No, JAMA does not now recommend chiropractic care first for low back pain

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.

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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?

By Eric Lund (not verified) on 18 Jul 2014 #permalink

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.

By Helianthus (not verified) on 18 Jul 2014 #permalink

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.]

By palindrom (not verified) on 18 Jul 2014 #permalink

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.

By c0nc0rdance (not verified) on 18 Jul 2014 #permalink

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.

By Eric Lund (not verified) on 18 Jul 2014 #permalink

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.

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.

By Scott Sheridan (not verified) on 18 Jul 2014 #permalink

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.

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

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?

By Old Rockin' Dave (not verified) on 18 Jul 2014 #permalink

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?

By sciencemonkey (not verified) on 18 Jul 2014 #permalink

@ 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.

@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.

"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.

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...

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.

By palindrom (not verified) on 18 Jul 2014 #permalink

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

By palindrom (not verified) on 18 Jul 2014 #permalink

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.

By The Grouchybeast (not verified) on 18 Jul 2014 #permalink

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

By not a turd (not verified) on 19 Jul 2014 #permalink

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

By not a turd (not verified) on 19 Jul 2014 #permalink

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

Well done!

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

By NumberWang (not verified) on 19 Jul 2014 #permalink

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

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

@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.

@ #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.

By Newcoaster-MD (not verified) on 20 Jul 2014 #permalink

@ 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...

By Helianthus (not verified) on 20 Jul 2014 #permalink

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

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.

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.

I love it. Even when there are studies and positive results Orac manages to explain away. I wonder how he manages to cross the street with those giant blinkers he wears.

"explain it away"

By completely ignoring the nuance in the so-called "positive results" as described in Orac's post aren't you the one with the 'blinkers', Sandra?

First we need to find out who the best chiropractors are. Rank them and test the best ones. It makes no sense to have average or less than average chiropractors producing poor results in whatever studies. Whenever I get a disabling crink in my back, I go to a particular chiropractor who is very good - he uses the low impact "activator method". He gets my back fixed in only 1 or 2 visits. When he was on vacation, the other chiropractor worked on my back 8 times and no relief, it only got better when the other chiropractor returned from vacation and worked on my back - in only 2 visits.
I would never go to a hospital if I woke up with a disabling "crink" in my back. I wouldn't know whether to go to the ER, or is there an "outpatient" waiting area? What would a AMA doctor do for me? Give me pain pills? How long would I have to wait? Would he demand an Xray? Would he tell me it's all in my head, or that it would self-resolve in a couple weeks? How much money would I have to pay him?

No, first we need to determine if chiropractic is any different from placebo for anything other than low back pain (which seems to resolve with lots of different therapies or none at all, BTW).

And if you're unfamiliar with the difference between a hospital's emergency functions and its outpatient care, I'd say you just might be lacking in the kinds of skills needed to dispassionately analyze a treatment's effectiveness.

By Scottynuke (not verified) on 29 Jul 2014 #permalink

I would never go to a hospital if I woke up with a disabling “crink” in my back.

That's sure the hell what I did one day when I woke up as an undergraduate and couldn't stand up without excruciating pain. I had to walk three blocks bent at a 90 degree angle. Nothing like some muscle relaxants.

Though perhaps Thaddeus should go his family doctor and learn ways to prevent the back pain. There are things like how to lift, plus exercises to strengthen the muscles (they are mostly leg lifts).

Remember an ounce of prevention is worth a pound of cure.

" What would a AMA doctor do for me?"

What does Thaddeus think an "AMA doctor" is?* The American Medical Association does not license physicians, measure their competency or regulate them. The A.M.A. does not mandate what physicians should do for back "crinks" (whatever those are)** or any other condition.

*most American physicians do not belong to the A.M.A.
**it's tempting to define "crinks" as vague pains reported by crocks, but that wouldn't be nice.

By Dangerous Bacon (not verified) on 29 Jul 2014 #permalink

More immediately important for me when I had sciatic nerve impingement were the EMT squad who hauled me from my bedroom, downstairs on a stretcher with a back back board.

When I got to the ER, a resident doctor shot me up with a potent painkiller before I was sent for a MRI and before my orthopedist arrived at the hospital.

I've never been to a chiropractor. My physical therapists have always provided the therapies I've ever needed.

"First we need to find out who the best chiropractors are. Rank them and test the best ones."

Given that subluxations have been shown not to exist, wouldn't the best chiroproactics be the ones that administered the least chiropractic manipulations?

Does imbrication exist? Yes? Then subluxation exists because mechanically they are the same.

subluxation is equivocal to imbrication or locking and when it affects the DRG that's when u get paresthesia and tingling. Make sense now? Look if your back or neck are bothering you or if u get chronic headaches, seek out a reputable chiropractor.

