MD, PhD, FMedSci, FSB, FRCP, FRCPEd

The mechanisms thorough which spinal manipulative therapy (SMT) exerts its alleged clinical effects are not well established. A new study investigated the effects of subject expectation on clinical outcomes.

Sixty healthy subjects underwent quantitative sensory testing to their legs and low backs. They were randomly assigned to receive a positive, negative, or neutral expectation instructional set regarding the effects of a spe cific SMT technique on pain perception. Following the instructional set, all subjects received SMT and underwent repeat sensory tests.

No inter-group differences in pain response were present in the lower extremity following SMT. However, a main effect for hypoalgesia was present. A significant interaction was present between change in pain perception and group assignment in the low back with participants receiving a negative expectation instructional set demonstrating significant hyperalgesia.

The authors concluded that this study provides preliminary evidence for the influence of a non- specific effect (expectation) on the hypoalgesia associated with a single session of SMT in normal subjects. We replicated our previous findings of hypoalgesia in the lower extremity associated with SMT to the low back. Additionally, the resultant hypoalgesia in the lower extremity was independent of an expectation instructional set directed at the low back. Conversely, participants receiving a negative expectation instructional set demonstrated hyperalgesia in the low back following SMT which was not observed in those receiving a positive or neutral instructional set.

More than 10 years ago, we addressed a similar issue by conducting a systematic review of all sham-controlled trials of SMT. Specifically, we wanted to summarize the evidence from sham-controlled clinical trials of SMT. Eight studies fulfilled our inclusion/exclusion criteria. Three trials (two on back pain and one on enuresis) were judged to be burdened with serious methodological flaws. The results of the three most rigorous studies (two on asthma and one on primary dysmenorrhea) did not suggest that SMT leads to therapeutic responses which differ from an inactive sham-treatment. We concluded that sham-controlled trials of SMT are sparse but feasible. The most rigorous of these studies suggest that SMT is not associated with clinically relevant specific therapeutic effects.

Taken together, these two articles provide intriguing evidence to suggest that SMT is little more than a theatrical placebo. Given the facts that SMT is neither cheap nor devoid of risks, the onus is now on those who promote SMT, e.g. chiropractors, osteopaths and physiotherapists, to show that this is not true.

86 Responses to Spinal manupulation: little more than a theatrical placebo?

  • Thinking_Chiro says:

    Edzard Wrote:
    “the onus is now on those who promote SMT, e.g. chiropractors, osteopaths and physiotherapists, to show that this is not true.”
    The article you referenced is from 2008 and your statement above has hit the nail on the head. The volume of literature over the last few years has definitely accelerated, So!
    I did a quick scan of my Mendeley library:
    Manual therapy followed by specific active exercises versus a placebo followed by specific active exercises on the improvement of functional disability in patients with chronic non specific low back pain: a randomized controlled trial.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518179/?tool=pmcentrez&report=abstract
    The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775050/?tool=pmcentrez&report=abstract
    Spinal Manipulative Therapy-Specific Changes in Pain Sensitivity in Individuals With Low Back Pain (NCT01168999).
    http://www.jpain.org/article/S1526-5900%2813%2901300-X/abstract
    A long way to go: practice patterns and evidence in chronic low back pain care.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664198/?tool=pmcentrez&report=abstract
    Changes in pain sensitivity following spinal manipulation: a systematic review and meta-analysis.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3349049/
    Prevention of low back pain: effect, cost-effectiveness, and cost-utility of maintenance care – study protocol for a randomized clinical trial
    http://www.trialsjournal.com/content/15/1/102
    The patient-physician relationship in patients with chronic low back pain as a predictor of outcomes after rehabilitation.
    http://www.ncbi.nlm.nih.gov/pubmed/22476813
    Cost-effectiveness of different strategies to manage patients with sciatica.
    http://www.ncbi.nlm.nih.gov/pubmed/24726924
    Research on placebo analgesia is relevant to clinical practice
    http://www.chiromt.com/content/22/1/6/abstract
    Expectation of recovery from low back pain: a longitudinal cohort study investigating patient characteristics related to expectations and the association between expectations and 3-month outcome.
    http://www.ncbi.nlm.nih.gov/pubmed/24108283
    Effectiveness of Physical Therapist administered spinal manipulation forEffectiveness of physical ther the treatment of low back pain: a systematic review of the literature.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3537457/?tool=pmcentrez&report=abstract
    Outcomes of Acute and Chronic Patients With Magnetic Resonance Imaging–Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low-Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One-Year Follow-Up
    http://www.jmptonline.org/article/S0161-4754%2814%2900034-7/abstract
    Symptomatic Magnetic Resonance Imaging–Confirmed Lumbar Disk Herniation Patients: A Comparative Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either High-Velocity, Low-Amplitude Spinal Manipulative Therapy or Imaging-Guided Lumbar Nerve Root Injections
    http://www.sciencedirect.com/science/article/pii/S0161475413000572
    Long-term effects of an outpatient rehabilitation program in patients with chronic recurrent low back pain.
    http://www.ncbi.nlm.nih.gov/pubmed/24413743
    Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. 2: economic evaluation alongside a randomized controlled trial.
    http://www.ncbi.nlm.nih.gov/pubmed/23811491
    Representation of spatial information in key areas of the descending pain modulatory system.
    http://www.ncbi.nlm.nih.gov/pubmed/24672009
    Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?
    http://www.ncbi.nlm.nih.gov/pubmed/21245790
    Spinal high-velocity low amplitude manipulation in acute nonspecific low back pain: a double-blinded randomized controlled trial in comparison with diclofenac and placebo.
    http://www.ncbi.nlm.nih.gov/pubmed/23026869
    Temporal Filtering of Nociceptive Information by Dynamic Activation of Endogenous Pain Modulatory Systems
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2739444/?tool=pmcentrez&report=abstract

    This presentation from Chris Maher of the George Institute is very relevant:
    http://sydney.edu.au/medicine/21st-century/back-pain.php

    Virtually all chiropractors I know use a multimodal approach to the treatment of back pain. There needs to be more research as the catch phrase in medicine these days is cost effectiveness. As in medicine I think it is the accountants who will be dictating patient care!

    • Blue Wode says:

      Thinking_Chiro wrote: “Virtually all chiropractors I know use a multimodal approach to the treatment of back pain.”

      The chiropractors you know are irrelevant. The fact remains that the majority of chiropractors push pseudoscientific nonsense on their customers because the regulators don’t seem to care about evidence. Here’s the problem:

      Quote:
      “Chiropractic is perhaps the most common and egregious example of the bait and switch in medicine…..someone may go to see a chiropractor and think they will be seeing a medical professional who will treat their musculoskeletal symptoms, but in reality they will see the practitioner of a cult philosophy of energy healing…The bait — claims that chiropractors are medical practitioners with expertise in the musculoskeletal system. The switch — practitioners of discredited pseudosciences that have nothing to do with the musculoskeletal system…..A more subtle form of the bait and switch among chiropractors is the treatment of musculoskeletal symptoms with standard physical therapy or sports medicine practices under the name of chiropractic manipulation. Ironically, the more honest and scientific practitioners among chiropractors are most likely to commit this subtle deception. The problem comes not from the treatment itself but the claim that such treatments are ‘chiropractic’…. But by doing so and calling it ‘chiropractic’ it legitimizes the pseudoscientific practices that are very common within the profession — like treating non-existent ‘subluxations’ in order to free up the flow of innate intelligence.”

      Ref: http://www.sciencebasedmedicine.org/the-bait-and-switch-of-unscientific-medicine/

      • fedup says:

        Blue wode showing a real unbiased science based view on things here, he/she is shown 20 pieces of published evidence regarding smt and what does he/she do? study and argue with the evidence provided? No go back to using their own biased website’s quote. Yes.

        Blue wode the quote you have provided is irrelevant, the fact remains that the majority of chiropractors use smt. You have just been given 20 pieces of evidence to support it.

        • Blue Wode says:

          fedup wrote: “Blue wode the quote you have provided is irrelevant, the fact remains that the majority of chiropractors use smt.”

          It’s how they use it that’s important. The majority use it as a blanket term to disguise the their use of bogus ‘specific spinal adjustments’ to correct mythical subluxations.

          fedup wrote: “You have just been given 20 pieces of evidence to support it.”

          None of the 20 citations can trump the current robust evidence for SMT:

          Quote
          “A comprehensive review has concluded that spinal manipulative therapy (SMT) is no more effective for acute low back pain than inert interventions, sham SMT…”

          Link: http://www.ebm-first.com/chiropractic/research-and-efficacy.html

          • fedup says:

            Oh come on Blue wode, your link has this “The studies varied greatly in quality and contained very little data on recovery, return-to-work, quality of life, and costs of care.”

            Please check the 20 given as they include all of the above.

            “None of the 20 citations can trump the current robust evidence for SMT” in your opinion. Thats all you have I’m afraid.

