely dramatic.

I've asked some of the basic science professors if they really know what their students are being taught in the 3rd/4th years, and for the most part the profs dont really seem to know or concern themselves with that phase of the curriculum. They have no influence on the 3rd/4th years, thats totally run by quack DCs.

In medical school, we take the principles we learned in the first 2 years and begin to apply them with patients in a clinical setting. In chiro school, they totally ignore what they learned the first 2 years and instead get indoctrinated into a belief system that has very little to do with science or evidence.

[Dr. Imago]

Originally posted by HopkinsMedStudent
In medical school, we take the principles we learned in the first 2 years and begin to apply them with patients in a clinical setting. In chiro school, they totally ignore what they learned the first 2 years and instead get indoctrinated into a belief system that has very little to do with science or evidence.

Another difference too, HMS, is that we then have to take United States Medical Licensing Exam Step 1 (at least in the U.S.), which tests our mastery of all that information we learned in the first two years. (Then, of course, we also have Steps 2 & 3 in addition.) I don't know about you, but that was the hardest test I've taken in my life. It made the MCAT look like a kindergarten entrance exam.

I'm not sure about the "boards" for chiropractic, but a big beef I have with a lot of these so-called 'medical' practitioners is that they don't seem to have a nationally standardized criteria and set of exams that levels the playing field, so to speak. In the U.S., we have the National Board of Medical Examiners who offers the USMLE. Furthermore, we also have to do a residency - at least three years - in the field we want to practice in. Then we have board-certification exams after that for our specialty. At the very least, if you can learn what the NBME thinks is relevant and deem that which every medical student should know, you'll never have the privilege of calling yourself "doctor". And, if you don't get into and complete a residency program in something, you're not going to be able to be legally licensed. Without these things, you can't practice real medicine.

-TT

[Dr. Popalot]

Thirdtwin,
I do know about the Chiropractors national board. It is much easier than the USMLE1 exam. I am studying for my USMLE 1 exam right now. I only studied for the chiropractic boards for two days. I am spending about 30 days preparing for my medical exam.

I agree with hopkinsmedstudent, the science learned in the first two years of chiropractic school is all but ignored during the last two years (and after graduation as well). After graduation all one has to do to be licensed is take the state licensing exam and your ready to go into practice. This is only the begining for the medical doctors. They don't turn the MD loose after graduation, they have to work for years in their respective areas of specality. This is where they really learn medicine. In chiropractic, all that is left to learn after graduation is maketing schemes.

[Rolfe]

Originally posted by Dr. Popalot
They don't turn the MD loose after graduation, they have to work for years in their respective areas of specality. This is where they really learn medicine. In chiropractic, all that is left to learn after graduation is maketing schemes. This is really, really scary when seen from the perspective of a country where "chirporactor", "osteopath", "masseur" and "physiotherapist" are all much of a muchness in many people's eyes, and the cognoscenti understand that while all do somewhat similar things, the last two are much less woo than the first two.

The idea of chirporactors being in any way whatsoever regarded as "doctors" is about as foreign as Thanksgiving and the 4th of July.

Rolfe.

[Dr. Imago]

Originally posted by Dr. Popalot
Thirdtwin,
I do know about the Chiropractors national board. It is much easier than the USMLE1 exam. I am studying for my USMLE 1 exam right now. I only studied for the chiropractic boards for two days. I am spending about 30 days preparing for my medical exam.

I agree with hopkinsmedstudent, the science learned in the first two years of chiropractic school is all but ignored during the last two years (and after graduation as well). After graduation all one has to do to be licensed is take the state licensing exam and your ready to go into practice. This is only the begining for the medical doctors. They don't turn the MD loose after graduation, they have to work for years in their respective areas of specality. This is where they really learn medicine. In chiropractic, all that is left to learn after graduation is maketing schemes.

Good luck on Step 1, buddy. Don't go light on the Biochem and Statistics - this is where you score points. Also, BRS Pathology is 100% on the money.

When you get to the wards, buy a good review book right away and, in each rotation you do, take notes in it. Step 2 is more and more about proper patient management than it is brute knowledge. If you don't see the patients, you won't do well. And, whatever you do, don't blow-off OB/Gyn (like I did) because I had at least ten questions on "pregnant woman with abdominal pain" and what you do. On my subject breakdown, this is where I did the worst. (So, no worries ladies... I'm not going to be a gynecologist.)

-TT

[Dr. Imago]

Originally posted by Rolfe
The idea of chirporactors being in any way whatsoever regarded as "doctors" is about as foreign as Thanksgiving and the 4th of July.

Yeah, for you lot. Sadly, it's as commonly known and accepted as Thanksgiving and 4th of July over here...

-TT

[Renfield]

"Unqualified DC's"

I'm usually not one to be the grammer police, but this sounds like a reduncy to me.

[Renfield]

Originally posted by Eos of the Eons
Considering the quackery most peddle, I would have to wonder if any DC is 'qualified' to touch anybody for anything.

