MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

There is some (albeit not compelling) evidence to suggest that chiropractic spinal manipulation might be effective for treating non-specific back pain. But what about specific back pain, such as the one caused by a herniated disc? Some experts believe that, in patients suffering from such a condition, manipulations are contra-indicated (because the latter can cause the former), while others think that manipulation might be an effective treatment option (although the evidence is far from compelling). Who is correct? The issue can only be resolved with data from well-designed clinical investigations. A new trial might therefore enlighten us.

The stated purposes of this study were:

  1. to evaluate patients with low-back pain (LBP) and leg pain due to magnetic resonance imaging-confirmed disc herniation treated with high-velocity, low-amplitude spinal manipulation in terms of their short-, medium-, and long-term outcomes of self-reported global impression of change and pain levels
  2. to determine if outcomes differ between acute and chronic patients using.

The researchers conducted a ‘prospective cohort outcomes study‘ with 148 patients with LBP, leg pain, and physical examination abnormalities with concordant lumbar disc herniations. Baseline numerical rating scale (NRS) data for LBP, leg pain, and the Oswestry questionnaire were obtained. The specific lumbar spinal manipulation was dependent upon whether the disc herniation was intraforaminal or paramedian as seen on the magnetic resonance images and was performed by a chiropractor. Outcomes included the patient’s global impression of change scale for overall improvement, the NRS for LBP, leg pain, and the Oswestry questionnaire at 2 weeks, 1, 3, and 6 months, and 1 year. The proportion of patients reporting “improvement” on the patient’s global impression of change scale was calculated for all patients and for acute vs chronic patients. Pre-treatment and post-treatment NRS scores were compared using the paired t test. Baseline and follow-up Oswestry scores were compared using the Wilcoxon test. Numerical rating scale and Oswestry scores for acute vs chronic patients were compared using the unpaired t test for NRS scores and the Mann-Whitney U test for Oswestry scores.

Significant improvements for all outcomes at all time points were reported. At 3 months, 91% of patients were “improved”, and 88% were “improved” after 1 year. Acute patients improved faster by 3 months than did chronic patients. 81.8% of chronic patients 89.2% felt “improved” at 1 year. No adverse events were reported.

The researchers concluded that a large percentage of acute and importantly chronic lumbar disc herniation patients treated with chiropractic spinal manipulation reported clinically relevant improvement.

Does this new study meaningfully contribute to our knowledge about the effectiveness of chiropractic manipulation for back pain caused by herniated discs? The short answer to this question is NO.

A longer answer might be that the report does tell us something relevant about the quality of this research project. We know from countless studies that ~50% of patients experience adverse effects after spinal manipulations by a chiropractor. This means that any report claiming that NO ADVERSE EFFECTS WERE REPORTED is puzzling to a degree that we have to seriously question its quality or even honesty. In this context, it is relevant to mention that a recent review of the evidence concluded that a cause-effect relationship exists between the manipulative treatment and the development of disc herniation.

The positive outcomes reported in this new study could, of course, be due to a range of factors which are unrelated to the manipulations administered by the chiropractors:

  1. placebo-effects
  2. natural history of disc herniation
  3. regression towards the mean
  4. other treatments employed by the patients
  5. social desirability

To be able to say with any degree of certainty that the manipulations had anything to do with the observed positive outcomes would require an entirely different study-design. Should we assume that this is not known in the world of chiropractic? Or should we consider that chiropractors shy away from rigorous research because they fear its results?

The term prospective cohort outcomes study, seems to be a chiropractic invention (cohort studies are by definition prospective, and observational studies are usually prospective). It seems that, behind this long and impressive word, one can easily hide the fact that this study design fails to make the slightest attempt of controlling for non-specific effects; the term sounds scientific – but when we analyse what it means, we discover that this methodology is little more than a self-serving consumer survey. Most scientists would call such an investigation quite simply an OBSERVATIONAL STUDY.

I think it is time that chiropractors start doing proper research which actually does answer some of the many open questions regarding spinal manipulation.