Casey - do subluxations exist as defined by chiropractors? If so, can they actually detect them?

BTW - I don't think you mean equivocal (open to more than one interpretation, or not easily explained).

By Mephistopheles… (not verified) on 18 Aug 2014 #permalink

Yes, with one caveat. If subluxation necessarily nerve root involvement then fixation and subluxation may not be the synonymous.
The issue revolves around the term "nerve involvement"
Where paraesthesia or radiculitis exists (DRG is being affected) and the MRI is found to be free of nerve root encroachment by a disc, what is the mechanism of irritation?....when the patient receives a manipulation encounter (or several) and the paresthesia abates...what was the mechanism of relief? A chiropractor would say the vertebrae were subluxated causing pressure or irritating the DRG and that the adjustment(s) corrected (unlocked) the subluxation.

What of fixated vertebrae that are causing scleratogenous pain patterns (facet syndrome as an example.) When those vertebrae receive an adjustment or series of adjustments and THAT pain pattern or chronic headache resolves, would the chiropractor say he corrected a subluxation? Maybe. others would argue that he corrected a "fixation" because there was no nerve ROOT involvement.

In any event vertebrae become fixated and sometimes involve the nerve root which affects the DRG. At times the entire nerve root is involved and weakness ensues. Chiropractors and DO's and PT's alleviate that pressure and irritation. Although I wouldn't go to anyone but a chiropractor for this kind of work because that's all chiro's do all days... CMT and PT and OT.

As in all fields, there are a lot of quacks in the chiropractic profession. But there are some true, genuine, honest miracle workers. Don't sell the entire profession short because of prejudice.

Casey,"Imbircation" and Subluxation" are not synonyms for a single entity.

As generally defined imbrication is "an overlapping of edges", as defined mdeically it's "the operative overlapping of layers of tissue in the closure of wounds or the repair of defects" and as 'surgical pleating and folding of tissue to realign organs and provide extra support".

Subluxation, on the other hand, is defined by the American Chiropractic as "a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health".

Make sense now?

No: given that the definitions aren't synonymous it makes no sense.

Look if your back or neck are bothering you or if u get chronic headaches, seek out a reputable chiropractor.

That's an oxymoron I haven't encountered before...

Where paraesthesia or radiculitis exists (DRG is being affected) and the MRI is found to be free of nerve root encroachment by a disc, what is the mechanism of irritation?

Why are you presuming that there is a source of irritation responsible for the reported parasthesia, in the absence of evidence to that effect? It's on some basis other than "what else could it be?", I would hope ("The patient reports parasthesia--something must be irritated somewhere. Let's crack his spine a couple of times and see if that helps.")

When the patient receives a manipulation encounter (or several) and the paresthesia abates…what was the mechanism of relief?

Unknown: suggesting it's the manipulations is simply embracing a post hoc ergo procter hoc logical fallacy.

A chiropractor would say the vertebrae were subluxated causing pressure or irritating the DRG and that the adjustment(s) corrected (unlocked) the subluxation.

And he'd not only be saying this in the absence of any evidence thiswas the case but in the face of evidence (the MRI demonstrating no nerve root encroachment) it was not the case--again on no basis other than that post hoc ergo procter hoc logical fallacy.

You'll find this interesting:

1. Target Article: Pickar, J. G. (2002). Neurophysiological effects of spinal manipulation. The Spine Journal, 2, 357-371.

2. The effects of spinal manipulation on neural tissue within the IVF
• because there is less connective tissue support and protection in the IVF, and due to dense sodium channels in the dorsal root ganglia, the neural tissue within the IVF may be vulnerable to mechanical and or chemical changes by the disc or facets
• available evidence indicates dorsal roots and dorsal root ganglia (DRG) are more susceptible to mechanical compression than peripheral nerves and that compression of either can increase discharge of Group I, II, III, and IV afferents, with more discharge occurring for the DRG
• compression can also impair axoplasmic transport and hence nutritional transport
• neuroactive chemicals released from discs can also explain neurological findings associated with herniated discs, which perpetuate the mechanical sensitivity of dorsal roots and DRG’s
• although studies provide evidence that mechanical and chemical changes of herniated discs can influence neural tissue within the IVF, no studies show the effects of spinal manipulation on the mechanical or chemical environment of the IVF
• however, the recent findings of facet joint gapping by Dr. Cramer and colleagues (Spine, 2002) following spinal adjusting suggest that there may be some effect on the dimensions of the IVF post-adjustment

