Respectful Insolence

jama-image

Of all the alternative medical systems out there, chiropractic is one of the oddest. Unlike many of the others, it has a modicum of plausibility, at least for back problems due to musculoskeletal strains. After all, the science-based specialty of physical therapy uses spinal manipulation to treat back problems. Of course, the big difference between chiropractic and physical therapy is that chiropractic is based on a delusion, namely the concept of subluxations. To science-based specialties, a subluxation a painful partial dislocation. This is different from a chiropractic subluxation, which is claimed to cause disease by interfering with nerve supply to organs. Such subluxations have never been shown to exist, nor has it ever been shown that “innate intelligence,” which to chiropractors is the organizing property of living things and a term originally coined by Daniel David Palmer, the founder of chiropractic. Palmer proclaimed that subluxations interfered with the body’s expression of “innate intelligence,” that controls the healing process. One notes that this vitalistic concept is very much like qi in acupuncture, except that instead of needles redirecting or unblocking the flow of qi in chiropractic adjusting subluxations unblocks the flow or function of the “innate intelligence.” Unfortunately, chiropractic subluxations have never been shown to exist.

Such is the reason why I like to refer to chiropractors as physical therapists with delusions of grandeur. They claim to be able to treat all manner of disease, not just back problems, by adjusting the spine. Even more unfortunately, among the alternative medical specialties, chiropractic is arguably the most entrenched, the most accepted, of them all.

Still, chiropractors have a much-earned inferiority complex. They desperately crave the acceptance that they don’t deserve and the scientific acceptance they don’t have. That’s why, whenever a story like this pops up, it’s spread far and wide as though it’s some sort of validation of chiropractic. In this case, the story is entitled JAMA recommends chiropractic as first means of back pain treatment. Let’s just say that the title of this article is profoundly misleading:

Medical doctors and chiropractors are often at odds with each other. The Journal of the American Medical Association now recommends chiropractic as a first means of treating back pain.

Dr. Alex Vidan wasn’t going to let that pass by without a comment. He stops by FOX2 with his pal Mr. Spine with more information.

As is the video itself:

My first inclination when I saw this article and the accompanying video was to wonder what the source of Vidan’s claims were? What article in JAMA was he referring to? I couldn’t find it, search as I could. The article didn’t seem to exist. Then I finally found it when I came across another chiropractor touting the article, and the reason why there’s much less there than meets Vidan’s eye became apparent. Basically, it’s an article by Denise M. Goodman, MD, MS; Alison E. Burke, MA; Edward H. Livingston, MD entitled, Low Back Pain. It’s a brief article on the causes and treatment of, yes, low back pain. It’s very simple, and it’s very short.

To be fair, the article does mention chiropractic—once. It’s less than a glowing endorsement:

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

All in all, it’s pretty vague, and saying that “some people” benefit says nothing about evidence or science. It’s actually not a very good article, at least not with respect to discussing treatment. More importantly, just because JAMA published a brief Patient Page on low back pain does not mean that JAMA endorses chiropractic, any more than a medical journal publishing on any topic implies endorsement. Vidan is suffering from self-delusion at best and is being disingenuous at worst. He should know that publishing an article in a journal doesn’t necessarily imply endorsement of the concepts of that article by the journal. If Vidan doesn’t know that, he’s more clueless than the average chiropractor.

But what about this further claim:

The JAMA`s recommendation comes on the heels of a recent study out of the medical journal Spine where sufferers of lower back pain all received standard medical care (SMC) and half of the participants additionally received chiropractic care. The researchers found that in SMC plus chiropractic care patients, 73% reported that their pain was completely gone or much better after treatment compared to just 17% of the SMC group.