127 Responses to Spinal manipulation for herniated discs? Chiropractors should start doing meaningful research

  • It was quite enjoyable to read this; the misleading use of scientific-sounding words and phrases is par for the course for pseudoscientists such as chiropractors. It is really a bit disheartening to see people you know are very intelligent and even well-educated fall for language like this. The problem at its root is a failure to question things, to ask “What, exactly, is meant by this-and-such term?” One sister took her daughter to a chiropractor because, this sister said, she likes the idea of “naturopathic” medicine. When asked if she had any idea what “naturopathic” even means, she couldn’t answer. You’ve got to question this stuff, really look into it, not just take it at face value because it sounds good.

    • Hi Larry,

      following your own advice and as a Chiropractor myself I am very interested in your definition of ‘pseudoscience’? As you just called me a ‘pseudoscientist’, I think it is only fair to ask this question, to be able to respond to your comment. Would you mind elaborating on this for me and let me know what exactly you mean by that?
      Looking forward to your response.

      Kind Regards,

      Ivo

      • Dear Ivo,

        Here are a few definitions of pseudoscience that Larry might have missed.

        “Pseudoscience includes beliefs, theories, or practices that have been or are considered scientific, but have no basis in scientific fact. This could mean they were disproved scientifically, can’t be tested or lack evidence to support them.”

        Read more at http://examples.yourdictionary.com/examples-of-pseudoscience.html#84vewFjzHisfRfx8.99
        ” A collection of beliefs or practices mistakenly regarded as being based on scientific method.’”

        “A system of theories or assertions about the natural world that claim or appear to be scientific but that, in fact, are not.”

        “pseudo-science may be defined as one where the uncertainty of its inputs must be suppressed, lest they render its outputs totally indeterminate”

  • Professor Ernst wrote:
    “In this context, it is relevant to mention that a recent review of the evidence concluded that a cause-effect relationship exists between the manipulative treatment and the development of disc herniation.” yet the abstract quoted appears to be a case report of osteopathic manipulation and cervical disc herniation, and has limited relevance to the subject of this blog.

    • Also, how does prof ernst explain the common finding of disc herniations in asymptomatic people?

      • he doesn’t

        • and why not?

          • not my area of expertise

          • Is it possible to conclude whether spinal manipulation cause disc herniations, when they occur in asymptomatic patients?

          • this depends on the situation/case, I guess

          • So how come you haven’t question the validity of the review you cited which states “that a cause-effect relationship exists between the manipulative treatment and the development of disc herniation”, if it depends on individual circumstance i.e cannot be generalised

          • because its authors had good reason to assume cause and effect in this case.

          • However, in the context of the sentence it is not a recent review of the evidence (as stated) but rather a finding in a singular case i.e a case report

          • Can you comment on how a case report is not a recent review of the evidence

            note – evidence means all data available

          • the article discusses other evidence as well; and, no evidence does not mean ALL data available.

          • Can you send a link to full article because the abstract does not describe any other evidence for spinal manipulation causing disc herniations other than the case report itself.

          • sorry, I have no link

          • So you used an abstract of a case report does not describe any other evidence for spinal manipulation causing disc herniations other than the case report itself. Is that a review of the evidence pertaining to spinal manipulation causing disc herniation? I would say a review of the recent evidence would include more than 1 case report

          • as I tried to tell you before: the article does discuss more evidence.

          • in case you want an article that is available in full online, you might try this one: http://www.ncbi.nlm.nih.gov/pubmed/12015249
            its abstract reads as follows:
            The aim of this systematic review was to summarize the evidence about the risks of spinal manipulation. Articles were located through searching three electronic databases (MEDLINE, EMBASE, Cochrane Library), contacting experts (n =9), scanning reference lists of relevant articles, and searching departmental files. Reports in any language containing data relating to risks associated with spinal manipulation were included, irrespective of the profession of the therapist. Where available, systematic reviews were used as the basis of this article. All papers were evaluated independently by the authors. Data from prospective studies suggest that minor, transient adverse events occur in approximately half of all patients receiving spinal manipulation. The most common serious adverse events are vertebrobasilar accidents, disk herniation, and cauda equina syndrome. Estimates of the incidence of serious complications range from 1 per 2 million manipulations to 1 per 400,000. Given the popularity of spinal manipulation, its safety requires rigorous investigation.