Take into consideration that blood vessels broken when chiros crack necks can and do lead to strokes, then I wonder why they are allowed to be edumacated and granted degrees at all.

I would be thrilled to see the chiroquackery schools vanish from the face of the earth.

Far worse, they are actually covered by medicaid and most medical insurances.

Have they actually looked into Chiro before deciding it has any validity? Treating arthritis by opening up nerve passages through "realignments" of the vertebrae that can't be detected by x-rays, cat scans, etc for example? If they can decide this kind of thing is valid, anything could be next. Homeopathy, whatever.

[Eos of the Eons]

Originally posted by Renfield
Far worse, they are actually covered by medicaid and most medical insurances.

Have they actually looked into Chiro before deciding it has any validity? Treating arthritis by opening up nerve passages through "realignments" of the vertebrae that can't be detected by x-rays, cat scans, etc for example? If they can decide this kind of thing is valid, anything could be next. Homeopathy, whatever.

Ugh, don't remind me. I was "forgetting" that quite nicely until now.

Thing is the public. They freak out when chiros are not covered by insurance. It's their right to "choose" their treatment, blah blah. I say Fine, then it's your right to pay for quackery, I don't want my premiums paying for quackery.

Chiros have been around for a while. They really need to shut down the quack schools. They shouldn't be allowed to charge people to learn crap. Education needs to be based on facts. It's our only way out of the insanity. At the same time, educate the public.

People tell me I'm a liar when I say Palmer claimed to cure deafness by "straightening" a guy's back (align the energy flow route and you miraculously cure anything). People just don't believe me.

Hell, I'm not the liar for gosh sakes. Don't get mad at me for telling you the truth. So you have to face that you got sucked in, wah. Get over it and move on.

[Renfield]

Originally posted by Benguin
In terms of the UK, by law they must be registered with the GCC. Anyone claiming to be able to offer Chiropractic without being registered is liable to prosecution.

I think the only other Alt Med with that kind of system is acupuncture.

Searching the GCC site for hits on "subluxation" produces only two, a boring reading list and this little gem (http://www.gcc-uk.org/files/link_file/Findings_Gage.pdf), which (whilst entertaining) should disabuse you of the notion they are totally without scruples.

Dewd, chiropracty is grade A BS, of the first order. With all that wrenching of the spine they might actually make your back feel better, but then, so does a good massage or even an amateur back rub. If you look into Chiro and the rational behind it, how it works, even regarding back pain, it is utterly transparent woo woo nonsense.

Save yourself a few dollars and go to a massage therapist. Anything more a Chiro is doing for you is all placebo. They really don't have much in the way of real medical knowledge. The really can't reallign your spine (all that popping of the back they do is pure sho bidness. not much different then cracking your nuckles. there is no such thing as "Inate intelligence" and opening up your pathways or making your body "balanced" is just vague woo woo jargon.).

You seem like a rational

[Renfield]

Originally posted by ThirdTwin
But, they are not doing it! That's the point. I presented data on the 10 vertebral artery dissections that showed only one patient had given his informed consent.

Think about it: if you tell a patient that there is a risk of verterbral artery dissection and stroke with neck manipulation, there's a chance they'll say "no thank you" to the chiropractor.

-TT

Yes, and that would go against a Chiropracters training. Top priority: keep them coming back.

You can go to ten chiro's for a given ailment, or even go in completely healthy, and each will tell you something different. The only thing they will all have in common is you are going to need to need a lot of treatment!

[Eos of the Eons]

:D
For Benguin: http://www.subluxation.com/html/frameset.htm

Note all the "doctors" pictured.

Note their "product"

http://www.subluxation.com/html/surface-emg.htm



This compelling case study could be your patient:

Anecdotes. Hmph. "Case Study" indeed.

[Dr. Imago]

Originally posted by Eos of the Eons
Thing is the public. They freak out when chiros are not covered by insurance. It's their right to "choose" their treatment, blah blah. I say Fine, then it's your right to pay for quackery, I don't want my premiums paying for quackery.

Well, unfortunately, a lot of what we do in medicine is based on politics and not good sense. Either way, all of it should still be scientific.

-TT

[Dr. Imago]

Originally posted by Renfield
With all that wrenching of the spine they might actually make your back feel better, but then, so does a good massage or even an amateur back rub. If you look into Chiro and the rational behind it, how it works, even regarding back pain, it is utterly transparent woo woo nonsense.

I agree with this, but I think that chiro - by deeply manipulating the paraspinal muscles - actually may get to deeper muscles, such as the paraspinal muscles, that less agressive massage cannot reach effectively. Aside from their woo-woo rationale, this may actually be what's at play. Perhaps such patients would benefit from shiatsu or Swedish massage, and I have a strong hunch that compartive studies would show similar benefits. Likewise, we know about point tenderness and nerve entrapment within muscles. Pain specialists actually use trigger-point injections, which work quite effectively, in releasing superficial muscles that don't for instance respond to massage.

Point is, the rationale behind such practices are sound and based on verifiable evidence, not some unsupportable, non-reproducible theory on subluxation and energy and whatnot.

-TT