          • Gibley Gibley says:

            Blue Wode, you seem to spend an inordinate amount of time researching spinal manual therapy and chiropractic. Could you tell me, in neuro-physiological terms, why chiropractic care or spinal manual therapy would or should not work. Please refrain from using the propaganda you have used in the past and instead use sound scientific research and knowledge.

  • Ragnvi says:

    Actually, the chiropractors themselves have already performed quite good placebo trials without reralizing it, viz. with an activator instrument — which only they believe in. Several studies have shown that there is no difference in effect between manual SMT and activator-assisted SMT. As far as I can see there is no way the activator can adjust a vertebra in a living subject.
    See for example:
    1. Shearar & al http://www.ncbi.nlm.nih.gov/pubmed/16182023
    2. Wood & al http://www.ncbi.nlm.nih.gov/pubmed/11353937

  • SkepdicProf says:

    Interesting. It seems that the physio trade schools are upgrading their education and teaching spinal manipulation now. Would the fizzeo students have any legal recourse if they sued their schools for teaching them spinal manipulation since “SMT is not associated with clinically relevant specific therapeutic effects.”? Could the schools be forced to refund the tuition paid by the physio students?

    https://www.facebook.com/pages/Spinal-Manipulation-Gibbons-Tehan/230596113746257

    Looks like lots of good old spinal manipulation fun and theatrical placebo going on here, combined with creative beer drinking by the fizzeos and osteos. But at least everyone is having a good time!

  • Thinking_Chiro says:

    Blue the bottom line for all health professions is “if you want to make a claim, Prove it”. I cited the recent research, which I utilize in practice and noted that most of the chiro’s I know are the same and your response is “The chiropractors you know are irrelevant”. They are totally relevant! They are the allies within the profession that are worthy of your support!
    You are fixated on the subbies to the exclusion of the evidence based chiropractors! You demand change, then dismiss the chiro’s who are leading and that change. As I have said previously, your response to chiropractic should involve 2 steps:
    Step 1 – Point out whats wrong!
    Step 2 – Point out whats right and support it!
    You have been doing step 1 for decades, now its time for step 2.

  • Blue Wode says:

    fedup wrote: “…“None of the 20 citations can trump the current robust evidence for SMT” in your opinion. Thats all you have I’m afraid.”

    @ fedup

    The title of Professor Ernst’s blog post is ‘Spinal manipulation: little more than a theatrical placebo?’. I would remind you that it’s not just his views, or mine, that are being opened to examination here. For example, this is what Edward Rothman, DC, a senior lecturer at the UK’s Anglo European College of Chiropractic (AECC), feels about spinal manipulation…

    QUOTE:
    “…it is my perception that there are very few rational chiropractors willing to leave, what I have termed, the ritual induced placebo of our manipulative techniques…”

    Link: http://tinyurl.com/32l9o5e

    To me, it looks like he’s saying that it takes five years’ study to master a placebo intervention (which carries an unacceptable risk). In support of his views, here’s what three chiropractic staff members at the University of Glamorgan have to say:

    Quote
    “…we know patient satisfaction scores are usually quite favourable following chiropractic care, but it has also been shown that patients are very pleased and satisfied with chiropractic care whether they get better or not. Is it so bad that patients get well despite what we do?…Furthermore, it has been said that chiropractic’s greatest contribution to health care has been the development of a solid doctor-patient relationship. So, let’s not kid ourselves. It may not be what we say (subluxation, pinched nerve, tilted pelvis, herniated disc, sacroiliac syndrome, etc.), but simply the way in which we say it that stimulates some measurable change in patient’s general health care status. Some studies support this view.”

    Link: http://web.archive.org/web/20041215180456/www.familychiropractic.co.uk/news/Articles/article3.htm

    • Fedup says:

      So all 20 pieces of recent research are useless? You call for evidence but when it’s presented at many levels by many researchers you fall back on your own pet piece of research, bias.
      You call for evidence then argue against that evidence with quotes and anecdotes and personal opinion?
      Again the title of the blog asked a question. Thinking chiro answered it at all levels. You seem unable to see that. I wonder why.

      • Blue Wode says:

        fedup wrote: “So all 20 pieces of recent research are useless? You call for evidence but when it’s presented at many levels by many researchers you fall back on your own pet piece of research, bias. You call for evidence then argue against that evidence with quotes and anecdotes and personal opinion?”

        No, I provided solid research. Here are the most recent papers from the link I provided:

        Review questions spinal manipulative therapy
        FEBRUARY 2013: A comprehensive review has concluded that spinal manipulative therapy (SMT) is no more effective for acute low back pain than inert interventions, sham SMT, or as adjunct therapy, and also seems to be no better than other recommended therapies. The reviewers looked at 20 randomised controlled trials with a total of 2,674 participants. The studies varied greatly in quality and contained very little data on recovery, return-to-work, quality of life, and costs of care. [Rubinstein SM and others. Spinal manipulative therapy for acute low back pain: An update of the Cochrane Review. Spine 38:E158-E177, February 2013] The situation faced by consumers who consult chiropractors is actually much worse than published studies indicate. In the most important studies, patients are appropriately screened for contraindications – often by medical teams – and the treatment is limited by the experimental protocol. However, in the real world, the odds of getting appropriate treatment are much lower because fraud, overtreatment (including “adjustments” to correct “subluxations”), and a wide variety of other unscientific practices are rampant in chiropractic offices.

        Spinal manipulation: an update of a systematic review of systematic reviews
        “The aim of this update is to critically evaluate the evidence for or against the effectiveness of spinal manipulation in patients with any type of clinical condition…Conclusion: Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition.” Paul Posadzki, Edzard Ernst, New Zealand Medical Journal.

        A systematic review of systematic reviews of spinal manipulation
        Concludes that there is no convincing evidence to suggest that spinal manipulation is a recommendable treatment option for any medical condition. E. Ernst and P. H. Canter, Journal of the Royal Society of Medicine

        COCHRANE SYSTEMATIC REVIEWS [Note to readers: The Cochrane Collaboration is a worldwide network of independent scientists dedicated to systematically summarising the totality of the evidence related to specific medical subjects in a rigorous and transparently impartial fashion.]

        Spinal manipulative therapy for acute low-back pain: update of the earlier Cochrane review, first published in January 2004
        Conclusions: “SMT [Spinal Manipulative Therapy] is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies.” (12th September 2012)

        Spinal manipulative therapy for chronic low-back pain (Cochrane Review)
        “High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority.” Cochrane Systematic Review (16th February 2011)

        Combined chiropractic interventions for low-back pain (Cochrane Review)
        “Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. Future research is very likely to change the estimate of effect and our confidence in the results.” Walker BF, French SD, Grant W, Green S., Cochrane Database Systematic Review 2010; 4: CD 005427
        [Comment on the above review from Professor Edzard Ernst: “The hallmark treatment of chiropractors is spinal manipulation. If critical evaluations of spinal manipulation fail to show what chiropractors had hoped for, defendants may argue that chiropractic typically combines a wide range of modalities in practice, including manipulation, mobilisation, massage, exercise and heat. Thus, it might not be fair to judge the value of chiropractic solely by the effectiveness of spinal manipulation. This Cochrane review is an attempt to overcome this pitfall. Its results show that, for the most prevalent indication for chiropractic treatment (i.e. LBP), very few studies are available. Those that do exist are often seriously flawed. For acute and subacute LBP, chiropractic seems to be as good or marginally better than conventional treatments. However, I recommend taking this result with a pinch of salt; what is still required is independent replication through high-quality studies, which also account for the risks and costs associated with chiropractic. For chronic LBP, chiropractic does not seem to be any better than conventional treatments. All in all, this review serves as a poignant reminder that chiropractic may not be as soundly based on evidence as it is often made out to be.”] [Subscription to Focus on Alternative and Complementary Therapies required.]

        Spinal manipulative therapy for low back pain (Cochrane Review)
        Concludes that there is no evidence that spinal manipulative therapy is superior to standard treatments for patients with low-back pain.

        Manipulation or mobilisation for neck pain (Cochrane Review)
        Update of Cochrane Database Syst Rev. 2004;(1):CD004249
        AUTHORS’ CONCLUSIONS: Cervical manipulation and mobilisation produced similar changes. Either may provide immediate – or short-term change; no long-term data are available. Thoracic manipulation may improve pain and function. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

        Link: http://www.ebm-first.com/chiropractic/research-and-efficacy.html

        fed up wrote: “Again the title of the blog asked a question. Thinking chiro answered it at all levels. You seem unable to see that. I wonder why.”

        Thinking_Chiro did answer the question, but not robustly enough to counter the current best evidence. I did think this citation was fairly pertinent, though:

        QUOTE
        “For patients with chronic diseases, especially those with chronic low back pain, the patient-physician relationship is significant for treatment adherence. In a sample of N = 688 low back pain patients, we examined the hypothesis that aspects of the patient-physician relationship (e.g. satisfaction with care, trust in the physician, patient participation) have a significant association with outcomes (pain, disability, quality of life, pain-related psychological impairment) after a multimodal treatment program (rehabilitation) after adjusting for a number of sociodemographic, medical, and psychological factors. Results show that the patient-physician relationship is significantly associated with the outcome.”