Again, this is something that irritates the hell out of me: News articles that mention a study but don’t give me any easy way of identifying it, no link, no author, no title, no anything. As far as I can tell, this article from November appears to be the right article. it’s from the Palmer Center for Chiropractic Research, Davenport, IA; Physical Medicine and Integrative Care Services, Fort Bliss, TX; Samueli Institute, Alexandria, VA; Palmer College of Chiropractic, Davenport, IA; TriMax Direct, Saint Paul, MN; and Palmer College of Chiropractic, San Jose, CA, and entitled Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study. It’s a randomized trial of standard medical care (SMC) versus standard medical care plus chiropractic manipulative therapy (SMC+CMT).

Pragmatic trial. It had to be a pragmatic trial.

I’ve discussed pragmatic trials before. Alternative medicine advocates love them because they don’t have rigorous controls. “pragmatic trials” are basically an attempt to determine whether treatments validated in properly designed randomized clinical trials (RCTs) work under “real world” conditions. RCTs are intentionally designed to make the population studied as homogeneous as possible, both to minimize differences between the control group and the experimental groups and to decrease variability within groups, the better to isolate the signal from the difference between treatment and control. However, once a treatment gets out into the community, it becomes more widely used, and the rigid inclusion and exclusion criteria used to select subjects for clinical trials fly out the window. The patients upon whom the treatment is used become much less homogeneous, and differences between academic medical centers and the community can change how the treatment is delivered. So “pragmatic” trials seek to determine effectiveness in the real world, which is a different thing than the efficacy determined in the rarified, tightly controlled world of RCTs. Here’s the problem. Pragmatic trials in CAM are putting the cart before the horse. You need to demonstrate efficacy in RCTs before it’s appropriate to consider doing pragmatic trials to determine real world effectiveness. There’s a reason why the National Center for Complementary and Alternative Medicine (NCCAM) loves pragmatic trials.

One way to look at pragmatic trials is that they often don’t have a placebo control. That’s one of their big problem in many pragmatic trials, and it’s definitely a problem in this trial, which studies two groups, SMC (N=46) and SMC + chiropractic (N=45). SMC consisted of this:

The study did not restrict access to SMC or prescribe a SMC delivery protocol. Thus, both groups had normal access to the SMC typically provided to patients with LBP at WBAMC. Standard care included any or all of the following: a focused history and physical examination, diagnostic imaging as indicated, education about self-management including maintaining activity levels as tolerated, pharmacological management with the use of analgesics and anti-inflammatory agents, and physical therapy and modalities such as heat/ice and referral to a pain clinic.

And:

The number of visits in the SMC group was in the range of 0 to 8, with a mean of 1.4 visits. The majority of participants (n = 24) in this group had only 1 visit. Medications were prescribed for 37% of the participants and included nonsteroidal anti-inflammatory drugs, muscle relaxants, benzodiazepines, analgesic creams, and narcotics. Thirty-three percent were placed on a treatment plan (exercise program, range of motion, stretching and modalities including heat and electrical stimulation) delivered primarily by a physical therapist. Fifty percent were given referrals, with a majority for physical therapy (38%) followed by radiographical evaluation (31%). The SMC group providers were physician assistants (28%), family practice physicians (18%), physical therapists (16%) or aides (12%), nurse practitioners (9%), or specialty providers (physical medicine [3%], athletic trainer [3%], and chiropractor [3%]).

Inclusion criteria included male and female US active-duty military personel between 18 and 35 years of age with acute low back pain (LBP). Acute LBP is defined as LBP of less than four weeks of duration. Exclusion criteria were pretty minor, including not being at the post for at least six weeks, LBP for more than four weeks, pregnancy, or other conditions for which CMT is contraindicated. The specific type of chiropractic manipulation was specified in the study criteria. Outcomes studied included pain measured using the numerical rating scale and physical functioning measured using the Roland-Morris Disability questionnaire (RMQ) and the Back Pain Functional Scale (BPFS). The NRS asks participants to rate their level of pain during the past 24 hours on an ordinal 11-point scale (0 = no LBP; 10 = worst possible pain). The minimal clinically important difference is a change of 2.5 points. 20 The modified RMQ assesses LBP-related disability and the minimal clinically important difference is estimated at 2 to 3.5 points. Finally, secondary outcomes included satisfaction, measured on the same 0-10 point scale as the pain scale to respond to the question, “How satisfied were you with the overall results of your care?” Patients were also ased to rate their improvement on a seven-point Likert scale answering the question, “Compared to your first visit, your back pain is…”

No attempt was made to blind treating personnel or research subjects, although the principal investigator and data analysts were blinded to subject group.