3. The effects of spinal manipulation on central facilitation
• central facilitation refers to the increased excitability of dorsal horn neurons to afferent input
• evidence from Denslow has suggested that persistent alterations in sensory input from a functional spinal unit increases the excitability of neuronal cells in the spinal cord
• because of central facilitation, subthreshold mechanical stimuli may initiate pain
• spinal manipulation may either remove these subthreshold stimuli or may stimulate large diameter A fiber neurons that inhibit the response of dorsal horn neurons to nociceptive stimuli from C fibers (this latter mechanism has been termed the “gate control theory”) Effects on pain and processing
• numerous studies suggest spinal manipulation alters central processing of mechanical stimuli because pain thresholds increase (measured for example by pressure algometry)
• the effect of manipulation could also be modulated by the neuroendocrine system through release of beta-endorphin, but the release of this substance within the CNS is unknown

4. The effects of spinal manipulation on somatosomatic (muscle) reflexes
• much evidence indicates that spinal manipulation elicits paraspinal muscle reflexes and alters motoneuron excitability
• some studies have found paraspinal EMG activity to increase following manipulation while other studies particularly in symptomatic patients have found EMG activity to decrease following manipulation
• other studies have found spinal manipulation to improve muscle function (e.g., paraspinal strength) either by facilitating or inhibiting neural pathways
• in asymptomatic subjects, spinal manipulation has increased central motor excitability, while also depressing H reflex activity
• recent evidence suggests that sensory input from facet joints stimulated during spinal manipulation might reflexively decrease paraspinal muscle activity
• although Cramer et al. have shown gapping of Z-joints following adjustments, it is not know whether these forces are sufficient to load the facet tissues to elicit reflex muscle responses
• most importantly, because manipulation has been shown to stimulate muscle spindle activity, it could normalize spindle biomechanics and return discharge of these receptors to normal

5. The effects of spinal manipulation on somatovisceral reflexes
• numerous studies provide evidence supporting the link between altered paraspinal sensory input and somatovisceral change
• generally, non-noxious paraspinal sensory input appears to inhibit sympathetic outflow, whereas noxious input is excitatory
• Sato and Swenson studied mechanical stimuli to rat spinous processes and found reflexive inhibition of sympathetic nerve activity (renal and adrenal sympathetic neurons) by way of supraspinal reflexes
• very few studies have been performed to determine the effects of manipulation on the sympathetic nervous system but a recent study by Budgell measured changes in heart rate variability of sham versus upper cervical adjustment – the findings indicated a possible shift in the balance of autonomic control of the heart to the parasympathetic system (as measured by enhanced low frequency components in the power spectrum)
• spinal manipulation has also been shown to prime polymorphonuclear leukocytes (PMN’s) and enhance the respiratory burst, which are markers of immune system activity

The conclusions reached in this paper are that:
a. spinal manipulation evokes neuromuscular changes
b. spinal manipulation impacts proprioceptive primary afferent neurons from paraspinal tissues
c. spinal manipulation can affect pain processing and can affect motor function
d. animal experiments show that sensory input from the paraspinal tissues can reflexively alter the autonomic nervous system
e. multiple mechanisms likely explain manipulation

Also, the current evidence is in favor of the following mechanisms underlying spinal manipulation:
• alteration of Group Ia and Group II mechanoreceptor discharge
• influencing the sensory processing in the spinal cord (e.g., central facilitation)
• influences control of skeletal muscle reflexes (e.g., somatosomatic reflexes)

In summary, this article has presented an intensive amount of information on the neurophysiological mechanisms of spinal manipulation. While the exact mechanisms of how spinal manipulation influences neurophysiology are not clear, the present review points to studies that are beginning to look at these issues. The human nervous system is complex, as is our mechanical structure. It appears that the mechanisms of action of the chiropractic adjustment are also complex and appear to differ based on the symptomatic presentation of the patient, location of the adjustment and the force/speed of the adjustment. Despite all the variables that go into making an adjustment, the results that chiropractors achieve in their offices on a day-to-day basis are consistently positive. Perhaps some of the above mentioned mechanisms explain results that occur in your chiropractic office. As Dr. Pickar mentions, chiropractic is in need of continuing research examining these mechanisms to obtain more support from the broader scientific community. I would add, that the individual chiropractor can contribute to the process by getting involved in research through a chiropractic college or local university, and/or by taking successful cases from their practice and writing them up for publication.

JGC, I hope the above captioned info helps you to be less angry.

Casey, why do you think JGC is angry?

As in all fields, there are a lot of quacks in the chiropractic profession.

If a chiropractor claimed they could cure deafness by manipulating the spine, would they be a quack, or would that be plausible?

Casey, your cut-and-paste contains a bunch of statements about physiologic alterations supposedly associated with manipulation, without demonstrating that those alterations have positive effects.

There is also a bunch of "may", "could" and "evidence suggests" wording which highlights the uncertainty of the basic physiologic alterations ascribed to manipulation.