        Ref: The patient-physician relationship in patients with chronic low back pain as a predictor of outcomes after rehabilitation
        http://www.ncbi.nlm.nih.gov/pubmed/22476813

        However, I don’t understand why he included the paper on cost-effectiveness of different strategies to manage patients with sciatica when the current evidence for spinal manipulation is highly dubious:
        http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1826-chiropractic-for-sciatica.html

        Nor do I understand why he included the ‘research on placebo analgesia is relevant to clinical practice’ paper
        http://www.chiromt.com/content/22/1/6/abstract when the unreliability of placebo makes it problematic to count on its effects in clinical practice (and that’s once you get past the ethics issue):
        http://web.archive.org/web/20100103080345/http:/www.arc.org.uk/news/arthritistoday/131_1.asp

  • Fedup says:

    The evidence given shows smt works and chiropractors use smt. Blue wode and Prof Ernst please show me the connection between that and “relating to acting, actors, or the theatre.”

    • Blue Wode says:

      fedup wrote: “The evidence given shows smt works and chiropractors use smt. Blue wode and Prof Ernst please show me the connection between that and “relating to acting, actors, or the theatre.””

      I don’t think that Thinking_Chiro’s citations can discount the non-specific effects produced by the laying on of hands coupled with engaging the patient in conversation (intense attention) – in other words, spinal manipulative therapy is essentially a ‘performance’. Even the World Health Organisation (WHO) seems to agree:

      QUOTE:
      …the WHO’s 2003 bulletin on Lower Back Pain mentions chiropractic and the reasons people turn to it:

      People with low back pain often turn to medical consultations and drug therapies, but they also use a variety of alternative approaches. Regardless of the treatment, most cases of acute back pain improve. At the time, people in such cases may credit the improvement to the interventions some of which clearly are more popular and even seemingly more effective than others (e.g. chiropractic and other manipulative treatments in which the laying on of hands and the person-to-person interaction during the treatment may account for some of the salutary results).”

      The spread of chiropractic and other manipulative treatments worldwide has won many adherents to this treatment, who perceive that it works better than others. This hypothesis was recently put to the test (25) and, although the respondents still favoured such approaches (chiropractic adjustment, osteopathic manipulation, and physical therapy) perhaps because of the time spent and the laying on of hands meta-analysis cannot confirm the superiority of manipulative treatments (or, for that matter, of acupuncture and massage (26)) over other forms of therapy, or even time as a healer (25), which substantiates the contentions of WHO’s document (1). In most instances, manipulative treatments are more expensive than others (apart from surgery) and not more helpful to outcome (26).”

      Link: http://www.ebm-first.com/chiropractic/various-concerns/1848-world-health-organisation-who-says-that-the-consequences-of-the-chiropractic-subluxation-are-hypothesized.html

      BTW, it’s very interesting that the WHO mentions acupuncture, because it also appears to be a theatrical placebo:
      http://www.dcscience.net/?p=6060

      Suffice to say that if both acupuncture and chiropractic become universally accepted as theatrical placebos, how ironic will it be that ‘chiropractor’ contains the word ‘actor’…

  • Fedup says:

    Blue wode I’m sorry but you do nothing but show your own bias. You can site and quote from your own site and prof Ernst till the cows come home. That does not make YOUR evidence more valid than the 20 given. You do nothing but show author bias as you seem incapable of viewing the evidence subjectively. Your own bias towards this subject has blinkered you, which is a shame. As for actor in chiropractor. Well I think we can all judge your attitude from that.

    • Blue Wode says:

      @ fedup

      I understand that you’re a chiropractor. Does that mean that you are free from bias? Can you explain why you think the Cochrane reviews provided by me are biased and the 20 citations provided by Thinking_Chiro are not?

      As for ‘actor’ being found in the word chiropractor, I think it sits well with the subluxationists who are basically selling an imaginary cure.

      • fedup says:

        Blue wode, I am a chiropractor, I have bias, I have lots more evidence than you regarding chiropractic, now it may not be Gold standard, but there is lots of evidence out there, at all levels that supports SMT and chiropractic. I view the positive evidence the same way I view the negative evidence, but I have 20 years of lower level evidence to back up my bias, what have you got that supports your total lack of subjectivity on this subject? What props up your bias? Please don’t say evidence because you have been shown lots of good evidence but dismiss it out of hand as it differs from your views, “my evidence is better than your evidence” “all evidence that does not agree with my evidence is wrong” “it does not matter what evidence you show me I will not change my mind” Thats how you come across. I’ve heard those sort of statements somewhere else.

          • fedup says:

            I knew you would say that! But the science tells you different things, some say yes some say no. You are in the No camp, won’t move for anything, your own bias forces you to adopt a blinkered approach, that is not the way of science. You cannot look further than Prof Ernst work and any research that doesn’t fall within your beliefs is discarded. Again that is not science. When given evidence it is never good enough, you even then use quotes and straw man arguments by including what this or that chiropractor has said. That is not science. Then to finish an ad hominem. Not science.

  • Gibley Gibley says:

    Fedup. BW is an apologist for Stephen Barrett. Barrett’s writings were described by the NZ Commissioners in the Inquiry as being “propaganda”, and discounted in their entirety. BW quotes and references Barrett extensively in previous posts, as if Barrett is a legitimate reference. Nothing more than this needs to be said about the quality of BW’s argument…..”propaganda”.

  • Thinking_Chiro says:

    In reply to Blue Wode:
    As I said in previous blogs and in this one:
    Step 1-Point out whats wrong.
    Step 2-Point out whats right and support it.
    You have still not answered this issue, bottom line are you prepared to support the evidence based chiropractors and take step 2?
    Additionally, you state that the subbies are in the majority, yet research into chiropractic practice patterns show that they are the minority, very vocal I must admit, but still a minority. Here are the recent papers:
    Chiropractic Observation and Analysis Study (COAST): providing an understanding of current chiropractic practice.
    http://www.ncbi.nlm.nih.gov/pubmed/24237100
    Management of patients with low back pain: a survey of French chiropractors
    http://www.chiromt.com/content/22/1/13/abstract
    Treatment preferences amongst physical therapists and chiropractors for the management of neck pain: results of an international survey
    http://www.chiromt.com/content/22/1/11/abstract
    Evidence-based practice in chiropractic practice: A survey of chiropractors’ knowledge, skills, use of research literature and barriers to the use of research evidence
    http://www.complementarytherapiesinmedicine.com/article/S0965-2299%2814%2900031-4/abstract
    Are Swiss chiropractors different than other chiropractors? Results of the job analysis survey 2009.
    http://www.ncbi.nlm.nih.gov/pubmed/20937430
    Practice patterns of 692 Ontario chiropractors (2000–2001)
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1839931/?tool=pmcentrez&report=abstract
    Perspectives of older adults on co-management of low back pain by doctors of chiropractic and family medicine physicians: a focus group study
    http://www.biomedcentral.com/1472-6882/13/225
    Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey
    http://www.biomedcentral.com/1472-6882/14/51
    I think its time you also support the majority Blue!

    • Blue Wode says:

      Thinking_Chiro wrote: “In reply to Blue Wode: As I said in previous blogs and in this one: Step 1-Point out whats wrong. Step 2-Point out whats right and support it. You have still not answered this issue”

      If you browse the comments above, you’ll see that I have answered the issue.

      Thinking_Chiro wrote: “bottom line are you prepared to support the evidence based chiropractors and take step 2?”

      I do, and I have. However, I don’t know how my support of evidence based chiropractors is going to bring about universal reform – i.e. it’s not my responsibility. Why aren’t the evidence based chiropractors taking control?

      Thinking_Chiro wrote: “Additionally, you state that the subbies are in the majority, yet research into chiropractic practice patterns show that they are the minority, very vocal I must admit, but still a minority.”

      No, they’re not the minority. See here:
      http://edzardernst.com/2012/11/the-risk-of-neck-manipulation/#comment-8844

  • Blue Wode says:

    @ Thinking_Chiro

    Here’s a recent paper that seems to support Professor Ernst’s suggestion that SMT is likely to be little more than a theatrical placebo:

    Natural course of acute neck and low back pain in the general population: the HUNT study
    Pain. 2013 Aug;154(8):1237-44. doi: 10.1016/j.pain.2013.03.032. Epub 2013 Apr 2.

    Improvement in subjects who largely refrain from health care services was not critically different from that of patients in clinical studies receiving a variety of different interventions.
    http://www.ncbi.nlm.nih.gov/pubmed/23664654

  • Blue Wode says:

    fedup wrote on Thursday 15 May 2014 at 12:05: “You are in the No camp”

    Of course I’m in the ‘no’ camp. I don’t have to rely on chiropractic/spinal manipulation to earn a living.

  • fedup says:

    Blue wode its interesting how you answer little snippets, very revealing.
    So come on Blue be honest now, do you regard all chiropractic and smt as useless, can have no benefit and is actually dangerous. Is associated with a group of people who should be in a theatre as they act out an interaction with mythical subluxations. Con every person that comes to see them with the good ol bait and switch and no amount of evidence of any sort will change your mind?

