Crticism of Chiropractic

[JJM]

Two new articles have just been published in the journal Chiropractic & Osteopathy which are relevant to this thread: ...

Commentary on the United Kingdom evidence report about the effectiveness of manual therapies
http://www.chiroandosteo.com/content/18/1/4


ETA. Page 77 of the pdf of the report says that it was funded by the GCC:
http://www.chiroandosteo.com/content/pdf/1746-1340-18-3.pdf

The first thing I noticed was the standard, chiro "bait and switch" ploy. That is probably why the report is titled "Effectiveness of manual therapies" [italics added] rather than referring to "chiro therapies." You might think this is an evaluation of chiro practices; but it includes manipulation performed by PTs, masseurs, and reflexologists (and, probably, doctors).

The problem is that chiros usually claim superiority and different techniques from those employed by PTs and doctors. Moreover, it illustrates the chiro notion that they can substitute for PTs; for which they lack proper training. When chiros are not detecting and adjusting "subluxations" they are trying to emulate other fields. Note that they often re-name and re-define "subluxation"; but it is all the same.

 

[Mojo]

The first thing I noticed was the standard, chiro "bait and switch" ploy. That is probably why the report is titled "Effectiveness of manual therapies" [italics added] rather than referring to "chiro therapies." You might think this is an evaluation of chiro practices; but it includes manipulation performed by PTs, masseurs, and reflexologists (and, probably, doctors).

It doesn't always work:

In relation to the chiropractic treatment of IBS we noted the evidence provided included a 2007 randomised controlled pilot study relating to osteopathy and another randomised controlled study where results involving the treatment of IBS with osteopathy were described as "promising"; we noted, however, that those studies referred to osteopathy, not chiropractic.

 

[Blue Wode]

'Effectiveness of manual therapies: the UK evidence report'

IMO, the General Chiropractic Council's (GCC) newly published report http://www.chiroandosteo.com/content/pdf/1746-1340-18-3.pdf doesn’t seem to have a great deal to do with ‘chiropractic’.

For example, the Background section on page 2 says that the report is “a summary of scientific evidence regarding the effectiveness of manual treatment…” The chiropractic ‘bait and switch’ http://www.dcscience.net/?p=1516 doesn’t seem to be addressed, nor do valid concerns about the apparent high frequency of under-reporting of serious complications http://jrsm.rsmjournals.com/cgi/content/full/100/7/330

Page 15 is particularly interesting. It includes a look at the Hancock et al study (published in the Lancet in 2007), and states that: “Hancock et al found spinal mobilization in addition to medical care was no more effective than medical care alone at reducing the number of days until full recovery for acute LBP. This study had a low risk of bias.” Since the GCC report looks at the scientific evidence for manual therapy, it makes one wonder why, when the Lancet study was originally published, the GCC was up in arms about it, protesting that it didn’t address the effectiveness of ‘chiropractic’:
http://www.gcc-uk.org/files/page_file/LANCET Australian study statement9Nov07.pdf

Indeed, both the GCC and the British Chiropractic Association (BCA) wrote to the Press Complaints Commission (PCC) in an attempt to elicit a public apology from three newspapers for saying that the study showed that chiropractic was ‘a waste of money’. See here
http://www.gcc-uk.org/files/page_file/Letter PCC 20Nov07 (Website).pdf

You can read about the BCA’s complaint, and the outcomes of both complaints, on pages 6 and 7 of the GCC’s March 2008 newsletter here:
http://www.gcc-uk.org/files/link_file/WEBSITE_GCCNews23.pdf

Now here's a summary of the Lancet study, with a link to its full text at the end of the quote…

Patients with acute low back pain receiving recommended first-line care do not recover more quickly with the addition of diclofenac or spinal manipulative therapy.

-snip-

The spinal manipulative therapy given in this trial included a range of low-velocity mobilisation and high-velocity manipulation techniques done by physiotherapists with postgraduate training in manipulative therapy. A systematic review of spinal manipulation concluded that there is no evidence that high-velocity spinal mobilisation is more effective than low-velocity spinal manipulation, or that the profession of the manipulator affects the effectiveness of treatment.

Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial Hancock MJ et al; Lancet:370:1638-43 (2007)
http://www.acatoday.org/pdf/Lancet_Acute_Back_Pain_Nov.07.pdf

…and this is what the Consumer Health Digest newsletter, published by the National Council Against Health Fraud, had to say about the study:

Doubt cast on value of spinal manipulation and NSAIDS for acute back pain.