The paper indicates areas that might be fruitful for research. Right now all it supplies is window dressing for chiros who are uncomfortable with the traditional nonsense about relieving "subluxations".

I am reminded of homeopaths who are convinced their magic water works wonders, and who come up with versions of "quantum theory" and exude scads of sciency verbiage to explain how they are transcending the laws of physics.

In my opinion, chiros should spend less time dreaming up possible scenarios involving complex neurophysiologic mechanisms, and just accept that they practice a version of laying on of hands that appears to help some people with musculoskeletal complaints, just as massage and physical therapy help some people with these problems.

By Dangerous Bacon (not verified) on 21 Aug 2014 #permalink

Casey, I'm not angry--at best, I'm vaguely amused.

I'll note that your citations do not provide evidence that subluxations (as defined by the American Chiropractic association) either exist as defined or share identity with imbrication. They similarly do not constitute evidence that the chiropractic manipulations is effective as a treatment because it addresses, relieves or corrects subluxation.
The list certainly doesn't suggest that chiropractic manipulation is likely to be of greater benefit than competing evidence-based medical approaches, such as standard physiotherapy.

That pesky subluxation thang. Let's discuss it over a beer!
Can we agree that that your best bet is a chiropractor who is adept at spinal adjusting, understands the principles of biomechanics, utilizes standard rehabilitation methods and practices evidence based care is the first best option when your back is jacked? Please say yes.

Or these heretics! Stick to back pain I say.....AWAY Cultists!

UNLEASH THE KRAKEN!

Let’s discuss it over a beer!

... or eight, judging from the Y——be salvo.

"UNLEASH THE KRAKEN!"

Sorry, Casey, I still want to know why you thought JGC was angry? Which words in his response indicated agitation or anger?

Also could you provide a study that compared the relative efficacy between chiropractic treatment and physical therapy that is not published in "Spinal' or any other chiropractic journal.

Thanks a bunch in advance.

By the way, I expect PubMed indexed studies, not video news reports.

I really wish I had more studies to offer Chris but the problem is that it takes money to finance these studies and without the money, we cant get it done as quickly as we'd like. Certainly the Rx companies aren't going to support them. The fact of the matter is that there is some credible studies being published. Organizations like the University of Chicago have piqued curiosity about the relationship between upper cervical subluxation and blood pressure...That's big stuff for chiropractic...... The chief of fertility medicine at Johns-Hopkins agreed there was something there regarding lumbar subluxation and unexplained or idiopathic infertility but needed further investigation and I agree.

....and more chiropractors are embracing evidence based care and that too helps give the profession some credibility.

Regarding JGC , reread his comment about DC's and oxymorons. You can tell by the tenor of his post he's not a happy guy.

But Casey, all the evidence I have seen strongly suggests that subluxations are as imaginary as acupuncture meridians and Reiki healing energy. They don't exist, which is why sensible chiropractors are distancing themselves from the concept.

BTW, I reread JGC's comment, and can detect no indication of irritation at all.

By Krebiozen (not verified) on 26 Aug 2014 #permalink

If anyone needs further evidence that "subluxations" don't exist, I suggest they read this article. Oh, and manipulation of the atlas cervical vertebra for hypertension? Highly implausible, whatever Rush University (no longer associated with the University of Chicago, BTW) may have found: read this.

In my 43 years of practice as a chiropractor, I was never able to determine that manipulation of the spine ever permanently changed the position of the atlas or any other vertebra that is freely movable.

By Krebiozen (not verified) on 26 Aug 2014 #permalink

Of COURSE the Rush study was non-credible...As It lent some credibility to one of the chiropractic theories.
Any non-biased observer would recommend further studies.....that's ok. No worries.

So in the future do not make claims unless you can back up those claims. Since chiropractors and their colleges make those claims, they are the ones that should provide the funding for unbiased studies. They have not done that in any of the decades they have existed.

Chiropractic is not a real medical science, and should not be considered a valid form of treatment.

Casey, now that your back, can you answer my question at #52? I would really value your opinion.

Of COURSE the Rush study was non-credible…As It lent some credibility to one of the chiropractic theories.

I wrote "implausible" not "non-credible", since if vertebral subluxations cannot be demonstrated objectively and replicably, for practical purposes they do not exist, and cannot interfere with "innate intelligence".

Perhaps you could explain how the atlas cervical vertebra could possibly:
a) change position permanently in response to manipulation or
b) have any effect on blood pressure if its position were so moved.

The results of the study are more believably explained by poor blinding or other problems with the study design. I'll happily take back what I've written here if further studies replicate the Rush paper, though I would bet that if they do, the mechanism will be found to have nothing at all to do with 'subluxations'.