    You should use science to find the truth not reinforce your truth.

    • Blue Wode says:

      You know perfectly well what my views are. Either that, or you haven’t you been paying attention to my comments every time you’ve engaged me on this blog and others.

      • SkepdicProf says:

        Not sure, Blue. Hope you don’t mind my calling you by your first name. ;-)

        Does that mean you have used spinal manipulation on patients?

        If it is a theatrical placebo, then why is it taught at weekend seminars to the physio trade at the University of Oklahoma?
        http://www.ah.ouhsc.edu/rehab/documents/Oklahoma_2014_Spinal_Manipulation_brochure.pdf

        Isn’t it unethical for these osteopaths to be teaching bogus methods to unsuspecting physios and allopaths? Don’t misunderstand me now. I think it is admirable that the physio trade wants to improve their skills and abilities above that of a technician subservient to doctors. The PTs need doctors for a referral stream. People just don’t refer themselves for physio and walk in off the street as they do in allopathic medicine and chiropractic health care. So it is good that they take weekend seminars to improve their schooling.

        Problem is that if it is bogus and they know it, then it is unethical for them to perform SMT and should refer the patient out immediately back to the doctor. Second, unfortunately, is the fact that the physios like the ones at the weekend seminar at the University of Oklahoma attempt crude manipulation on the Monday morning following their once-a-year seminar mistakenly thinking that they are proficient in this skill when they are not. That creates a potentially dangerous situation with the likelihood of serious injury to the unsuspecting public from their inept new “skills”.

        Isn’t it ironic that surgeons “perform” their work in a surgical “theater”?

          • Blue Wode says:

            SkepdicProf wrote: “If it is a theatrical placebo, then why is it taught at weekend seminars to the physio trade at the University of Oklahoma?”

            Because it has not yet been confirmed/accepted as a theatrical placebo. That’s what’s being discussed here.

            SkepdicProf wrote: “Isn’t it unethical for these osteopaths to be teaching bogus methods to unsuspecting physios and allopaths?”

            Not at the moment. Also, it’s worth remembering that SMT will form only a tiny part of the interventions they offer (unlike chiropractors who use it most of the time). I addressed the whole issue with you previously here:
            http://edzardernst.com/2014/01/chiropractors-use-of-x-rays/#comment-54969

            Here’s quick reminder:

            [SkepdicProf wrote:] “The lesson here is that you do take your life in your hands having any spinal manipulation done by poorly trained physios as they only take a weekend class once or twice a year and then return to their employer on Monday and attempt to practice their new-found but highly unfocused ‘skills’. Very dangerous. Don’t do it. No. Not a good idea.”

            [ME] I think you need to do a bit more learning before attempting to teach other people lessons. Bearing in mind that the majority of chiropractors are subluxationists, and that the public generally has no understanding of the two different practice styles of chiropractors, three chiropractic academics at the University of Glamorgan in the UK (David Byfield, Susan King and Peter McCarthy) have asserted the following:
            Quote
            To view primary health care as eliminating discrete little lesions (subluxation) is truly missing the point and shouldn’t take more than a couple of weekends to master.”
            IMO, that confirms that physiotherapists practicing spinal manipulation will be a far safer bet than chiropractors. BTW, the three academics more or less admitted that the successes derived from the chiropractic clinical encounter owed much to non-specific (placebo) effects:
            Ref: http://tinyurl.com/32odolf

            SkepdicProf wrote: “People just don’t refer themselves for physio”

            They can in the UK.

            SkepdicProf wrote: “Isn’t it ironic that surgeons “perform” their work in a surgical “theater”?”

            Yes, it is, but there’s a big difference. The work of surgeons is normally based on solid science, and their patients are usually unconscious, so their performances are hardly those of actors. In other words, they don’t need to convince, their work is important rather than dramatic…

            theatre (ˈθɪətə) or theater: 6. a setting for dramatic or important events
            http://www.thefreedictionary.com/theatre

  • Neil says:

    Whats the problem Zard!? It’s just some friendly high school humour!
    I tried to highlight a while ago the disrespect of deliberately calling someone the wrong name. Hopefully your more direct approach will have a greater affect than mine.

  • Thinking_Chiro says:

    In reply to Blue Wode:
    “I do, and I have. However, I don’t know how my support of evidence based chiropractors is going to bring about universal reform – i.e. it’s not my responsibility. Why aren’t the evidence based chiropractors taking control?”
    Supporting the evidence based chiropractors pushes the reforms forward from within, not just bludgeoned from without.
    Thankyou for the “I Do”, I do as well, “I now pronounce us chiro and sceptic”. ;-)
    I’m fine with you pointing out the BS as you are well researched and referenced and don’t blow hot air out your ……..!
    All I’m asking is that you be surgical in your criticism and balance it with support for the reformers and thinkers!
    Universal reform will certainly be a challenge, especially with the likes of Billy De Moss. This will require generational change to achieve with him.
    Chiropractic has a poor history of self criticism and objective evaluation. Critics like yourself are therefore important, as is seen by the results of Reasonable Hanks blogs that resulted in the Chiropractic Board (AHPRA) clamping down on the anti-vaccinators. Good outcome in my humble opinion and long overdue! This also makes the critics and reformers within the profession even more precious and important and therefore all support is vital. Hurting them is counter productive.
    Time to stop carpet bombing the profession and lumping us all into the same basket!

    • Blue Wode says:

      Thinking_Chiro wrote: “Supporting the evidence based chiropractors pushes the reforms forward from within”

      I think that’s a little naïve. The regulatory boards are full of elected chiroquacks. As the reformists still comprise a tiny minority, how is the old guard ever going to be voted out?

  • Thinking_Chiro says:

    P.S.
    “Natural course of acute neck and low back pain in the general population: the HUNT study
    Pain. 2013 Aug;154(8):1237-44. doi: 10.1016/j.pain.2013.03.032. Epub 2013 Apr 2.”
    Poor reference Blue, as acute pain will resolve no matter what the patient does. Chronic pain that its all about!

  • Thinking_Chiro says:

    In reply to Blue Wode:
    There are already chiro’s pushing the reforms like COCA, Murdock Uni, Macquarie Uni and RMIT Uni here in Australia with the CAA coming around. We still have issues with the ASRF and CQU Uni. The chiro’s in Denmark and Switzerland are doing well and are a great role model. Who are the reformers in the UK?
    The boards here are full of EBP chiro’s like Phillip Donato. Following a past exchange with you over the WHO guidelines I was fortunate to listen to John Sweaney who was intimately involved with writing the guidelines and the WFC at a seminar. We had a very interesting conversation about registration, standards and what they have been doing over the last 20 years. You would be stunned by how hard they have been working on and pushing reform globally and what they have acheived!
    As for chronic pain the recent research, some already cited above, is looking good!
    In the meantime, I will continue to nudge you in the right direction and bring balance and harmony to your online life!

    • SkepdicProf says:

      Thinkin’ Chiro wrote: “As for chronic pain the recent research, some already cited above, is looking good!
      In the meantime, I will continue to nudge you in the right direction and bring balance and harmony to your online life!”

      Chronic schmonic, Thinkin’ Chiro. Think again. This whole pain thing that you seem to find is so important is a medical construct. Treat the pain and all is well. Not. So maybe you should think about this from a different viewpoint. The pain is not the problem. It is the alarm that something is wrong and needs to change in their life.

      Of course, our first goal is to take care of the patient’s needs. They want to get out of pain and feel better. Who wouldn’t? I certainly would. But that’s where the care begins not ends like in the medical world: “Call me when you have your next crisis, Mrs. Jones!”

      I let everyone know that non-drug approaches like chiropractic health care may take longer than pharmaceutical drug-based sick care. If they want to take medication, fine with me. Send them to the family allopath for multiple meds. Most have already tried these things on their own or with a script from the allopath and have no interest in taking them any longer. Usually they don’t help very much anyway and the patient realizes that it’s not changing anything in the problem. That’s why they are coming to see us. They either find us on their own or are sent over by the local MD.

      Most people who choose the natural, non-drug approach are not even interested in the drug scene. They are holistically minded, educated, workout, eat healthfully, etc. Most want to change something in their life to prevent problems from reoccurring. They want out of the downward spiral. They want to change the decades-old pattern they have been in. That’s where you come in because you are a doctor, not a physiotherapist.

      This, of course, takes two things – - Time and Commitment. They usually feel better in a week or two and they usually function better in a few months. In a year, they feel 10 years younger, have better posture, regained flexibility, sleep better, wake refreshed, have more energy. You are going to help them to be healthier than they were last year. That’s why millions of people all over the world of all ages seek out chiropractic for health care not sick care. That’s why you became a chiropractic doctor. It is a beautiful thing, and that’s the way it is, even if no one on this “blog” likes that. This is not within the medical paradigm, so therefore, it can’t be allowed to exist.