Australian researchers found that neither spinal manipulation or the drug diclofenac hastened recovery of acute low-back pain patients who had been properly counseled by their primary physician and prescribed paracetamol for pain relief. The study involved 240 patients who received either (a) diclofenac plus spinal manipulation, (b) diclofenac and sham spinal manipulation, (c) spinal manipulation and a placebo pill, or (d) sham manipulation plus a placebo pill. About half recovered within two weeks and nearly all recovered within three months.

[Hancock MJ and others. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomized controlled trial. Lancet 370:1638-1643, 2007]
http://www.ncbi.nlm.nih.gov/sites/e...med.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID). Paracetamol is a pain-reliever marketed in the United States as acetominophen or Tylenol. An accompanying editorial noted:

**Systematic reviews had concluded that NSAIDS and spinal manipulation were more effective than placebos. However, the patients in the reviewed studies did not have optimum first-line care, and the apparent benefit was not large.

**Advice to remain active and prescription of paracetamol will be sufficient for most patients with acute low back pain.
[Koes BW. Evidence-based management of acute low back pain. Lancet 370:1595-1596, 2007]


http://www.ncahf.net/digest07/07-47.html

Page 73 of the GCC’s report is also interesting. It cites a systematic review of adverse events associated with paediatric spinal manipulation. However, that review failed to include the harms listed at the end of this summary:

Adverse events associated with chiropractic care of children. A systematic review has identified 34 cases in which spinal manipulation in children was associated with adverse events. [Vohra S. Adverse events associated with pediatric spinal manipulation: A systematic review. Pediatrics 119(1) January 2007, pp. e275-e283]

Fourteen of the cases involved "direct" events in which the treatment was followed by death, serious injury, symptoms requiring medical attention, or soreness. The rest involved "indirect" events in which appropriate diagnosis was delayed and/or inappropriate manipulation was done for serious medical conditions such as meningitis.

The reviewers commented that despite the fact that spinal manipulation is widely used on children, pediatric safety data are virtually nonexistent.

This type of review cannot determine how often adverse events occur. That would require a prospective study with active surveillance. The article did not consider harmful aspects of chiropractic care that are far more common than the reported events. These include (a) decreased use of immunization due to misinformation given to parents, (b) psychologic harm related to unnecessary treatment, (c) psychologic harm caused by exposure to false chiropractic beliefs about "subluxations," and (d) financial harm due to unnecessary treatment.

http://www.ncahf.org/digest07/07-14.html

The first harm (a) is a particular concern when you consider that only one out of 16 UK chiropractors who responded to this survey advised in favour of the MMR vaccination:
http://www.dcscience.net/schmidt-ernst-vaccine-2003.pdf

For those interested, there’s more discussion on the GCC report at Chirotalk http://chirotalk.proboards.com/index.cgi?action=display&board=evidence&thread=4685&page=1

and at Zeno’s blog http://www.zenosblog.com/2010/02/the-gccs-plethora/

Also, watch out for a Guardian article on it on Monday by Martin Robbins http://layscience.net/node/956


[NB. The information above also has some bearing on the GCC’s newly published revalidation document. You can read a scanned copy here: http://www.gcc-uk.org/files/page_file/C-170210-04a.pdf ]

 

[Mojo]

Since the GCC report looks at the scientific evidence for manual therapy, it makes one wonder why, when the Lancet study was originally published, the GCC was up in arms about it, protesting that it didn’t address the effectiveness of ‘chiropractic’:

Did they still have promotion of chiropractic as part of their remit when they made the complaint?

 

[Blue Wode]

Did they still have promotion of chiropractic as part of their remit when they made the complaint?

Yes, but remember that the Lancet study said this:

The spinal manipulative therapy given in this trial included a range of low-velocity mobilisation and high-velocity manipulation techniques done by physiotherapists with postgraduate training in manipulative therapy. A systematic review of spinal manipulation concluded that there is no evidence that high-velocity spinal mobilisation is more effective than low-velocity spinal manipulation, or that the profession of the manipulator affects the effectiveness of treatment.

Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial Hancock MJ et al; Lancet:370:1638-43 (2007)

http://www.acatoday.org/pdf/Lancet_Acute_Back_Pain_Nov.07.pdf

 

[Soapy Sam]

"The spinal manipulative therapy given in this trial included a range of low-velocity mobilisation and high-velocity manipulation techniques done by physiotherapists with postgraduate training in manipulative therapy. A systematic review of spinal manipulation concluded that there is no evidence that high-velocity spinal mobilisation is more effective than low-velocity spinal manipulation, or that the profession of the manipulator affects the effectiveness of treatment"

"Included" or the much misused "comprised"? If the trial therapy was only given by one profession, it's invalid to conclude that it makes no difference what profession applied it. I'm prepared to bet , were the same techniques of HV spine snapping applied by (say) marine commandos, the results might be rather different.
Seriously I don't follow the argument there, unless the second sentence "A systematic review..." bears no relation to the events decribed in the first sentence.
It's a bit opaque.

 

[borealys]

Don't be surprised if chiropractors claim in their defence that the authors only went looking for one type of subluxation...

Well now, I only skimmed that list, but one item on it jumped out at me.

They're seriously claiming that dysarthria is a form of "sacroiliac subluxation"?

Dysarthria is a motor speech disorder. Actually, it's a family of motor speech disorders, which can have numerous causes, absolutely none of which have anything to do with the sacroiliac joint. It's a head and neck disorder, for crying out loud! Couldn't they at least have blamed it on a subluxation a little higher up in the spinal column?

 

[Blue Wode]

"Included" or the much misused "comprised"? If the trial therapy was only given by one profession, it's invalid to conclude that it makes no difference what profession applied it. I'm prepared to bet , were the same techniques of HV spine snapping applied by (say) marine commandos, the results might be rather different.

Seriously I don't follow the argument there, unless the second sentence "A systematic review..." bears no relation to the events decribed in the first sentence.

It's a bit opaque.

Soapy, the problem centres on a lack of standardisation which allows confusion to prevail to chiropractors’ advantage. Spinal manipulation is not *real* chiropractic, but chiropractors will shout from the rooftops when a positive study for spinal manipulation is published. However, when a negative study for spinal manipulation appears, they are usually quick to condemn it as not being representative of ‘chiropractic’. Veteran chiropractor, Samuel Homola describes the problem in this article:
http://jmmtonline.com/documents/HomolaV14N2E.pdf

Snippet –

The reasons for use of manipulation/mobilization by an evidence-based manual therapist are not the same as the reason for use of adjustment/manipulation by most chiropractors. Only evidence-based chiropractors, who have renounced subluxation dogma, can be part of a team that would research the effects of manipulation without bias…

As I warned in Bonesetting, Chiropractic and Cultism, if chiropractic fails to specialize in an appropriate manner, there may be no justification for the existence of chiropractic when there are an adequate number of physical therapists providing manipulative therapy. Many physical therapists are now using manipulation/mobilization techniques. Of the 209 physical therapy programs in the US, 111 now offer Doctor of Physical Therapy (DPT) degrees. Some of these programs have been opened to qualified chiropractors.

According to the American Physical Therapy Association, “…Physical therapy, by 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists. Consumers will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services. Physical therapists will be practitioners of choice in patients’/clients’ health networks and will hold all privileges of autonomous practice…”

It matters little who does spinal manipulative therapy as long as it is appropriate and evidence-based. There can be cooperation between chiropractors and other practitioners of manual therapy if everyone works under the common denominator of science and if treatment methods are standardized.

It’s important to note that although the GCC’s report is on the effectiveness of *manual therapies*, it fails to make an explicit distinction between the type of manual therapy offered by chiropractors (with its pseudoscientific underpinnings) and that offered by other manual therapists who are much less mired in quackery (if at all).

 

[fls]

Seriously I don't follow the argument there, unless the second sentence "A systematic review..." bears no relation to the events decribed in the first sentence.

This.

It's a statement made in reference to a different study (i.e. a systematic review).

Linda

 

[DrFrankmeister]

JJM

I am responding to your comments drawn from Dr. Joe Keating's 2001 article:

1. A prophylactic or health-maintaining effect of manipulation has not been experimentally demonstrated to date.

I'd like to draw your attention to this article, published the year before Joe wrote his comments:
Maintenance Care: Health Promotion Services Administered to US Chiropractic Patients Aged 65 and Older, Part II
J Manipulative Physiol Ther 2000 (Jan); 23 (1): 10–19
Available in the LINKS Section of Chirrg

The important points from this article are:

A: The cost of health care for patients receiving MC in this study was far less than that for patients of similar age in the general population, despite the doubling of physician visits (chiropractic visits vs. medical visits). The greatest difference in health care costs with patients receiving maintenance care was in the areas of nursing care and, especially, hospital care. This reduced need for hospital and nursing home services has recently been corroborated by the research of Coulter et al. [Review the Coulter et al statistics]

B: Chiropractic patients receiving maintenance care, when compared with US citizens of the same age, spent only 31% of the national average for health care services and reported a 50% reduction in medical provider visits.