So what were the results? They were pretty much what one would expect for a trial like this. Both groups improved. (After all, most acute back pain resolves on its own.) However, the SMC+CMT group improved a bit more. For instance, the pain scores for the SMC group was 6.1 and 5.2 at two and four weeks, respectively; for the SMC+CMT group, the scores were 3.9 and 3.9 at two and four weeks respectively, for a difference of 2.2 and 1.2. Remember, the minimally clinically important difference in pain scores is considered to be 2.5 points, which tells us that these differences were short-lived and probably not clinically significant. Differences were somewhat higher for the RMQ and BPFS.

Let me note one thing that stood out. Both treatment groups got very few visits to the conventional medical care practitioners. For instance, the number of visits in the SMC group ranged from 0 to 8, with a mean of 1.4 visits, but the majority of participants had only one visit. The same was true of the SMC+CMT group, whose visit number ranged from 0 to 4 for conventional therapy, with a mean of 1. In contrast, in this group, this group had a median of 7 visits for CMT, with a range from 2-8, which tells me that a lot of them got 7 or 8 visits in four weeks. This is a huge difference in contact with conventional therapists. Thus, even though 50% of subjects in SMC got referrals to physical therapy, their visit numbers tell me that few went, or at least went very often. Another big problem with this study is the disproportionate loss to followup. The loss to followup was only 15% in the SMC+CMT group and 35% in the SMC group. Although an analysis was done to try to see if this affected the results, bias due to this disproportionate dropout can’t be ruled out. Also, the investigators didn’t actually track medication use between the two groups.

Now here’s the result that was cherry-picked in the interview with Vidan:

Seventy-three percent of participants in the SMC plus CMT group rated their global improvement as pain completely gone, much better, or moderately better, compared with 17% in the SMC group (Figure 2). The mean satisfaction with care score on a 0 to 10 scale for the SMC plus CMT group was 8.9 at both weeks 2 and 4; the mean for the SMC group was 4.5 at week 2 and 5.4 at week 4 (Table 4).

Of course they did better. They got manipulation similar to physical therapy seven times during the eight weeks, while most of the control population didn’t. And of course they were more satisfied. They saw a practitioner more often and got an active intervention. Obviously, chiropractic is not physical therapy, but in this study clearly everyone in one group got some form of spinal manipulation on a regular basis (roughly twice a week), while most people in the control group did not get anywhere near that level of intervention. The real “pragmatic” trial would have been take physical therapy (PT) out of SMC for purposes of this study and study it as a separate variable, as in SMC, SMC+PT, and SMC+CMT. (Remember, I’m proposing what I’d consider to be a more rigorous pragmatic trial.)

I also note that this is one trial, and that its results conflict with another similar trial done published in 2009 that found that pain reductions and analgesic consumption were similar in all groups and concluded that spinal manipulative therapy “is unlikely to result in relevant early pain reduction in patients with acute low back pain.” Funny how Vidan never mentioned this.

And, of course, a rather weak article in JAMA that mentions chiropractic as a treatment for low back pain does not mean that JAMA recommends chiropractic first.

Comments

  1. #1 Eric Lund
    July 18, 2014

    Some people benefit from chiropractic therapy or acupuncture.

    On reading that sentence I immediately asked myself: How do we know it’s more than the placebo effect?

    Of course the one study is going to find that SMC + CMT does better than SMC alone. The former group gets physical therapy, the one part of chiropractic that has some basis in reality, and the latter group does not. How did the referees not notice this?