      Having RCTs to prove that natural, non-drug approaches to health like chiropractic care is better than a pain pill or muscle relaxer is medical stinkin’ thinkin’. It is a loser’s game. The anti-chiropractic extremists here like Blue Wode have you chasing your tail. He has been doing this full-time for decades. He has no balance or harmony in his life. Loving to hate chiropractic health care, and you, IS his life. He is not going to come over to your side or even meet you anywhere. It is his way or the highway. So good luck with that. Bring some harmony and balance into your own life. It’s the only one you can change.

      I hope you find this helpful. If not, no problem. If no one here likes this, well, what are you going to do? We will still be helping millions of people without drugs, helping those who seek our care to create a healthier environment in their bodies and in their lives. Millions will still be happy with what we do. And the world will be a better place.

      Please, EE, no thank you is necessary.

      • Julian Rowlands says:

        ”natural, non-drug approaches to health”
        There is NOTHING natural about chiropractic. The extensive reviews quoted above show that it has no benefit above placebo. We understand that it doesn’t work, we understand why it doesn’t work, and we understand why people mistakenly believe it does work. As a recovered casualty of chiropractic, I say to you and the other chiros who comment here: please, please, give it up. Change your life, do something good or something that doesn’t involve conning people and harming them in the process. You can do it. And stop attacking evidence based medicine: you may need it to save your life or the life of a loved one.

        • SkepdicProf says:

          See, Thinking Chiro, I told you they would hate this. Did you know that you don’t do anything or help anyone? Do what they want you to do… Drive a bus, work for the Postal Service. Or…just ignore their blathering.

          Julonion, glad to hear you are a recovered casualty. Each year, 800,000 Americans unfortunately aren’t so lucky and can’t claim that distinction as they are killed from preventable, scientific medical errors. 150,000 in tiny England. Just sayin’.

          BTW, I am not attacking evidence-based medicine. I fully recognize the miracles that medical care performs: Emergency medicine brings people back from near death after catastrophes. This is the true art of medicine. Organ transplantation gives people another 20 years of life. Microsurgery re-attaches hands, fingers, faces, etc. I take my hat off to the those who do these things for suffering humanity.

          Unfortunately, everyone is, or knows 10 people who are, a casualty of the “evidence-based drug care industry” dispensed by the neighborhood allopath who was influenced by the pretty drug rep and her free lunch for the staff or hard-to-get playoff tickets for the doctor. “Oops! That didn’t work? Here, Mrs. Jones, try this. The rep told me it works. If it doesn’t work, we’ll try something else. I have never met a drug I didn’t like!” — Real science? Not.

          Or how about hospital bloopers. We won’t even go there. Or the world-wide health catastrophe of ineffective antibiotics due to miss-use and over-prescription by the allopaths by handing them out like candy on Halloween for the past 50 years and still going strong. Now we are all up a creek. Thanks, real docs!

          I see many medical professionals who come for chiropractic health care and refer their families, too. Guess they mistakenly believe natural health care doesn’t work. I guess they are not so smart after all, eh?

          So, Julian, change your life. You can do it.

          • Julian Rowlands says:

            All medical treatment carries risks. The question is whether the risks are worth taking. In the case of sham procedures such as chiropractic, they are not – there is no upside.

            I know it must be difficult for you. You’ve done some sort of training, now you ”treat” four or five punters an hour, give em the old wack-and-crack and pocket the dosh. Then tell them they’ve got a really bad case of whatever and they need to come back regularly, at least until your boat loan’s paid off and your kids are through college.

            It must be difficult to imagine making that sort of dough that easily in a different line of work.

          • SkepdicProf says:

            Julian wrote: “All medical treatment carries risks.”

            So, Julian, 800,000 Americans die each year from preventable errors, goof-ups, bloopers and blunders by the medical trades that never should have happened and you just chalk it up to that it comes with the territory, it’s the chance you take for showing up for medical care, so just suck it up and you are OK with this? Yes, treatments do have their risks. But this huge number is from errors, not the side-effects of the medical industry’s interventions. That’s another few hundred thousand customers who become casualties.

            I don’t think that these 800,000 victims of medical bloopers would agree with you that it was worth the risk.

            Yeah, the dough is good. The boat is nice, too much income to qualify for any college loans, though. Success does have it’s burdens I suppose. But I am considerate enough to send the local allopaths a ‘Thank You’ card every Christmas for the steady stream of medical failures they send over that we end up helping.

            I can’t imagine doing anything else!

          • Julian Rowlands says:

            So you’re not attempting to defend chiro – just attacking real medicine. I hope you realise that use of the term ”allopath” marks you out as either a con-artist or a nut-job.

  • Blue Wode says:

    Thinking_Chiro wrote: “Who are the reformers in the UK?”

    There aren’t any as far as I know. The British Chiropractic Association likes to present itself as the respectable face of UK chiropractic, however…

    QUOTE:
    “The BCA opposes restricting the scope of practice of chiropractors, yet it recognises that there are boundaries. It actively prohibits unethical practice building or unprofessional marketing which undermines the integrity of the profession. Those limits aside, the BCA supports equality of opportunity and diversity and indeed it has been this rich diversity that has given the chiropractic profession its colour and vibrancy for nearly 85 years.”
    Link: http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1524-chiropractic-towards-new-horizons.html

    That sounds to me like “‘we have to be seen to frown on chiroquackery, and will condemn it *if we have to* where it’s explicit, otherwise chiropractors can do what they like”.

    In the U.S., where the majority of chiropractors practice, it’s still a wild west of quackery. The few reformists there have have had no real impact:
    http://westhartfordgroup.com/

  • Thinking_Chiro says:

    In reply to SkepdicProf:
    Business as usual just isn’t acceptable any more. There is a level of accountability now that wasn’t around 20 years ago. This blog is a good example. On this one thread there is a medical sceptic and public sceptic who are well read and have done their research, a jaded ex-patient, a chiropractor who blames medicine and a chiropractor who asks why. We are sitting on our computers in the USA, UK and Australia referencing websites, forums, blogs and research from all over the world.
    We are now being held accountable by registration boards, insurers, lawyers, governments, universities and ultimately the public. They are all asking one question “Prove It?”. As a profession we must ask this same question so as to provide the best possible care for our patients. Our practices should be constantly changing and evolving as best evidence and best practice presents itself. This means testing and evaluating with RCT’s and cohort studies that have a high level of evidence and not case studies and anecdote that have the lowest level and none. This is the currency of modern health!

    Your “well what are you going to do?” is already happening, it is called legislation, registration, practice guidelines, best practice, minimum standards, patient advocacy, informed consent, continuing professional development hours, cost/benefit, risk/benefit, scope of practice etc! Health is the ultimate team sport, practicing in isolation is not an option.
    You talk about helping millions, yet we see only 8% of the population, Who sees the other 92%? I have been actively engaging with doctors for over 2 decades and I am helping the 92% and have a thriving practice. I offer advice on health, lifestyle and prevention and it is up to the patient to accept that advice and take action or settle for pain relief, but it is the patients choice and I respect that decision.

    Years ago upon graduating I went to all the seminars to see what was available. I remember going to AK and SOT seminars and repeatedly asking one question “Why?”. I was told over and over “it’s in the manual, follow the protocols, they work”. They were mystified and annoyed, by the end they actively avoided me. That was the first and last time I used those techniques.
    You criticise medicine, yet some of the most vocal critics of medicine that I know are doctors and specialists. Medicine has a culture of critical self assessment, leading to change and this is what is in short supply in chiropractic.

    In reply to Blue Wode:
    “There aren’t any as far as I know.”
    Your so focused on the subbies that you havn’t bothered to look! Seek and Ye shall find! Then support! The BCA has to cater to all parties, but I am sure thare are EBP chiro’s in their ranks! Even the CAA here recognises the writing on the wall and is slowly coming around (often cicking and screaming). Support those reformers!

    “That sounds to me like “‘we have to be seen to frown on chiroquackery, and will condemn it *if we have to* where it’s explicit, otherwise chiropractors can do what they like”.
    The BCA like the CAA and COCA are advocates for the profession. The registration boards are advocates for the patients and they are the ones who enforce standards and who hold chiropractors accountable! COCA has proactively lead on many issues and is doing a good job.

    “In the U.S., where the majority of chiropractors practice”.
    Interestingly, there are now more chiropractic colleges and universities outside the USA! Thanks for the link to the “West Hartford Group”, there are some very good chiropractors on their executive worthy of all our support!

    • Blue Wode says:

      Thinking_Chiro wrote: “Your so focused on the subbies that you havn’t bothered to look! …The BCA has to cater to all parties, but I am sure thare are EBP chiro’s in their ranks!”

      I have bothered to look and it’s impossible to distinguish between ‘subbies’ and EBP chiropractors.

      Thinking_Chiro wrote: “The registration boards are advocates for the patients and they are the ones who enforce standards and who hold chiropractors accountable!”

      What utter nonsense. Globally, registration boards continue to allow chiropractic quackery to flourish. They usually don’t act unless the complaints whey receive are drug, drink, or sex related. If standards were properly enforced (from the outside), the chiropractic industry would be destroyed.