C: The health habits of patients receiving maintenance care were better overall than the general population, including decreased use of cigarettes and non-prescription drugs. Furthermore, 95.8% believed the care to be either “considerably” or “extremely” valuable.

2. The value of “regular check-ups” by chiropractors is also unknown.

The last article discusses "maintenance" (aka wellness, aka asymptomatic) care, and does find significant differences between chiropractic patients and their matched peers.

3. The disease-producing and pathology-producing effects of subluxation-complex, if any, have not been demonstrated experimentally.

I presume that you are not a doctor, so I'll keep these comments simple. The classic explanation of the subluxation complex is:

Kinesiopathology, or loss of alignment and/or motion irregularities (the 739 and 839 and the 737 ICD-9-CM codes), Neuropathology, which occur due to compressed or facilitated nerve tissue (the 722-24, 353 ICD-9-CM codes), Myopathology, or soft tissue changes due to muscle and ligament damage, involving spasm, muscle weakness/atrophy and development of myofascial disorders (the 728-29, 847 ICD-9-CM codes), Histopathology, or the pre and post inflammatory changes that result as sequela to the primary soft tissue damage, progressing from edema to congestion of tissue to eventual remodeling (the 719, 782 ICD-9-CM codes), and Pathophysiology, or the degeneration and/or fibrous tissue formation which are the inevitable outcomes of poor management of the other components (the 732-39, 723 ICD-9-CM codes).

There is significant (though unrelated) studies that demonstrate each of these processes. They are too extensive to list here, but much of this material is archived on the Chirrg website in the Research and LINKS Sections:

The LINKS and Research Section are both available at Chirrg


4. Adjusting has not been experimentally demonstrated to alter vertebral alignment or “nerve pressure”; such effects, if possible, have not been shown to influence neuritis.

You seem to be relying on relatively ancient chiropractic theories for your critique, because of the use of the term "nerve pressure". Chiropractic has been shown to reduce radiculopathy, and radiculopathy has been shown to evolve from irritated facet joints. Please refer to the Radiculopathy Page.
Available in the LINKS Section of Chirrg

5. Currently available experimental data do not justify any claims for the value of chiropractic care in populations of children.

Wrong! There has been negative results in trials on colic and asthma, but the results for low back pain, thoracic spine pain, neck pain, and headaches has been positive. I'd like to quote a passage from a newly published article:

"numerous claims made by chiropractors over the years, based on their clinical observations, have not stood up to critical analysis and the results of studies often suggest that these observations are due to placebo or the natural course of the disorder rather than the actual treatment. This has been true of a vast number of medical treatments. A recent Special Issue of The Spine Journal on Evidence Informed Management of Chronic Low Back Pain listed over 200 treatments currently being offered patients with low back pain, most of which are offered by medical physicians [3]. Of these, less than 10% have a reasonable body of support based on high quality clinical trials. The greatest research support was for therapies commonly used by chiropractors including the manual therapies, education and exercise."

"Commentary on the United Kingdom evidence report about the effectiveness of manual therapies"
Chiropractic & Osteopathy 2010 (Feb 25)


The conclusions from this extensive review are:

"Spinal manipulation/mobilization is effective in adults for: acute,
subacute, and chronic low back pain; migraine and cervicogenic headache;
cervicogenic dizziness; manipulation/mobilization is effective for several
extremity joint conditions; and thoracic manipulation/mobilization is
effective for acute/subacute neck pain. The evidence is inconclusive for
cervical manipulation/mobilization alone for neck pain of any duration,
and for manipulation/mobilization for mid back pain, sciatica,
tension-type headache, coccydynia, temporomandibular joint disorders,
fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal
manipulation is not effective for asthma and dysmenorrhea when compared to
sham manipulation, or for Stage 1 hypertension when added to an
antihypertensive diet. In children, the evidence is inconclusive regarding
the effectiveness for otitis media and enuresis, and it is not effective
for infantile colic and asthma when compared to sham manipulation. Massage
is effective in adults for chronic low back pain and chronic neck pain.
The evidence is inconclusive for knee osteoarthritis, fibromyalgia,
myofascial pain syndrome, migraine headache, and premenstrual syndrome. In
children, the evidence is inconclusive for asthma and infantile colic. "

"Effectiveness of manual therapies: the UK evidence report"
Chiropractic & Osteopathy 2010 (Feb 25)


This article, in particular, addresses the difference between clinical experience, opinion, and verifiable, reproducible, and measurable results in a clinical trial.