    • This only means that any researcher and, of course, any chiropractor should really make use of MRI.

  • Interesting study and a step in the right direction. I always enjoy searching PubMed to see what other research the authors have done.
    http://www.ncbi.nlm.nih.gov/pubmed?term=Humphreys%20BK%5BAuthor%5D&cauthor=true&cauthor_uid=24636109
    http://www.ncbi.nlm.nih.gov/pubmed?term=Humphreys%20BK%5BAuthor%5D&cauthor=true&cauthor_uid=24636109
    They also are collaborating with orthopods, physio’s and OT’s (among many others) within the same university and hospital. Good to see!
    http://www.balgrist.ch/en/Home/Unsere_aerzte/Alphabetisch.aspx
    They are also doing comparative studies on different approaches to the treatment of chronic LBP.
    This is the right model and approach.
    The chiropractic PhD’s are doing the same here working with a late career physio researcher, Prof Chris Maher at the George Institute (Sydney University), who just got ranked No 2 pain researcher in the world!
    This collaboration is occurring more and more.

    Some other interesting chiropractors doing the right research http://www.ncbi.nlm.nih.gov/pubmed/?term=Pickar%20JG%5Bauth%5D
    Joel Pickar is at Palmer College which now has a large research facility.
    http://www.ncbi.nlm.nih.gov/pubmed/?term=Bolton%20PS%5Bauth%5D
    Phillip Bolton is based in The University of Newcastle and Hunter Medical Research Institute. The same faculty which boasts N Bogduk, who has done brilliant work advancing our knowledge on the neurology of the spine, and who contributed a chapter to the book “Rehabilitation of the Spine” by chiropractor Craig Leibenson (standard course text for chiro’s and physio’s) and who is also collaborating with Gray Cook (Physio) and Stuart McGill (Kinesiology). I’m definitely going to their next seminar later this year!
    Food for thought!

  • Professor Ernst wrote: “…should we consider that chiropractors shy away from rigorous research because they fear its results?”

    Most definitely. For example, in the Journal of the Canadian Chiropractic Association in 2011, a chiropractor highlighted chiropractors’ fear of the consequences from negative results arising from high quality research:

    QUOTE
    “I was recently bewildered when colleagues and chiropractic representatives feared the possible negative consequences of good quality research and of its dissemination within and outside the profession.”

    Read on…
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154060/?tool=pubmed

    I take that as confirmation that many chiropractors are prepared to do whatever it takes to suppress inconvenient truths rather than lose their lucrative livelihoods (be that in chiropractic education, marketing, or running ‘successful’ practices).

    • Hi Blue,

      thank you for those comments. As a Chiropractor myself, I would love to do a research the way you want me to do. Unfortunately am I running short of a few 10s of millions of dollars to do so. I might knock on the door of pharmaceutical companies to see if they like to sponsor such research, but I have the suspicion that might not go down too well? Mmh, where does that leave us? Millions and millions of people around the world every year get blinded by us ‘pseudoscientists’ and we build our existence on solely placebo effect. That makes sense and you are probably well educated in the intricate system of the nervous system and understand quite too well what drives the brain and how it is nourished? Please remind me again what dysafferentation to the brain due to lack of or altered proprioceptive input does?
      Looking forward to hearing your response as I am eager to share with my patients your knowledge on this matter as you seem to be an expert in this field looking at your comment.