It's a little ironic that the university is named after Benjamin Rush, a highly intelligent and skilled doctor who nevertheless went to his grave believing that bloodletting was a useful treatment for practically everything. If such a great ma could be so completely fooled by his own cognitive biases about a treatment modality that actively harmed patients, how much easier is it for chiropractors to fool themselves about their treatment modality, which only occasionally ruptures an artery or causes a stroke?

You may detect some petulance in my tone. This is because I am fed up with people desperately trying to pretend that various forms of magic (acupuncture, homeopathy, Reiki, therapeutic touch as well as chiropractic) are real. They aren't. It's time to let go and move on.

By Krebiozen (not verified) on 26 Aug 2014 #permalink

Rush was a "great man", not a "great ma", as far as I know.

By Krebiozen (not verified) on 26 Aug 2014 #permalink

Well Johnny, of course it would be anecdotal situation if that were the case... As is this story:

Right after school, I first got into practice as an associate in Florida and I was caring for a German woman with a long history of S0 headaches. She explained that her friend in Germany had been suffering from headaches for well over 10 years. She said her eyes had been progressively worsening during this time. Apparently she had been to all the big neurology and optometry centers in Munich and got no answers. The patient told her that Chiropractic had resolved her headache problems and invited her to visit Florida for a holiday.... and a visit with me. The first thing I noticed about her was eyeglasses that literally looked like "the bottom of Coke bottles"

I examined her found that she was VERY SUBLUXATED (Chris) that is, that the C1 and C2 articulations were locked and jammed . I started adjusting her axis on the first visit. After her initial adjustment, she began blinking. I asked if she was ok and in a very thick German accent said she said that she "could see more clearly" Her headaches dramatically improved with several adjustments but then started worsening.
Several visits later she dropped out of care. About a week later she re-entered the office with a new eyeglass prescription that was almost "normal" looking. She said that she visited a local optometrist who said her eyeglass prescription was 3x to strong. She wore those glasses for ten years and could not see without them.

I was weirded out by all of this but my boss who had been practicing for 10 years said that he sees stuff like that all of the time.

Do I tell people tat I will improve their eyesight with chiropractic adjustments to "SUBLUXATED VERTEBRAE" (CHRIS) absolutely not.

And to answer your question, yes if a DC made those kind of claims he/she would have feathers and quack.

Wow, a single anecdote finding something that only chiropractors believe in. Again, it is up to the chiropractors and their colleges to get the studies done showing subluxations actually exist, and that their treatments work for more than lower back pain. And even for the latter that their treatments are more effective than physical therapy.

Well then Krebiozen, I guess that Chiropractic care is the biggest scam ever perpetrated in the history of health care because millions of people get adjusted regularly..

Anecdotal does not cut it. The British Chiropractic Association learned that lesson when they sued Simon Singh because he said they did not have proof. They were told to pony up the proof, and they failed:
http://www.newscientist.com/article/dn18780-simon-singh-wins-libel-batt…

"I guess that Chiropractic care is the biggest scam ever perpetrated in the history of health care because millions of people get adjusted regularly."

No, that honor goes to homeopathy.

Well, Casey, I think I and everyone here would agree with you, that D. D. Palmer, the man that pulled the theory of chiropractic out of thin air, was a quack.

It's good that we can find common ground, don't you think?

It seems plausible that chiropractic care, if done right, could be of benefit for back pain. And (anecdote) a friend got improvement in his back when a chiropractor recommended shoe inserts so he would stand straighter.

Of course, none of that requires believing chiropractors provide any benefit for other conditions.

By Mephistopheles… (not verified) on 26 Aug 2014 #permalink

“I guess that Chiropractic care is the biggest scam ever perpetrated in the history of health care because millions of people get adjusted regularly.”

No, that honor goes to homeopathy.

Not Reiki?

As for chiropractic as a medical treatment, as I recall (one of these days I'll try to find a direct source) back when the AMA thought they had some influence and teeth, they filed a legal action against chiropractors for practicing medicine without a license and lost.
A key point in the chiropractors' defense was that they weren't doctors treating a patient, they were just businessmen providing a service, or something to that effect.
Having snuck through on that basis, they now want to gain legitimacy by claiming without good evidence that their services really do treat a medical condition.

By squirrelelite (not verified) on 26 Aug 2014 #permalink

Johnny, no I don't believe that is quite the case. But it would be quackery to infer that getting adjusted would make your hearing or eyesight better. Man has known for centuries that there exists a connection between spinal dysfunction and general health.

Squirelite, the basis of the case was that the vermin at JAMA were trying to contain and eliminate the chiropractic profession, as they threatened to do to the Osteopaths.
They were violating the Sherman Act.

Man has known for centuries that there exists a connection between spinal dysfunction and general health.

Argument from antiquity is pretty lame. Are you going to start advocating for Humorism too?