  2. #2 Helianthus
    July 18, 2014

    Some people benefit from chiropractic therapy or acupuncture.

    I love (well, not really) how the above sentence, lost in the middle of bunch of others treatments, became translated as the following (emphasis added):

    JAMA now recommends chiropractic as a first means of treating back pain.

    Maybe chiropractors should be working as translators for the UN. They are good at interpretation.

  3. #3 palindrom
    July 18, 2014

    I am not a medical scientist (I wake up every day and thank my lucky stars, so tot speak, that I went into astrophysics, which is much easier), but it also seems to my naive eyes that N = 46 is a pretty small number.

    In reports of experiments of this kind, I’d think it would be clearer, instead of saying “73 percent”, or whatever, to say
    “73 percent (30/42)” so that the reader could get an immediate idea of the power of the experiment, and the large counting-statistics error bar on the “73 percent” figure, which reeks of spurious precision. [I didn't check the arithmetic, by the way.]

  4. #4 c0nc0rdance
    July 18, 2014

    I am always perplexed by the number of people who think that chiropractors actually mobilize vertebral joints back to some optimum. They’ve been told that the bones of the spine are impeding nerve flow (the pseudoscientific explanation offered by most chiropractors), and that their spinal column is being realigned. I find no evidence that this is actually the case. The more likely mechanism is that of mechanical stimulation leading to natural painkiller release.

    Re-aligning the spine with manipulation would be like rearranging the rebar in a load-bearing column in an office building.

    As someone with a back herniation, I was dumb enough to believe these off-hand comments about “conservative therapy, including acupuncture and chiropractic may give some relief”. What I didn’t know was that I would be given: full-body X-rays, free samples of miracle herbal cream, and instructions on how to defraud my insurance.

    Some chiropractors are very nice folks, and very knowledgeable. I won’t make blanket statements about them. They seriously need to clean up the dirt in their profession, though.

    “The DC disciplinary categories, in descending order, were fraud (44%), sexual boundary issues (22%), other offenses (13%), abuse of alcohol or drugs (10%), negligence or incompetence (6%), poor supervision (2%), and mental impairment (.3%).”
    J Manipulative Physiol Ther. 2004 Sep;27(7):472-7.
    “Chiropractors disciplined by a state chiropractic board and a comparison with disciplined medical physicians.”

    And, just because of Simon Singh, I feel obliged to point out that the British Chiropractic Association happily promotes bogus treatments.

  5. #5 Eric Lund
    July 18, 2014

    it also seems to my naive eyes that N = 46 is a pretty small number

    For laboratory experiments in physics, it’s ridiculously small. For many other fields, especially (but not exclusively) when human subjects are involved, you take whatever value of N you can get. As I have said before, one reason lab physicists like to use a 5σ significance threshold, rather than the p < 0.05 (about 2σ) standard common in many other fields, is because they can: you can repeat the experiment all day (or even week or month, if your lab controls the apparatus) to get the kind of statistics you need to enforce the stricter standard.

    That’s not to say that N values that small aren’t problematic. But it is quite time consuming, and very expensive, to do a lot better than that. Your fractional error bars scale as 1/sqrt(N), so to make the error bars ten times smaller you need a hundredfold increase in N.

  6. #6 KayMarie
    July 18, 2014

    Humans tend to be expensive to work on so you usually see some pretty small N’s trying to generate enough numbers to get the funding for studies with N’s in the hundreds or thousands. So you do see a lot of pilot studies or preliminary studies in the 8-50 person range. Often that is the step right after it works like this in 900 of 1,000 mice or 100,000 of 110,000 fruit flies.

    Once you get enough data to think you can or want to do a more conclusive study usually you play with the stats calculations to find the smallest number of people that will give you the power you need to make relatively conclusive statements.