I understand that you (like myself) have opinions, but this study helps us to distinguish between our perhaps-biased opinions and the realities of scientific conclusions.

I certainly have issues with the asthma trials published in the past, primarily because they ignore the fact that both the placebo and active treatment groups improved in symptoms compared with controls. The conclusion was wrong, because it was based on the premise that the "placebo" had no effect.

Today researchers are becoming more aware of the "non-specific" effects of care generated by the "laying on of hands" and the sense of hope generated by the distinctly different way in which a chiropractor interacts with a patient. I have collected a variety of articles on this topic:
The Problem with Placebos/Shams
In Chirrg's Research Section

Our website (Chirrg) is devoted to collecting articles about chiropractic, from case studies through randomized trials. Over time, we will all better understand why chiropractic is so loved by clinicians and patients alike. Meanwhile, I see patients improve every day in my office when other forms of medical treatment had left them suffering. It is that joy I experience every day that helps he maintain my perspective when I read the negative comments posted on the anti-quack and science-buff nay-sayer websites.

I hope you will find these articles informative.

Warmly,

Frank M. Painter, D.C.
[email protected]

P.S. This website prevented me from posting URLs to the pages I quoted above, but each section of the Chirrg website have their own Search Tools, so they can easily be found, if you are interested.

 

[fls]

JJM

I am responding to your comments drawn from Dr. Joe Keating's 2001 article:

1. A prophylactic or health-maintaining effect of manipulation has not been experimentally demonstrated to date.

I'd like to draw your attention to this article, published the year before Joe wrote his comments:
Maintenance Care: Health Promotion Services Administered to US Chiropractic Patients Aged 65 and Older, Part II
J Manipulative Physiol Ther 2000 (Jan); 23 (1): 10–19
Available in the LINKS Section of Chirrg

The important points from this article are:

A: The cost of health care for patients receiving MC in this study was far less than that for patients of similar age in the general population, despite the doubling of physician visits (chiropractic visits vs. medical visits). The greatest difference in health care costs with patients receiving maintenance care was in the areas of nursing care and, especially, hospital care. This reduced need for hospital and nursing home services has recently been corroborated by the research of Coulter et al. [Review the Coulter et al statistics]

B: Chiropractic patients receiving maintenance care, when compared with US citizens of the same age, spent only 31% of the national average for health care services and reported a 50% reduction in medical provider visits.

C: The health habits of patients receiving maintenance care were better overall than the general population, including decreased use of cigarettes and non-prescription drugs. Furthermore, 95.8% believed the care to be either “considerably” or “extremely” valuable.

2. The value of “regular check-ups” by chiropractors is also unknown.

The last article discusses "maintenance" (aka wellness, aka asymptomatic) care, and does find significant differences between chiropractic patients and their matched peers.

The only conclusion which can be drawn from this study is that people who choose to visit a chiropractor tend to be quite different from the general population. It should be quite obvious that this group would tend not to include those who already are undergoing treatment and care related to medical conditions. If you exclude from your sample those people most likely to require hospital care, of course you will see a below average utilization of that care, even if you do nothing useful for them over the course of the next few years.

Also, you posted this study in response to the comment that "a prophylactic or health-maintaining effect of manipulation has not been experimentally demonstrated to date". This was an observational study, not an experimental study, so I have to wonder why you bring up something which cannot be considered a valid response.

3. The disease-producing and pathology-producing effects of subluxation-complex, if any, have not been demonstrated experimentally.

I presume that you are not a doctor, so I'll keep these comments simple. The classic explanation of the subluxation complex is:

Kinesiopathology, or loss of alignment and/or motion irregularities (the 739 and 839 and the 737 ICD-9-CM codes), Neuropathology, which occur due to compressed or facilitated nerve tissue (the 722-24, 353 ICD-9-CM codes), Myopathology, or soft tissue changes due to muscle and ligament damage, involving spasm, muscle weakness/atrophy and development of myofascial disorders (the 728-29, 847 ICD-9-CM codes), Histopathology, or the pre and post inflammatory changes that result as sequela to the primary soft tissue damage, progressing from edema to congestion of tissue to eventual remodeling (the 719, 782 ICD-9-CM codes), and Pathophysiology, or the degeneration and/or fibrous tissue formation which are the inevitable outcomes of poor management of the other components (the 732-39, 723 ICD-9-CM codes).