  • Thinking_Chiro says:

    In Reply to Blue Wode:
    The chiropractic board of Australia (AHPRA) http://www.chiropracticboard.gov.au/About-the-Board/Functions-of-Board.aspx has legislative teeth and is run the exact same way as the other boards, with the same standards http://www.ahpra.gov.au/
    They all answer to and are accountable to the government, not the individual professions! I recently had a discussion with Phillip Donato and he is kept busy dealing with the same problems as the other boards. You should be more even handed with your cynicism!

  • Blue Wode says:

    It’s not cynicism. For decades, globally, the vast majority of chiropractors have chosen not to follow (far less lucrative) EBP. They have been able to do so because they know that the boards are crammed with members with vested interests who keep clueless, duped legislators asleep at the wheel.

  • Thinking_Chiro says:

    The legislators and public advocates are definitely not asleep at the wheel. I went to a recent AHPRA meeting on the introduction of the new social media rules and the Q&A at the end showed they knew what they were talking about. The new rules are primarily I think in response to complaints about chiropractic websites and social media, but have been standardized across all the boards. The physio’s have been caught out, especially on the ban on patient testimonials https://www.google.com.au/#cr=countryAU&q=physiotherapist+testimonials&tbs=ctr:countryAU and the doctors are screaming and lobbying hard to water it down. Nice to see regulation working both ways!

  • Thinking_Chiro says:

    In reply to Blue Wode:
    They are protected the same way as when entering a doctors or physio’s clinic! By identical boards, with identical standards and guidelines! How does a patient know a chiro, physio, GP or specialist is good? There are surgeons I know who are superb and others who I wouldn’t allow near me with a 50 foot barge pole, you mention their name to other surgeons and they are very frank in their assessment, yet the sub standard surgeon still weilds a scalpel! Why?
    When someone moves to a new city do they see any old doctor or do they make inquiries and an informed decision?
    Customers are far more cynical and cautious than you give them credit for, except for the USA!

    • Blue Wode says:

      Thinking_Chiro wrote: “They are protected the same way as when entering a doctors or physio’s clinic! By identical boards, with identical standards and guidelines! How does a patient know a chiro, physio, GP or specialist is good?”

      Chiropractic customers definitely not protected in the same way. Medicine and physiotherapy are based on evidence (e.g. medication, advice, exercise). The word ‘chiropractic’ describes a pseudoscientific concept, yet its purveyors, despite being regulated in most westernised countries, are free to practice their quackery on unwitting customers in droves.

      Thinking_Chiro wrote: “Customers are far more cynical and cautious than you give them credit for, except for the USA!”

      Citations please.

    • Neil says:

      Surely the argument about bringing chiropractors into line with EBM professions is a waste of time. If it brings them into line with other professions then they become.?.?.? Physiotherapists/Osteopaths? So if we label people differently then they wont have to choose between an evidence based Chiropractor and a traditional Chiropractor.

      I take the point of good and bad in every profession, but, trying to keep the label and change the product doesn’t make sense to me. If there is already a product that has the changes that are trying to be implemented then it would make sense to change the label not the product.

      • Alan Henness says:

        Neil said:

        Surely the argument about bringing chiropractors into line with EBM professions is a waste of time. If it brings them into line with other professions then they become.?.?.? Physiotherapists/Osteopaths?

        Indeed. And it’s a mystery why there are separate statutory regulators for osteopaths and chiros, particularly when chiros want to ‘appropriate’ evidence from studies of osteopathy as evidence for chiropractic.

    • SkepdicProf says:

      Hi Thinking Chiro. I don’t think the medical customers, or those customers of the physio trades are protected very well, given the huge number of casualties, 800,000, who are killed from errors each year in the US alone. What do you think?

      BTW, how’s it going nudging Blue Wode closer to your way of thinking?

      • Blue Wode says:

        @ SkepdicProf

        I’m still waiting for a link to a chiropractic adverse event reporting system in the United States. Is there one?

        Meanwhile, here, once again, is medicine’s answers to its critics:

        Part 1
        http://www.sciencebasedmedicine.org/answering-our-critics-part-1-of-2/

        Part 2
        http://www.sciencebasedmedicine.org/answering-our-critics-part-2-of-2-whats-the-harm/

        And here’s a snippet from Death by Medicine:

        QUOTE
        “…a treatment is not very “safe” if it causes no side effects but lets you die. Most of us don’t just want “safe:” we want “effective.” What we really want to know is the risk/benefit ratio of any treatment. The ironic thing is that all the statistics these doctor-bashers have accumulated come from the medical literature that those bashed doctors have written themselves. Scientific medicine constantly criticizes itself and publishes the critiques for all to see. There is NOTHING comparable in the world of alternative medicine.”
        Link http://www.sciencebasedmedicine.org/death-by-medicine/

        Considering that the data on spinal manipulation are increasingly pointing to it being a theatrical placebo – and we know that it carries rare, but catastrophic risks – it’s hardly surprising that SkepdicProf has to resort to diversionary tactics and sarcasm as the realisation sinks in that it’s highly likely that he has devoted his working life to an intervention that will probably go the same way as blood-letting.

  • Thinking_Chiro says:

    In relpy to Blue Wode:
    “Chiropractic customers definitely not protected in the same way.”
    It depends what you compare chiropractic to! Hospitals have a well established adverse event reporting system backed by a vast bureaucracy, a general practicioner in private practice is identical to chiro’s with same boards, regulations and adverse event reporting! Dr John Cunningham (Orthopod) recommended a standardised adverse event reporting system based in hospital emergency departments that is then sent to the appropriate board (chiro, physio etc) for investigation. Good idea!
    As for medical evidence base:
    There was a discussion at the Royal Australasian College of Surgeons not long ago concerning their evidence base. They put it optimistically at 20% of procedures. Their concerns boiled down to lack of research funds, difficulty recruiting surgeons and difficulty recruiting patients. Interesting especially when making life and death decisions!
    As for Citations on consumer behavior, I have never read papers on it. I have observed behavior from doctors and chiro’s in the USA that would not be permitted and would definitely face diciplinary action here! Billy De Moss would be gagged by a possy of annoyed chiro’s in Australia, let alone AHPRA!
    As for “pseudoscientific concept”, subluxation was only taught in a historical context even when I was studying at uni over 2+ decades ago! The majority of chiro’s have moved on as well, as is cited in the papers above!

    In reply to Neil:
    “Surely the argument about bringing chiropractors into line with EBM professions is a waste of time. If it brings them into line with other professions then they become.?.?.? Physiotherapists/Osteopaths? So if we label people differently then they wont have to choose between an evidence based Chiropractor and a traditional Chiropractor.”
    I am practicing in a medical centre working closely with doctors. We have regular meetings and co-manage patients, discuss what I treat, how I treat, scope of practice etc. The other doctors in the area are well aware of how I practice and many refer. Doctors do not refer lightly as it reflects straight back on them, be it a physio, chiro or specialist! I market myself to the doctors as another approach in the treatment of chronic spines, as no one approach has all the answers. I have developed a reputation for helping difficult backs and the doctors do tend to refer challenging ones. Working with doctors has also introduced a high level of accountability that is good for my patients. We communicate constantly!
    This is not a waste of time!

    “If there is already a product that has the changes that are trying to be implemented then it would make sense to change the label not the product”
    Good point! Chiropractors do not own the terms health, prevention, natural, wellness, rehab etc. We do own one word in the eyes of the consumer and that is “Spine”. Just as the physio’s have cardiac rehab physio, sports physio etc, chiropractic should have the same, Evidence based chiro, traditional chiro.

    In reply to Skepdicprof:
    Right now you are using a classic straw man argument. Any issue with medicine does not excuse or validate what goes on in chiropractic. Some of the greatest critics of medicine I know are doctors and they are very frank in their assessments. Chiropractic needs the same self criticism and self evaluation! Simple! Currently chiro’s who criticise are subject to personal attack accusations of being disloyal traitors. I would love to be able to post on these sites under my own name!

    In reply to Alan Henness:
    “Appropriate evidence from osteo’s”.
    If any profession does good research that inproves how I practice I will take it on board. I currently read 20+ journals and only 4 are chiropractic. They include Pain, Neurology, Orthopedic, Biomechanics Rehab, Physio, Sports Med etc! This cross pollination occurs throughout medicine and is healthy! The physio’s also reference chiro research so it is two way traffic!

    • Blue Wode says:

      Thinking_Chiro wrote: “Dr John Cunningham (Orthopod) recommended a standardised adverse event reporting system based in hospital emergency departments that is then sent to the appropriate board (chiro, physio etc) for investigation. Good idea!”

      Sadly, it’s likely that such a solution would be little more than a drop in the ocean. If it were to be implemented, then I suspect that it would remain in Australia where there’d be whitewash after whitewash whenever the chiropractic boards received any serious reports. For example, let’s not forget what happened in the recent case where an Australian baby’s neck was broken as a result of chiropractic ‘treatment’. See the 2nd, 3rd, and 4th links here:
      http://www.ebm-first.com/chiropractic/safe-for-children.html

      What I want to know is why, 118 years after chiropractic was invented by a grocer (who fancied him self as a magnetic healer), are there no reliable chiropractic adverse event reporting systems anywhere in the world?