    Additionally for a lot of human as the lab animal research, the bigger the N the less hands on you are with each person. Right now in my little corner of research there is a lot of interest in experiments where you are mostly just pulling data out of the electronic medical records, often for something like tens of thousands of people. A lot of the other big N studies are primarily surveys or something they can do on a blood samples (I’m in one study as a participant with 20,000 other people that was give one blood sample and every so often you get a survey to fill out depending on what showed up in the blood sample). Once you start having to actually interact with the people multiple times and do things to them (run them through an MRI, etc) the expense often dictates what the N is going to be based on what the limited resources are.

  7. #7 Scott Sheridan
    Bonney Lake washington
    July 18, 2014

    Please don’t assume all Chiropractors are subluxation based. This is an old school way of looking at our profession. Many schools are based on evidence based curriculums. I have never used the term “Subluxation” in my practice. Most of my work I centered around functional restoration of the spine and extremities which promotes proper joint motion rather than segmental position. Much like the medical field, most chiropractors are utilizing current research to base their treatments on.

  8. #8 Shay
    July 18, 2014

    Some people benefit from chiropractic therapy or acupuncture.

    I benefit from back-rubs. And the better looking the back-rubber is, the more I benefit. Pity I can’t get funding for a more thorough study.

  9. #9 Shay
    July 18, 2014

    I managed to completely flip-flop the desired italicization on that last comment…interesting.

  10. #10 Old Rockin' Dave
    Sittin' on top of the world...
    July 18, 2014

    I will say this much about chiropractic: in two episodes of back pain due to physical work, I made three visits total to two different chiros, and got near-instant relief.
    Now of course I have all the data I need to proclaim that chiropractic is the wonder of the ages, and can cure anyone of anything. Anecdotal evidence – is there anything it can’t prove?

  11. #11 sciencemonkey
    July 18, 2014

    I’m a PhD chemist and I’m not susceptible to woo, but I did have a decent experience with a chiropractor.

    I think I’ve told my story here once already. I had some pain in the mid-upper right of my back, which would get really bad when I walked long distances. I went to the local chiropractor college to see what they could do, and I got ~8-10 treatments that consisted of a massage and then a cracking of the painful spot. By cracking I mean I laid back into his finger (angled into a triangle) to crack that part of the back, like you might crack your fingers. He also recommended back exercises, etc.

    http://en.wikipedia.org/wiki/Cracking_joints

    Ever since the treatment my pain in that area is a lot less, and I can sometimes feel that area crack just from stretching my shoulder blades.

    Do you think there is something to this cracking that helps some types of back pain? Are physical therapists authorized to do this in the US and Canada?

  12. #12 Beamup
    July 18, 2014

    @ Eric:

    There’s a lot more to the variation of typical sigma levels than that. In particular, it is absolutely false that getting the better statistics is free. Even leaving aside the time factor (time you’re spending on improving statistics for one experiment is time you’re not spending on a new, more interesting, experiment), the 5-sigma threshold is most typical of high-energy physics specifically. Which means you’re talking about experiments costing billions of dollars to build, and millions to run.

    The far more interesting reason is that, in physics, you CAN meaningfully get statistical uncertainty down to that level – so long as you’re careful with your systematics. In medicine, your systematic uncertainties are so much larger that even if you DID run a trial with 100 million subjects, the results would be no better than one with 50,000 (numbers pulled from nether regions, but you get the idea).

    On a related note, it seriously irks me that medical research doesn’t quantify systematics. It really means that you have no clue what your actual level of significance is, ever.

  13. #13 KayMarie
    July 18, 2014

    @sciencemonkey

    I’ve had a physical therapist do some manipulation of the back that could lead to cracking and make things feel better, although I’ve usually had more heat treatment or been given exercises to do.

    It doesn’t surprise me some of the manipulations can relieve pain for some things.

  14. #14 David
    July 18, 2014

    “It also seems to my naive eyes that N = 46 is a pretty small number … For many other fields, especially (but not exclusively) when human subjects are involved, you take whatever value of N you can get.”