There is significant (though unrelated) studies that demonstrate each of these processes. They are too extensive to list here, but much of this material is archived on the Chirrg website in the Research and LINKS Sections:

The LINKS and Research Section are both available at Chirrg

I am a physician. You have simply listed established medical conditions without establishing any connection between them and something you call a 'subluxation complex'.

4. Adjusting has not been experimentally demonstrated to alter vertebral alignment or “nerve pressure”; such effects, if possible, have not been shown to influence neuritis.

You seem to be relying on relatively ancient chiropractic theories for your critique, because of the use of the term "nerve pressure". Chiropractic has been shown to reduce radiculopathy, and radiculopathy has been shown to evolve from irritated facet joints. Please refer to the Radiculopathy Page.
Available in the LINKS Section of Chirrg

Again, you reference observational, rather than experimental research. All this demonstrates is that many people with radiculopathy show improvement in their symptoms with conservative treatment - something we already knew. None of these studies allow you to conclude that chiropractic in general or treatment directed at something you call subluxation complexes, alters that outcome.

5. Currently available experimental data do not justify any claims for the value of chiropractic care in populations of children.

Wrong! There has been negative results in trials on colic and asthma, but the results for low back pain, thoracic spine pain, neck pain, and headaches has been positive. I'd like to quote a passage from a newly published article:

"numerous claims made by chiropractors over the years, based on their clinical observations, have not stood up to critical analysis and the results of studies often suggest that these observations are due to placebo or the natural course of the disorder rather than the actual treatment. This has been true of a vast number of medical treatments. A recent Special Issue of The Spine Journal on Evidence Informed Management of Chronic Low Back Pain listed over 200 treatments currently being offered patients with low back pain, most of which are offered by medical physicians [3]. Of these, less than 10% have a reasonable body of support based on high quality clinical trials. The greatest research support was for therapies commonly used by chiropractors including the manual therapies, education and exercise."

"Commentary on the United Kingdom evidence report about the effectiveness of manual therapies"
Chiropractic & Osteopathy 2010 (Feb 25)


The conclusions from this extensive review are:

"Spinal manipulation/mobilization is effective in adults for: acute,
subacute, and chronic low back pain; migraine and cervicogenic headache;
cervicogenic dizziness; manipulation/mobilization is effective for several
extremity joint conditions; and thoracic manipulation/mobilization is
effective for acute/subacute neck pain. The evidence is inconclusive for
cervical manipulation/mobilization alone for neck pain of any duration,
and for manipulation/mobilization for mid back pain, sciatica,
tension-type headache, coccydynia, temporomandibular joint disorders,
fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal
manipulation is not effective for asthma and dysmenorrhea when compared to
sham manipulation, or for Stage 1 hypertension when added to an
antihypertensive diet. In children, the evidence is inconclusive regarding
the effectiveness for otitis media and enuresis, and it is not effective
for infantile colic and asthma when compared to sham manipulation. Massage
is effective in adults for chronic low back pain and chronic neck pain.
The evidence is inconclusive for knee osteoarthritis, fibromyalgia,
myofascial pain syndrome, migraine headache, and premenstrual syndrome. In
children, the evidence is inconclusive for asthma and infantile colic. "

"Effectiveness of manual therapies: the UK evidence report"
Chiropractic & Osteopathy 2010 (Feb 25)

This evidence report does not support your assertion that the use of chiropractic in children is evidence-based. For one thing, that report was directed at manual therapies, not solely chiropractic therapies, so the included therapies are not directed at the idea of 'subluxation complexes'. And, more importantly, there were no uses in children that were supported by evidence.

This article, in particular, addresses the difference between clinical experience, opinion, and verifiable, reproducible, and measurable results in a clinical trial.

I understand that you (like myself) have opinions, but this study helps us to distinguish between our perhaps-biased opinions and the realities of scientific conclusions.

I certainly have issues with the asthma trials published in the past, primarily because they ignore the fact that both the placebo and active treatment groups improved in symptoms compared with controls. The conclusion was wrong, because it was based on the premise that the "placebo" had no effect.