      As for the rest of your reply to me, it’s based on personal anecdote and wishful thinking.

      • SkepdicProf says:

        Blue, your chiro-paranoia is showing. Why would you post with such glee a “story” about a baby’s neck being broken that turned out not to be true? No one has devoted more of their life to our profession than you, or has a greater digital storage vault of all things chiropractic than you, so surely you must be aware that the story was false. It was run up the flagpole by people like you and yours and the drug-based medical/allopaths to take the spotlight off, for a few minutes, of their own carnage, damages, injuries and deaths that they cause by the hundreds each day.

        Guess you missed this or have deliberately ignored it:

        http://www.theaustralian.com.au/news/nation/chiropractor-cleared-over-break/story-e6frg6nf-1226740575036

        I am surprised that Thinking Chiro hadn’t caught this and called you to task. Isn’t he from Australia?

        Blue wrote “What I want to know is why, 118 years after chiropractic was invented by a grocer (who fancied him self as a magnetic healer), are there no reliable chiropractic adverse event reporting systems anywhere in the world?”

        Well, when the all of the adverse events from drug and surgery-free chiropractic health care that ever happened since 1895 add up to one one-hundreth the carnage, injuries and deaths that the medical industry and physio trade’s cause EACH YEAR, then I am sure there will be an adverse event reporting system put into place that you can be proud of. Until then, well, no need, I guess.

        You seem to be reluctant to shine your light on the real issue — medically induced adverse reactions, injuries and deaths. Don’t want to bite the hand that feeds you?

    • Alan Henness says:

      In reply to Alan Henness:
      “Appropriate evidence from osteo’s”.
      If any profession does good research that inproves how I practice I will take it on board. I currently read 20+ journals and only 4 are chiropractic. They include Pain, Neurology, Orthopedic, Biomechanics Rehab, Physio, Sports Med etc! This cross pollination occurs throughout medicine and is healthy! The physio’s also reference chiro research so it is two way traffic!

      So, what’s the difference between osteopathic manipulation and chiropractic manipulation and why is there not more evidence for each?

  • SkepdicProf says:

    Blue wrote: “SkepdicProf has to resort to diversionary tactics and sarcasm”

    Sarcasm? Me!? So what’s the matter with a little sarcasm? On this site and those you preside over, sarcasm is almost polite! I won’t use your nasty netiquette methods that include insults with a generous dose of demeaning and dehumanizing language for anything you don’t like.

    And while most only banter on “blogs” like this, you have devoted your entire working life involving yourself in active engagement in questionable activities to undermine those you have pronounced as so-called “quacks”. IMO, you should have spent more time with the wife and kids, if you ask me. I know, you didn’t ask me.

    And, FYI, yes, I really do send those MDs Christmas cards to thank them for the steady stream of adults and kids that they refer for health care when sick care wasn’t what they needed.

  • Thinking_Chiro says:

    In reply to Blue Wode:
    “If it were to be implemented, then I suspect that it would remain in Australia where there’d be whitewash after whitewash whenever the chiropractic boards received any serious reports. For example, let’s not forget what happened in the recent case where an Australian baby’s neck was broken as a result of chiropractic ‘treatment’. See the 2nd, 3rd, and 4th links here:”
    You missed the point Blue, there is no compulsory, reliable adverse event reporting for chiro or physio or GP’s. Same standards for all, standardised and systematic is required! The physio’s have even discussed how they have dodged a bullet on this issue. You also fail to acknowledge the role of the boards to police all professions with the same standards.
    As for the baby it was a classic case of conflicting medical reports. First xray said hangmans fracture, subsequent CT and MRI the following week said no fracture and hangmans is a common misdiagnosis on plain films. Follow up CT at three months said no fracture. All this imaging was done at the childrens hospital and was reviewed later in the year with similar findings by the senoir registrar and senoir radiologist. A Ct at 6 months (done outside the hospital) said healing noted indicating possible fracture. Even before the investigation by AHPRA the doctors went to the press and it was trial by reporter. It was a mess. The investigation by AHPRA attempted to resolve the conflicting medical reports. The one thing that I couldn’t see in any report was all the imaging going to an expert in pediatric radiologist for an independent review. Another question is why was the baby exposed to an additional CT at 6 months if the 3 month CT was clear. This is a total of one xray, 3 CT’s and an MRI on a baby under 1 year old, that is a massive amount of ionizing radiation! What were the clinical reasons for ordering that last CT? Its not in any of the reports! Messy business by all!

    Does chiropractic need a reliable adverse event reporting system? Absolutely and John Cunningham’s proposal is a good one! But so does physiotherapy and GP’s and Osteopathy and homeopathy and naturopathy etc etc! The issue with chiropractic has just highlighted the deficiency across all professions!

    As for anecdote, I agree that my observations on the excesses of chiro’s and doctors in the USA is anecdote, but even you have noted the concentration of BS there! I would have thought that my experience working with doctors and the accountability it fosters would be applauded by you, not dismissed. Isn’t this accountability what you are demanding?

    In reply to Alan Henness:
    “So, what’s the difference between osteopathic manipulation and chiropractic manipulation and why is there not more evidence for each?”
    You forgot physiotherapy manipulation! They now use Activators, teach and practice high velocity-low amplitude manipulation, animal manipulation etc. They are acquiring some of chiropractics bad habits with less accountability or criticism! On the flip side, the papers I cited at the beginning of this thread are all recent (after the last Cochrane Review) and are encouraging in their findings. I am still waiting for a sceptic to say, good research just what we are demanding! You demand change and so do I, supporting it is important!

    • Alan Henness says:

      Thinking_Chiro said:

      “So, what’s the difference between osteopathic manipulation and chiropractic manipulation and why is there not more evidence for each?”
      You forgot physiotherapy manipulation!

      We can maybe get to that later – I’m interested in what differences there are between chiro and osteo manipulation. Do you know of a source that gives a good explanation?

    • Blue Wode says:

      Thinking_Chiro wrote: “You missed the point Blue, there is no compulsory, reliable adverse event reporting for chiro or physio or GP’s.”

      No, Thinking_Chiro, you missed the point:

      Scientific medicine constantly criticizes itself and publishes the critiques for all to see. There is NOTHING comparable in the world of alternative medicine.”
      Link http://www.sciencebasedmedicine.org/death-by-medicine/

      Thinking_Chiro wrote: “As for the baby it was a classic case of conflicting medical reports.”

      No, it was a classic case of an infant being injured after receiving bogus chiropractic treatment.

      Thinking_Chiro wrote: “I would have thought that my experience working with doctors and the accountability it fosters would be applauded by you, not dismissed. Isn’t this accountability what you are demanding?”

      Yes, it is, and you’ll hear my applause once the EBP chiropractors have taken control.

  • Blue Wode says:

    SkepdicProf wrote on Saturday 24 May 2014 at 12:32: “Right, so no broken neck.”

    Wrong. I said read the links I provided. Neck broken…

    QUOTE
    Spinal surgeon Mr John Cunningham said he and his colleagues had no doubt the child suffered a fracture…”I strongly suspect that the injury was through the congenital defect, the weak point, which would have contained cartilaginous tissue. This would not be visible on the initial CT as cartilage is simply not seen. A second CT, performed some weeks later [see paragraph 34 of the report http://www.parliament.qld.gov.au/documents/tableOffice/TabledPapers/2013/5413T3781.pdf ], clearly indicates new bone formation and healing of a concurrent fracture.” Mr Cunningham said the CAA [Chiropractors' Association of Australia] must have appreciated the significance of the second CT scan. “What I find disingenuous is the manner in which they only released to the press the first CT report,” he added.
    http://www.medicalobserver.com.au/news/no-doubt-babys-neck-was-fractured-doctors-say

  • Thinking_Chiro says:

    In reply to Blue Wode:
    The review cited in paragraph 34 mentions the CT’s at one week and 6 months and ignored the 3 month CT (where you would expect it to show signs of fracture healing but was clear) and the all important MRI (which was also clear). Even before the AHPRA report the doctor had gone to the press and did interviews with all the TV stations. On the forums in Australian Doctor magazine following the article doctors were discussing why an MRI had not been done, this is not surprising with the cherry picked information that was presented. The bulk of the AHPRA report is an attempt to sort out the conflicting radiologist reports, the senoir hospital radiologists review of the 1st 2 CT’s, xray and MRI and the 6 month CT. If you read further the chiropractor did not go anywhere near the upper cervical spine and used an activator which would not cause that injury. Interesting!
    I agree that the chiro should have not been there in the first place, but the media circus generated before any official investigation and the cherry picked information they presented and the reports they ignored was unbalanced to say the least!
    Your quote is a classic example:
    “This would not be visible on the initial CT as cartilage is simply not seen. A second CT, performed some weeks later [see paragraph 34 of the report http://www.parliament.qld.gov.au/documents/tableOffice/TabledPapers/2013/5413T3781.pdf ], clearly indicates new bone formation and healing of a concurrent fracture”
    The CT was not a few weeks later, it was 6 months. There was a MRI which does image soft tissue and a CT at 3 months that was ignored!
    The flip side is AHPRA should have given the whole lot to a world authority on pediatric radiology to put the issue beyong all rearonable doubt!