In reference to my statement that Palmer Ian a quack, Casey replied

Johnny, no I don’t believe that is quite the case. But it would be quackery to infer that getting adjusted would make your hearing or eyesight better.

This is exactly what Palmer claimed in his own book about the "discovery" of chiropractic - that his first spinal "adjustment" improved the hearing of a janitor, Harvy Lillard. This is the genesis of the whole bunch of crap Palmer made up. This is chiropractor number one and patient number one.

You seem to agree that Palmer's story isn't plausible, and that anybody that makes the claim is a quack, but Palmer isn't a quack.

I have to admit that your mind is a lot more flexible than mine.

...Palmer is a quack...

Stupid autocorrect.

I normally wouldn't bother with the correction, and I would trust y'all to figure it out, but I like typing "Palmer is a quack". It's fun, give it a try.

I didn't say Palmer was a quack because he restored the guys hearing with an adjustment.

I say he is a quack because he espoused that all disease was a manifestation of nerve pressure.

He was on to something important but he extrapolated to the nth degree.

On the other hand , the palmers legacy was that thhe gave people a philosophy of personal health and well being. He and his son taught that humans were engineered to be in a state of good health and that chiropractic adjustments helped move people in that direction. They also warned of what happened when you allowed the medicine man to control your bodies chemistry with drugs. I guess people didn't catch that because tens of thousands of people die each year taking Rx and OTC drugs for problems many of which we chiropractors help everyday.

Also if you want to discuss quackery....chew on this:

http://www.ncbi.nlm.nih.gov/pubmed/16086703

and I bet my back and body are more flexible because I have my subluxations adjusted (Chris) every week!

:o)

But it would be quackery to infer that getting adjusted would make your hearing or eyesight better.

I have heard similar anecdotes about hypnosis improving eyesight. A few seconds Googling finds an anecdote about acupuncture curing, "disciform keratitis (a corneal lesion) that had caused his blue eye to turn white like a marble", and another that claims homeopathy restored several patients' eyesight. Anecdotal evidence isn't highly valued for good reasons.

I guess that Chiropractic care is the biggest scam ever perpetrated in the history of health care because millions of people get adjusted regularly..

One of the biggest scams, yes. Are you really resorting to argumentum ad populum? Billions of people believe that Hindu gods and goddesses literally exist and that statues of Ganesh drink milk, over a billion others that the archangel Gabriel dictated a holy book to an illiterate camel-herder, while a billion more believe that a virgin became pregnant and gave birth to a man who was raised from the dead.

Millions of people can be wrong, and frequently are.

By Krebiozen (not verified) on 26 Aug 2014 #permalink

Casey: "and I bet my back and body are more flexible because I have my subluxations adjusted (Chris) every week!"

You are the very definition of gullible. I hope you are good with that.

Well Chris, lets look at it this way, At 52, I have ruptured every disc from T-12 to L5. A skydiving accident resulted in an L3 discectomy but in spite of of all that destruction I continue to jump out of airplanes, run every morning, chase my 3 kids around (constantly) am a competition level trap shooter and adjust patients 6 days per week. In 21 years I've seen over 6000 patients. I could sit here and tell you stories of scores people recapturing their lost health through chiropractic and stopping unnecessary meds all day and night but you wouldn't give it a thimble full of credit to chiropractic. In your world all chiropractors are liars and all chiropractic patients are delusional. You go right on believing that buddy, it's your world.

Personally, if wasn't for the chiropractors who helped me over the years I know I'd be on SSI.

Best wishes.

Casey,

They also warned of what happened when you allowed the medicine man to control your bodies chemistry with drugs.

Since life expectancy in the US has increased from around 47 years in 1900, just after chiropractic was developed, to 80 years today, and infant mortality has fallen from over 10% to less than 1%, I would say the "medicine man" is doing something right. I very much doubt that chiropractic has anything at all to do with those improvements.

I guess people didn’t catch that because tens of thousands of people die each year taking Rx and OTC drugs for problems many of which we chiropractors help everyday. Also if you want to discuss quackery….chew on this:

NSAIDs do have side effects, death being one of them (my grandmother died from complications following a gut bleed due to NSAIDs). However, they are also extremely effective drugs that immeasurably improve the quality of millions of people's lives, and in the case of aspirin save many lives by preventing cancer and cardiovascular disease. You have to measure the risks against the benefits, and it seems clear to me that in the case of NSAIDs, the benefits are far greater than the risks.

Another family of drugs that kill hundreds of people every year are anticoagulants. However, they save the lives of thousands more than they kill. What chiropractic treatment is there for clotting disorders, I wonder.

The evidence I have seen suggests that chiropracty offers no benefit over conventional care for lower back pain, and no benefits at all for anything else. It does, however, come with risks. In the case of chiropractic, it seems clear that, in the words of Edzard Ernst, "The risks of this treatment by far outweigh its benefit."