Today researchers are becoming more aware of the "non-specific" effects of care generated by the "laying on of hands" and the sense of hope generated by the distinctly different way in which a chiropractor interacts with a patient. I have collected a variety of articles on this topic:
The Problem with Placebos/Shams
In Chirrg's Research Section

The effects attributed to placebo are fairly mundane. Most of the effects simply represent biases inherent in choosing a study population, such as regression to the mean, which means that those effects are present even if you do nothing. The remainder of the effects represent small, clinically insignificant changes in reports of subjective perceptions, with changes in pain the best established alteration. Even then, the average improvement tends to be below the threshold which is considered by patients to be clinically relevant.

http://content.nejm.org/cgi/content/short/344/21/1594

I appreciate the idea of taking an evidence-based, rather than opinion-based approach to chiropractic, but then I have to wonder why you failed to use an evidence-based approach when addressing the criticisms.

ETA: Just to be clear, I did go to chiro.org and look at the articles you referred to. Your directions were clear and the articles were easy to find. The JREF forum blocks links until you have 15 posts in order to block spammers from flooding the forum with links.

Linda

 

[JJM]

There is little left for me to add.

JJM

I am responding to your comments drawn from Dr. Joe Keating's 2001 article: ...

4. Adjusting has not been experimentally demonstrated to alter vertebral alignment or “nerve pressure”; such effects, if possible, have not been shown to influence neuritis.

You seem to be relying on relatively ancient chiropractic theories for your critique, because of the use of the term "nerve pressure". ...

A minor point: "nerve pressure" was Keating's term, not mine.

... "Commentary on the United Kingdom evidence report about the effectiveness of manual therapies"

http://www.chiroandosteo.com/content/18/1/3 [JJM]
"Effectiveness of manual therapies: the UK evidence report"
Chiropractic & Osteopathy 2010 (Feb 25) ...

That review is not about chiropractic, and it is difficult to sort through all the original sources. However, it is clear that what counts for favorable evidence does not pass muster in scientific circles.

For example, they claim the evidence for chiro treatment of enuresis (bed wetting) is inconclusive but favorable. That is their summary of two papers: *[FONT=&quot]Reed WR, Beavers S, Reddy SK, Kern G: [/FONT][FONT=&quot]Chiropractic management of[/FONT]
[FONT=&quot]primary nocturnal enuresis. [/FONT][FONT=&quot]J Manipulative Physiol Ther [/FONT][FONT=&quot]1994, [/FONT][FONT=&quot]17: [/FONT][FONT=&quot]596-600.[/FONT]
[FONT=&quot]
[/FONT]
[FONT=&quot]Leboeuf C, Brown P, Herman A, Leembruggen K, Walton D, Crisp TC:[/FONT]
[FONT=&quot]Chiropractic care of children with nocturnal enuresis: a prospective[/FONT]
[FONT=&quot]outcome study. [/FONT][FONT=&quot]J Manipulative Physiol Ther [/FONT][FONT=&quot]1991, [/FONT][FONT=&quot]14: [/FONT][FONT=&quot]110-115.[/FONT]

The latter (1991) study was un-blinded and uncontrolled, and concluded that chiro did not work. The former (1994) was tiny, and the treatment and control groups were not closely matched; and the treatment and control groups were not statistically different after treatment. Maybe you can explain how this is interpreted as "inconclusive" and "favorable."

The review is rife with such over-enthusiastic interpretations of literature, and non-chiropractic references. Aside from low-back pain, there is little support for chiropractic.

 

[Rolfe]

Rolfe.

 

[zeno2712]

I think I'll join you, Rolfe.

 

[BenBurch]

want some garlic butter for that popcorn?

 

[Blue Wode]

...they claim the evidence for chiro treatment of enuresis (bed wetting) is inconclusive but favorable. That is their summary of two papers: *[FONT=&quot]Reed WR, Beavers S, Reddy SK, Kern G: [/FONT][FONT=&quot]Chiropractic management of[/FONT]
[FONT=&quot]primary nocturnal enuresis. [/FONT][FONT=&quot]J Manipulative Physiol Ther [/FONT][FONT=&quot]1994, [/FONT][FONT=&quot]17: [/FONT][FONT=&quot]596-600.[/FONT]
[FONT=&quot]
[/FONT]
[FONT=&quot]Leboeuf C, Brown P, Herman A, Leembruggen K, Walton D, Crisp TC:[/FONT]
[FONT=&quot]Chiropractic care of children with nocturnal enuresis: a prospective[/FONT]
[FONT=&quot]outcome study. [/FONT][FONT=&quot]J Manipulative Physiol Ther [/FONT][FONT=&quot]1991, [/FONT][FONT=&quot]14: [/FONT][FONT=&quot]110-115.[/FONT]

The latter (1991) study was un-blinded and uncontrolled, and concluded that chiro did not work. The former (1994) was tiny, and the treatment and control groups were not closely matched; and the treatment and control groups were not statistically different after treatment. Maybe you can explain how this is interpreted as "inconclusive" and "favorable."