    NO: especially when human subjects are involved, conducting a clinical trial with a small N is unethical as it means that the subjects are exposed to the trial (with risks of the trial treatment, inconvenience of the trial itself, and lost opportunity for other therapies) without having a meaningful chance of producing a valid scientific result. The ICH (an international body which sets standards for research) explicitly says “The number of subjects in a clinical trial should always be large enough to provide a reliable answer to the questions addressed.” (source: ICH guideline e9 section 3.5). Given the usual degree of variability of response, a clinical trial designed to detect a minimal clinically meaningful improvement in back pain typically requires a minimum of 100 subjects per study arm. Determining appropriate sample size is a mathematical science (and maybe partly black art).

    In fact, no adequate trial of chiropractic (adequate in terms of having an active but non-effective intervention in the control group to balance the degree of placebo response, in terms of blinding and assessment rigor, and in terms of sample size) has ever shown a benefit of this therapy, compared to sham (ineffective) treatment.

    Many people here have posted their anecdotes about how chiropractic seemed to help. Back pain is a disorder that is dominated by placebo response. Nowhere is it more true that the plural of anecdote is not data.

    disclaimer: I work for a pharma company, partly on developing pain treatments. I am paid to improve scientific rigor in clinical trials.

  15. #15 Mike
    July 18, 2014

    I’d be interested to see the study that combines SMC with conventional massage given by a masseuse considered attractive by the subject, vs SMC vs SMC + Chiro.

    My entirely unscientific guess is that Shay is on to something at #7 and we’ll see better results from that than either of the others…

  16. #16 palindrom
    July 18, 2014

    David – thanks for that.

    I’m serious (sort of) about the suggestion that smaller trials should routinely quote results as fractions as well as percentages. It seems a lot more impressive, for example, to say that you had positive results in 64% of the cases, than to say that 7 out of 11 patients improved.

  17. #17 palindrom
    July 18, 2014

    Mike — you’re forgetting that if the masseuse is sufficiently attractive, the patient may claim to need many more repeat treatments.

  18. #18 The Grouchybeast
    July 18, 2014

    this group had a median of 7 visits for CMT, with a range from 2-8, which tells me that a lot of them got 7 or 8 visits in four weeks. This is a huge difference in contact with conventional therapists.

    I spent a year taking classes to get a qualification in Swedish massage. During the first part of the course, the students practised on one another before being unleashed on the public. My personal experience suggests that if you get even a completely non-medical massage twice a week for a month, at the end of it your back will feel great. I’ve never been so relaxed and free of aches and pains as I was while I took that course.

  19. #19 not a turd
    not the MONSTROUS TURD OBAMATURD IS
    July 19, 2014

    I have read your rants against everyone who disagrees with you Dr. Mengela’s and your eugenics programs…you are merely a small insignificant turd compared to the MONSTRIOUS TURD OBAMATURD IS…and the joke is on you because oblivious was specifically choosen by the wall street bankers to FAIL with health care reform and take it sideways…so it is very amusing to see you a small insignificant turd and your army of turds all adding to the MONSTROUS TURD that OBAMATURD is and all the while the ONLY beneficiaries will be the insurance companies and big pharma who have no problem with this latest swindle to screw the American people being repealed any day as they got their up front when they CANCELLED whatever people friendly insurance policies they wanted and hi-jacked the debate on health care from what is effective to what policy can make them the most oddles of cash…YOU ARE BEING SWINDLED AND LAUGHED AT BY THE HUGE TURDS WHILE THEY GET YOU LITTLE TURDS TO SUPPORT THEIR MONSTROUS TURD: OBAMATURD…enjoy

  20. #20 not a turd
    July 19, 2014

    ps did i mention that YOU SPECIFICALLY ARE ALSO A TURD?…ALBEIT A TINY INSIGNIFICANT ONE…FACT!