What are the many problems that you claim chiropractors help with "every day" and what is the evidence that they really do help? Are they as effective as NSAIDs? What evidence is there that they can help osteoarthritis or rheumatoid arthritis, the conditions that NSAIDs are most used for? If there isn't any compelling evidence, after over a century of millions of people using chiropracty, why not?

By Krebiozen (not verified) on 27 Aug 2014 #permalink

Casey,

In your world all chiropractors are liars and all chiropractic patients are delusional. You go right on believing that buddy, it’s your world.

I don't think you are a liar, any more than I believe Benjamin Rush was a liar. I think you have fallen prey to the same cognitive biases that lead other alternative health practitioners to believe they are helping patients, when controlled clinical trials show they are fooling themselves.

If chiropractic was effective, clinical trials would clearly demonstrate the fact. If subluxations really existed, there would be objective, replicable ways to measure them. The fact that neither of these has come to pass, after over a century, strongly suggests to me that chiropractic is no better than acupuncture, homeopathy and energy healing.

Personally, if wasn’t for the chiropractors who helped me over the years I know I’d be on SSI.

I think you mean if it wasn't for gullible patients paying you for unproven treatments you would be on SSI. You don't know what your health, spinal or otherwise, would have been without chiropractic. The body has remarkable powers of repair, and the only reliable to way to figure out if an intervention is working is a randomized clinical trial.

By Krebiozen (not verified) on 27 Aug 2014 #permalink

Well, as you pointed out there AREN'T enough clinical trials to disprove or prove the results that DC's are getting with their patients.

That being stated, an old DC I once knew said in regard to clinical trials "I'll keep getting the results that I get; let me know when the guys in the lab catch up with me."

Until that time, I personally will keep resolving certain types of migraine, correcting whiplash, preventing unnecessary back and neck surgery, helping certain cases of asthma to breathe easier with less drugs (or none), resolving EVERY case of colic, resolving nearly every case of recurring OM, helping desperate pregnant women with debilitating back pain, resolving most instances' of torticollis, rehabbing shoulders, hips and knees etc. etc, etc.

And when the patients shake my hand or hug me and say "Thank you for your wonderful care." I will refrain from letting them know that Chris and Krebiozen say you didn't get better and that you are delusional.

Best of luck to you fellas. Thanks for the conversation.

PS, if I wait to long between adjustments, I end up with debilitating back spasms.

@Casey - so, adjusting the spine can clear up the lungs?

Who would have thought that one person could be so delusional....

Well then Krebiozen, I guess that Chiropractic care is the biggest scam ever perpetrated in the history of health care because millions of people get adjusted regularly..

Given this speaks to the popularity of chiropractic care and in no way to its efficacy, I'd say "one of the biggest scams in history' would be an accurate characterization.

That being stated, an old DC I once knew said in regard to clinical trials “I’ll keep getting the results that I get; let me know when the guys in the lab catch up with me.”

Except he doesn't know that he's getting those results--i.e.,that anything he's doing is repsonsible for the results observed. He's instead simply ascribing them to chiropractic adjustment on the basis of a post hoc ergo procter hoc logical fallacy.without attempting to rule out other possible and probable causes (self-limiting illness, regression to the mean, placebo effects, observer bias, etc.