The review is rife with such over-enthusiastic interpretations of literature, and non-chiropractic references. Aside from low-back pain, there is little support for chiropractic.

Indeed. One has to wonder about the impartiality of the review. It’s worth noting that its lead author, Gert Bronfort, serves on NCCAM's National Advisory Council for Complementary and Alternative Medicine (NACCAM): http://nccam.nih.gov/about/naccam/roster.htm

For those not up to speed with NCCAM, this is what the Skeptics Dictionary recently had to say about it:

“We've been waiting for 16 years for the NIH to announce some major breakthrough in health care that has emerged from NCCAM. Unfortunately, most of the "alternative" research is driven by faith, hope, and ideology rather than science. As Dr. Wallace Sampson noted: the NCCAM "is the only entity in the NIH [among some 27 institutes and centers] devoted to an ideological approach to health”….. $2.5 billion spent, no alternative cures found…”

http://www.skepdic.com/NCCAM.html

This is also interesting:

“Dr. Bronfort was recently commissioned by the British General Chiropractic Council to report on the evidence for chiropractic care. The Council and the British Chiropractic Association (BCA) has come under intense public scrutiny and pending litigation due to a large number of false-advertising claims filed against field practitioners. The purpose of the report was to help sort out what can and cannot be claimed about the effectiveness of chiropractic care, particularly manual therapies. The report is expected to be published in a peer-review journal in late 2009 or early 2010.

Drs. Bronfort and Evans [a co-author of the GCC’s Evidence Report] were keynote speakers at the British Chiropractic Association Conference held in Wales, England, in October 2009.”

http://www.nwhealth.edu/nwtoday/research1109.html

Tell your friends.

 

[Mojo]

$2.5 billion spent, no alternative cures found…”

http://www.skepdic.com/NCCAM.html

Well, since "cures which cannot be demonstrated to work" is a pretty good working definition of what they've been asked to investigate...

 

[DrFrankmeister]

There's been an interesting collection of responses to my posting to JJM:

1. The most egregious comment was the claim by "blue wode" that NCCAM spent $2.5 billion (LOL!) in 17 years. That was the total budget of NIH for all 27 instuitutes. The first year (1993?) the total alt-med budget was #1 million. WOW! I'm not sure how much clinical research you've done, but most trials I've seen budgets for were in the range of 1/4 to 1/2 million each, so how far would a million go?

2. I truly appreciated Linda's response. Your first point that The only conclusion which can be drawn from this study is that people who choose to visit a chiropractor tend to be quite different from the general population. may or may not be true. And it is a prospective study.

As for your comments about the "subluxation complex", I didn't realize you expected me to "prove" it's existence. I'd prefer to leave that to the NIH and the research centers at our colleges.

Observational versus experimental: Until the mid 90's MDs were blocked by the AMA and various other named medical sociaties from teaching, or conducting research with my profession. We were blocked access to any federal grant money to do research, and in fact the first 5 or 6 million granted to my alma mater Palmer college (in the late 90's) was primarily devoted to improving the infrastructure for research, and for funding some students to complete PhD study in epidemiology and public health. This is NOT a complaint....it's just background. Any research published and conducted previous to that was 100% funded by our federally un-subsidized schools. This is unheard of in the medical world, paying out of your own pocket to fund research.

Even so, there has been some good work done, and there's plenty more to do.

As your comment "This evidence report does not support your assertion that the use of chiropractic in children is evidence-based. For one thing, that report was directed at manual therapies, not solely chiropractic therapies," I never said it was solely about chiropractic. Do you have compelling proof that neck pain, low back pain, or headaches in children is uniquely different than that experienced by aldults? I believe that was the point I was trying to make.

I'm happy you found the website easy to utilize. Sadly, many of our materials are abstract only, but any articles that offer free accsess are clearly marked.

I had to give up half my lunchbreak to type this, so that's it for now.

Warmly,

Frank M. Painter, D.C.
[email protected]

 

[Here_to_learn]

Any research published and conducted previous to that was 100% funded by our federally un-subsidized schools. This is unheard of in the medical world, paying out of your own pocket to fund research.

One would hope so - at least I would hope that it would be the other way around - the research to verify that something actually works would come before teaching students about it.

 

[BenBurch]

One would hope so - at least I would hope that it would be the other way around - the research to verify that something actually works would come before teaching students about it.

And still they have nothing honest to show for it.