    “Scientific medicine constantly criticizes itself and publishes the critiques for all to see”
    Blue you must be kidding or to use your own words “I think that’s a little naïve”! Critically evaluating with clinical trials, drug trials and treatment protocols, yes, publicly airing their dirty laundry, I think not. A classic example of this was an expose on TV about a Neurosurgeon in Canberra last year.
    http://www.canberratimes.com.au/act-news/act-neurosurgeon-failed-3-patients-20120629-218fw.html
    and http://badrickunadulterated.com/?p=13788 and https://www.google.com.au/#q=raymond+newcombe+neurosurgeon
    Following this article I discussed the show with a surgeon who stated they’ve known about him for decades! Well why wasn’t he stopped? The story of what the medical establishment and shonky surgeon did to the whistleblowing doctor is a real eye opener!
    I have talked to a doctor on the health complaints commission who remarked on the sheer volume of what they have to deal with and another who is on the Death in Theatre Committee who said even they would now think twice before having surgery and this is a surgeon. I havn’t seen any of this published for all to see!

  • Thinking_Chiro says:

    In reply to Blue Wode:
    The review cited in paragraph 34 mentions the CT’s at one week and 6 months and ignored the 3 month CT (where you would expect it to show signs of fracture healing but was clear) and the all important MRI (which was also clear). Even before the AHPRA report the doctor had gone to the press and did interviews with all the TV stations. On the forums in Australian Doctor magazine following the article doctors were discussing why an MRI had not been done, this is not surprising with the cherry picked information that was presented. The bulk of the AHPRA report is an attempt to sort out the conflicting radiologist reports, the senoir hospital radiologists review of the 1st 2 CT’s, xray and MRI and the 6 month CT. If you read further the chiropractor did not go anywhere near the upper cervical spine and used an activator which would not cause that injury. Interesting!
    I agree that the chiro should have not been there in the first place, but the media circus generated before any official investigation and the cherry picked information they presented and the reports they ignored was unbalanced to say the least!
    Your quote is a classic example:
    “This would not be visible on the initial CT as cartilage is simply not seen. A second CT, performed some weeks later [see paragraph 34 of the report http://www.parliament.qld.gov.au/documents/tableOffice/TabledPapers/2013/5413T3781.pdf ], clearly indicates new bone formation and healing of a concurrent fracture”
    The CT was not a few weeks later, it was 6 months. There was a MRI which does image soft tissue and a CT at 3 months that were both ignored!
    The flip side is AHPRA should have given the whole lot to a world authority on pediatric radiology to put the issue beyong all rearonable doubt!

    “Scientific medicine constantly criticizes itself and publishes the critiques for all to see”
    Blue you must be kidding or to use your own words “I think that’s a little naïve”! Critically evaluating with clinical trials, drug trials and treatment protocols, yes, publicly airing their dirty laundry, I think not. A classic example of this was an expose on TV about a Neurosurgeon in Canberra last year.
    http://www.canberratimes.com.au/act-news/act-neurosurgeon-failed-3-patients-20120629-218fw.html
    and http://badrickunadulterated.com/?p=13788 and https://www.google.com.au/#q=raymond+newcombe+neurosurgeon
    Following this article I discussed the show with a surgeon who stated they’ve known about him for decades! Well why wasn’t he stopped? The story of what the medical establishment and shonky surgeon did to the whistleblowing doctor is a real eye opener!
    I have talked to a doctor on the health complaints commission who remarked on the sheer volume of what they have to deal with and another who is on the Death in Theatre Committee who said even they would now think twice before having surgery and this is a surgeon. I havn’t seen any of this published for all to see!

    • Blue Wode says:

      Thinking_Chiro wrote: “If you read further the chiropractor did not go anywhere near the upper cervical spine and used an activator which would not cause that injury. Interesting! I agree that the chiro should have not been there in the first place…”

      There continues to be a great deal of controversy surronding the case. However, given the poor standard of assessment and note-taking made by the chiropractor at each clinical encounter with the infant, it is very possible that he failed to detect the signs and symptoms of a hangman’s fracture:

      QUOTE
      “CAA president Dr Laurie Tassell (Chiro) said there was no doubt the baby had a hangman’s fracture.”
      http://www.chiropractors.asn.au/index.php?option=com_k2&view=item&id=371:outrage-at-claim-that-chiropractor-broke-babys-neck&Itemid=450

      Thinking_Chiro wrote in response to my pointing out that scientific medicine constantly criticises itself and publishes the critiques for all to see: “…Critically evaluating with clinical trials, drug trials and treatment protocols, yes, publicly airing their dirty laundry, I think not.”

      I don’t see much critical evaluation from chiropractors with regard to their clinical trials. Indeed, they’re known to manipulate reviews to yield a desired outcome. A particularly notorious example of a pseudo-systematic review is the famous ‘systematic’ review by Bronfort et al (commissioned by the General Chiropractic Council), which is critiqued by Professor Ernst here:
      http://edzardernst.com/2014/02/the-alchemists-of-alternative-medicine-part-5-pseudo-systematic-reviews/

      Also see:
      Sources of bias in reviews of spinal manipulation for back pain
      http://www.ebm-first.com/chiropractic-sp-361899502/research-and-efficacy/532-sources-of-bias-in-reviews-of-spinal-manipulation-for-back-pain.html

      Considering that the value of spinal manipulation is now seriously in question (the topic of this blog post), it’s not hard to see why chiropractic research continues to be so shoddy.

      As for chiropractic treatment protocols, why hasn’t the adjusting of mythical subluxations been consigned to the dustbin of history? The same for Applied Kinesiology, Craniosacral Therapy, leg-length testing, etc. Chiropractors continue to use these treatment interventions in droves.

      Thinking_Chiro, scientific medicine might have its flaws, but it’s no excuse for chiropractic not putting its house in order.

  • Thinking_Chiro says:

    Yep, we need to put our house in order, but it would be appreciated if you stopped shooting the house cleaners! Sustainable reform comes from within a profession with all support from without welcome, support the reformers!
    As for subluxation, it is taught in its historical context at most institutions here except CQU. New Zealand is also a problem when Brian Kelly was at the helm and they haven’t changed (Yet!).
    The quality of the research is improving, as is seen above and spinal and pain research in particular has exploded over the last 5 years across all professions. This is one of the reasons I now read so many journals as there is more and more cross pollination!
    As for the CAA, Facepalm! Why do you think I shifted to COCA 20 odd years ago!

    • Blue Wode says:

      Thinking_Chiro wrote: “As for subluxation, it is taught in its historical context at most institutions here except CQU.”

      Unfortunately, Australia doesn’t represent the rest of the world with regard to chiropractic education. You need to look at the broader picture.

  • JohnR says:

    Thinking chiro thankyou for clarifying the situation in Australia on the infant who was manipulated. it is good to see a more balanced view that is more informative. On the issue of subluxation this too is taught as an historical construct in the UK certainly at the AECC and WIOC and has been for many years and this is supported by the GCC and the BCA.

    There are however chiropractors in the UK who still use this out dated term and these are usually influenced by North American post graduate courses. However, BW and EE unfortunately only highlight this latter group and will never post anything positive about the chiropractic profession. You only need to look at their twitter feeds to see how they think. This is a great shame as this unbalanced approach, in my opinion, discredits them and leaves people wondering what their agenda really is.

  • Thinking_Chiro says:

    It is also a case of leadership by example. In Europe the Swiss and Danish chiropractors are great role models. In the USA I have seen good reports from Bridgeport University and Stephen Perle. who is closely associated with COCA here and has presented at their conferences and collaborated on research. I have even seen good research coming out of Palmer College over the last few years which is encouraging. Australia is not isolated and accountability fostered by blogs like this transcends borders! I am just bringing my local experience to the table!

  • Thinking_Chiro says:

    In reply to JohnR:
    Blue is very fixed in his ways and resistant to change, but Edzard may be different. Looking at what he has written over the years I get the feeling that he would be the first to publicly acknowledge and critically evaluate any good research when he sees it. The way he reads and evaluates a paper as a researcher is different to the way I read and apply it in practice as a practitioner.

    It is good to hear that subluxation is taught in its historical context only at those institutions.
    A good debate needs two participants otherwise it is just an unbalanced sermon pushing the agenda of one side. I enjoy my exchanges with Blue and it is all about putting both sides of the issue into the public record. Any reform needs this debate from without the profession and more importantly from within the profession. This is healthy and allows the profession to grow and evolve, otherwise business as usual leads to stagnation. Join the dabate and help push reform!

Leave a Reply

Your email address will not be published. Required fields are marked *


2 × four =

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

Recent Comments
Click here for a comprehensive list of recent comments.
Categories