  21. #21 LIz Ditz
    Goodby NaT
    July 19, 2014

    My oh my, off topic rant swith caplocks ON, overuse of ellipses, misspellings, run-on word salad, and personal attacks.

    Well done!

  22. #22 NumberWang
    July 19, 2014

    Goodness me. If I’d known there was this level of intellectual repartee available I’d have been glued to the blog all day.

  23. #23 Lawrence
    July 19, 2014

    Wow….I just don’t even know what to say….obviously, a village has lost their idiot….

  24. #24 Sarah A
    July 19, 2014

    What’s everyone complaining about? “You’re a turd and I’m not” seems like a perfectly legitimate argument to me

  25. #25 novalox
    July 19, 2014

    @turd

    I certainly hope you are a poe or drunk, because if your posts are any indication of your actual intelligence, I certainly fear for your family and friemds, as well as any of your future job or educational prospects.

  26. #26 Newcoaster-MD
    British Columbia
    July 20, 2014

    @ #11 sciencemonkey

    “I’m a PhD chemist and I’m not susceptible to woo”

    Everyone is susceptible to woo and fuzzy thinking. Yes, even PhD chemists. It’s why Michael Shermer put a separate chapter in Why People Believe Weird Things specifically on why smart people believe weird things. We are all subject to cognitive biases and logical fallacies.

    “I think I’ve told my story here once already ”

    By your very own choice of words, you have anecdotal evidence with an N=1. Your back got better, as the overwhelming majority of acute back pain always does, no matter what modality people undertake. You attribute it to chiropractic because that is what you were doing when your back got better. You can’t say that it wouldn’t have got better anyway, or by using some other approach.

    I can “crack” my own back by stretching, not to mention my neck and my knuckles. It’s a terrible habit. It makes a noise, and gives some immediate relief to tension. That is all. I have heard of chiropractors cracking their own knuckles when they “adjusted” clients ( I refuse to call them patients) and telling the sap that was the sound of their bones being put back in place.

    Chiropractic probably has some benefit in some people, but so does massage, stretching, analgesics, and staying active in general.

  27. #27 Helianthus
    July 20, 2014

    @ Lawrence

    obviously, a village has lost their idiot…

    I’m afraid NoT was rejected as a village idiot due to failure to meet minimal qualifications…

  28. #28 Dorothy
    Oz
    July 20, 2014

    If ever there was a (Not a) Turd that needed polishing…..

  29. #29 ann
    July 20, 2014

    What’s extra-pathetic about that ilk is how unquestioningly they’ve gone for the Obama’s-evil-commie-machinations story line.

    He’s not a very powerful president, in fact. And to the right of Nixon on most issues, too.

  30. #30 adelady
    city of wine and roses
    July 21, 2014

    I’d be interested to see the study that combines SMC with conventional massage given by a masseuse considered attractive by the subject, vs SMC vs SMC + Chiro.

    Well, for people like me who find massage of muscles excruciatingly painful, other physical therapies are much more appealing. Even the trigger point stuff, which really does hurt me (I don’t know about other people), is tolerable because it stays at a single point until you can feel the muscle relax. Well, the therapist feels the relaxation more directly, I just feel the pain go.

    One chiropractic group we went to didn’t talk about subluxation at all. They concentrated on loosening and stretching muscles that were unbalancing you physically. They determined that you were standing unbalanced by using a strange set of scales. Both the therapists were pretty good, but the effects were seriously temporary. If you didn’t go twice a week, it was hard to feel that they’d made much difference.

    Though you can get more or less science-based people in the same practice. One, who was a terrific physical therapist, claimed not to believe in Charcot-Marie-Tooth disease, let alone its effects on nerve and muscle (dis)function in obviously affected feet. The other, younger partner was actively researching whether and how physical therapy could help maintain function and/or delay the worst effects of degeneration in weakened hands, feet and legs.

    Once the anti-vaccination leaflets appeared in the waiting room though, I was out of there and didn’t go back.