      Kind Regards,

      • @Ivo
        “I would love to do a research the way you want me to do. Unfortunately am I running short of a few 10s of millions of dollars to do so.” The eternal bleat from Big Snakeoil practitioners of all types that they can’t afford to do proper research is a humbug. There is nothing stopping you and your colleagues from applying for support to the many agencies and charities that fund research. In the USA you have an entire branch of NIH set up specifically to fund altmed research. In the UK there’s the MRC, the Wellcome Trust and Cancer Research UK, for starters. What all of these sources need is a well-thought-through proposal for a study with the potential to produce robust results. To judge from the comments of chiropractors on this blog that may be a big ask: you all seem to value anecdote above data.

      • ivo wrote: “I would love to do a research the way you want me to do. Unfortunately am I running short of a few 10s of millions of dollars to do so.”

        @ ivo

        In the United States there are c. 70,000 chiropractors who could easily generate the research funds if they wanted to. A chiropractor turning 8 appts/day, 5 days/week, 40 weeks/year, at $100/apt with a levy of just 1% ($1) raises $112 million PER ANNUM.

        Over to you.

      • Blue Wode beat me to it, but here’s my handy calculator that will help.

        Now, when will chiros start raising this money and what will they research first?

        Of course, it’d be extremely embarrassing when customers ask what this extra $1 on their bill is for: “Oh, that’s to pay for the basic scientific research into the chiro I’ve just charged you for to find out if they are safe and effective.”

  • Thinking Chiro could also have mentioned Kelly Holt, a graduate of the New Zealand College of Chiropractic most recently completed his PhD studies at Auckland University (within the School of Medicine). His thesis was entitled “The Effects of Chiropractic Care on Sensorimotor Function Associated With Falls Prevention in the Elderly”. The research involved detailed statistical analysis, biomechanical engineering, computer analysis and clinical practice via randomised controlled trial in addition to the complex neurophysiology underpinning the processes involved.
    Heidi Haavik, Research Director at the New Zealand College of Chiropractic completed a PhD in human neurophysiology at Auckland University in the areas of somatosensory processing, sensorimotor integration and motor cortical output and how this is affected by chiropractic management. She is currently engaged in international multi-disciplinary collaborative research projects looking further into the rationale for the effectiveness of chiropractic care.
    Research is occurring.

    • Is that the same Heidi Haavik who adjusts subluxations and lectures on how best to communicate vitalistic chiropractic to health professionals, patients, and the public?
      http://www.sca-chiropractic.org/files/Heidi%20Haavik%20Seminar%20April%202012.pdf

      • BW, yes and when you look at her qualifications and research, you will realise that she is far better qualified to talk on these topics, than you and your ilk.

        • Gibley Gibley wrote: “BW, yes and when you look at her qualifications and research, you will realise that she is far better qualified to talk on these topics, than you and your ilk.”

          It’s the science that matters, not a person’s qualifications. I note that Heidi Haavik has been investigating “…the effects of chiropractic adjustments of vertebral subluxations on somatosensory processing…”:
          http://chiropractic.ac.nz/index.php/reseach/faculty

          As chiropractic vertebral subluxations are a myth, she must be ‘adjusting’ imaginary lesions. But perhaps we should be too surprised given that she is a graduate of the *vitalistic* New Zealand College of Chiropractic.

          • BW, let me get this right?
            A researcher with a PhD in neurophysiology, with an prestigious award from the University of Auckland, is doing research into spinal dysfunction and the effects on the body does not have enough “science”, in your opinion……..so one begs to ask…..”What “science” do you have?

        • @Gibley Gibley
          Beneath that very thin façade of civility, shown in the post on the 15th, is the lurking personal attack of the 17th.
          If you can’t maintain civility, objectivity and not resort to ad hominems, why do you bother to post here? You’ll be found out soon enough.

  • In reply to Blue Wode:
    “Most definitely. For example, in the Journal of the Canadian Chiropractic Association in 2011, a chiropractor highlighted chiropractors’ fear of the consequences from negative results arising from high quality research:”
    I agree with you on that point Blue, but it is not unique to chiropractic, publication bias in medical research and clinical trials is a huge issue in medicine and medical journals.
    http://blog.f1000research.com/2013/06/10/negative-results-in-medical-research-and-clinical-trials-an-interview-with-ben-goldacre/
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2949220/
    It is an important topic that needs to be discussed!