I graduated as a DC this past year from Logan University and I'm taking my part III boards tomorrow. I've seen a few different articles like this which cite DD Palmer and subluxation. Since I was studying anyway, I went through my entire Part III review book and the word subluxation was no where to be found. DD Palmer may be considered the founder of chiropractic but, you have to go back around 120 years to be citing whatever his theories were.
Chiro school is a minimum of 5 years or 10 semesters to complete and at our school the only figures I've found are for the completion rate after 15 semesters which is only a little above 80%. It is an extremely challenging program and the first 3 years of the program is 90% medical. It's not just the classes like biochemistry, gross human anatomy, physiology or even pharmacology that are the same but we use a lot of the same books and for some of the classes we have a couple teachers which either co-teach or previously have taught at local medical schools in St Louis.
Books like Guyton's Textbook of Medical Physiology has been used for decades around the world in medical schools. My general practitioner (MD) who graduated from med school back in 1973 recalled using the Guyton books. It takes a year and a half to get through that book. Gross anatomy is a year and that involves complete dissection of the human body, from head to toe. One anatomist who taught that class came from SLU med school and Logan procured another doctor after I took the class from the Albert Einstein School of Medicine.
The doc who taught our embryology class also taught embryology at SLU and said the only difference was that we (chiropractors) went into more detail.
Other classes I took like EENT, pharmacology and minor surgery were all taught by MD's.
OB/GYN was probably one of my favorite classes, largely in part due to the teacher who worked at a nearby hospital.
I don't know if it's odd or ironic but most of the people I've encountered who have the biggest problem with chiropractic are the ones who don't know much, if anything, about it. I've never had any problems with MD's and there's a couple I see socially on a weekly basis. (pediatrician & GP) I did talk with a plastic surgeon a few times and we kind of got a kick out of the fact that he said he's never actually seen a Cooper's ligament - sort of funny because he did breast augmentation and the Cooper's ligament is a suspensory ligament for the breast.
While I was still in school I got 5 page report from a cardiologist for a patient who had hypervagal tone. Basically, a parasympathetic nerve that innervates the heart was on overdrive and the patients heart rate was unable to maintain a rate above 40 bpm. I remembered the 2nd semester of gross anatomy, in the first week we cut off the cap to the skull, removed the brain then split the face down the center. After that I was able to see ganglions behind the cervical vertebrae. Plus, the removed brain was used for neuroanatomy so I had some familiarity with the vagus nerve (CN X) It took some time but eventually this lady went to a chiro and had a cervical adjustment and her pulse went up to 72 bpm and stayed there for about 1/2 hour. With subsequent treatments her pulse was able to maintain that higher pulse rate for days then weeks. Pretty good results for someone who got no results from years with the traditional medical route. No research and it was just an educated guess on my part but, that patient got their life back (it's hard to live a normal life when your pulse doesn't go past 40, she wasn't a marathon runner or anything so it was abnormal for her).
Actually, I had a TA for that gross anatomy class that went on to help discover a new body part after he graduated which is now called the cervical myodural bridge. His name is Frank Scali for anyone that is interested.
One of the first outpatient patients i had was a lady in her 80's with stage 4 pancreatic cancer. For her, it was a quality of life issue. She couldn't hold her head up to play bridge with her friends due to pain in her neck. We had that fixed in about two weeks.
After 2 years as an intern there was only one patient I was unable to help - elderly pt w/ lumbar compression fx that i wasn't allowed to adjust and there's only so much you can do with cold LASER & Graston.

It looks like another poster named Casey already mentioned the pain gate theory in his post on Aug 21 and that's a pretty well established and accepted theory, at least by every doctor I've ever talked with. In school we learn pretty quickly that proprioception inhibits nociception which is another way of referring the the pain gate theory. In layman terms I guess you could say movement inhibits pain. There's more proprioceptive fibers along the spinal cord than anywhere else on the body and the most per square inch are found along the cervical spine. In a similar way traps and scalene muscles can get tight in the neck, we can have tight rotatores in the spine. A lot of times it's about movement and without movement you lose that proprioceptive input to the brain.
That rotatore muscle reminded me of a medical mnemonic contest I won (got a brand new Greys Anatomy book from it) :)
Actually, even better than that was a video I put up on YouTube on how to draw the brachial plexus in 10 seconds :)
I've heard from a few schools that use the video in their curriculum and I was contacted by an anesthesiologist who works at a hospital in Germany who asked for a clip of the video so they could use it in a presentation for their fellow doctors.

If nothing else, I would hope my little study break blurb maybe at least sets chiropractors apart from other things like neuropathy or homeopathy. I dont' know anything about those things but for some reason chiro's seem to get lumped together with them. I'm pretty certain neither of those professions require anywhere close to the nearly 5,000 hours needed to obtain a DC degree and I'm also pretty certain neither requires $200,000+ in additional student debt loans.

I do agree we (chiro's) could use more research. I personally, would love to more fully research hypervagal tone patients - they aren't exactly a dime a dozen but I'd really like to see if those previous results can be duplicated or find out which patients are good candidates.
We do have a Dr at school by the name of Norman Kettner who does quite a bit of research with Massachusetts General Hospital which is the teaching hospital of Harvard Medical School. I remember him showing us fMRI images of the brain as it related to CTS (carpal tunnel syndrome)

MDs have their boards administered by the USMLE and they're called Step 1, 2, 3, 4 while Chiro's have boards administered by the NBCE and are called Parts 1, 2, 3, 4. There's kind of a transition from basic sciences in the first parts to more clinical knowledge in 2 & 3. For MDs Step 4 is for their specialty. I doubt the NBCE will ever go away because there's money involved plus, there are some differences which have to be addressed but, I wouldn't mind overlapping and to have been given a chance to take the Step 1 exam from the USMLE which pertains to all the basic sciences.
Right before I got into the DC program a friend from work asked if it was a 6 month program. Not quite, it's 9-10 years of higher education after high school along w/ the 2 years of clinical work. Course loads range from 30-36 hours a semester. Just a tad more than 6 months ;)

By Scott Dukowitz, DC (not verified) on 12 Sep 2014 #permalink