    • Thinking_Chiro wrote: “…it is not unique to chiropractic, publication bias in medical research and clinical trials is a huge issue in medicine and medical journals”

      Are you saying that chiropractors should wait until medicine puts its house in order before they do any meaningful research?

  • Further in reply to Blue Wode:
    Thanks for the Martin Dascarreaux reference, I had overlooked his research and he is on my favourites list!
    http://www.ncbi.nlm.nih.gov/pubmed?term=Descarreaux%20M%5BAuthor%5D&cauthor=true&cauthor_uid=24992817
    Another chiropractor worthy of your support!

  • Apologies for the Phillip Bolton research link not working. Hope this one works better:
    http://www.ncbi.nlm.nih.gov/pubmed/?term=Bolton+PS

  • And the Descarreaux link, apologies!
    I’m technologically challenged!
    http://www.ncbi.nlm.nih.gov/pubmed/?term=Descarreaux+M

  • As one of the authors of the SMT and disc herniation paper, I would like to add my comments. I will let my co-workers add their comments later.

    This particular paper is one of a series of outcomes studies that we started at the University of Zürich and the University Orthopedic Hospital of Balgrist. The idea came from our collaboration with the Balgrist and University radiology departments and their outcome studies. They had been doing research on outcomes for spine and extremity joint injections and infiltrations and had developed a large database related to the spine and extremities. One of our authors, Dr. Peterson is part of both the radiology as well as the chiropractic outcome studies.

    We decided to use the same database format and methodology as the radiology departments had used. This allowed us to develop a database of over 3,000 chiropractic patients with neck or back pain as well as symptomatic lumbar and cervical disc herniation patients and also to compare results with the radiology database. We followed these patients from baseline, at 1 week, (2 weeks for the disc herniation patients), 1, 3, 6, 12 months. The results are reported for pain, physical disability as well as psychosocial variables. We have also looked at predictors of outcomes and published this for low back and neck pain patients treated by chiropractors.

    Coming to the real point, if you believe our research is poor even though we used the same methodology and database construction as the radiology research then is their research poor also? You cannot have it both ways. Here are some of the references.
    Peterson CK, Pfirmann CWA, Hodler J. European Journal of Radiology 2014, in press. Peterson CK et al. J. Manipulative and Physiological Therapeutics 2013; 36:218-225.

    As Chair of the Chiropractic program at the University of Zürich, my approach is to build research collaborations within the university and university hospitals. I have developed a number of good research collaborations which is the basis for our publications. If you consider this poor research then I think our medical collaborators would have a few things to say about it.

    • the study you cited has the following aim: ” to compare self-reported pain and “improvement” of patients with symptomatic, magnetic resonance imaging-confirmed, lumbar disk herniations treated with either high-velocity, low-amplitude spinal manipulative therapy (SMT) or nerve root injections (NRI).” And its conclusions were that “there were no significant differences in outcomes between NRI and SMT”.
      I think that this is quite a bit more sensible than the study I discussed here.

  • You may also want to look at the following:

    The development and implementation of an outcomes database for imaging-guided therapeutic musculoskeletal injections.
    Peterson CK, Pfirrmann CW, Hodler J. Skeletal Radiol. 2014 Jul;43(7):979-84. doi: 10.1007/s00256-014-1881-y. Epub 2014 Apr 16.

  • In reply to Blue Wode:
    “Are you saying that chiropractors should wait until medicine puts its house in order before they do any meaningful research?”
    No, the issue of publication bias is a significant issue for everyone. It should be discussed by everyone and chiro’s are like Descarreaux I cited above . Subluxation chiropractors fear research and the advances/chamges it fosters as you have said, and I agree with you. Chiropractors working with and learning from established medical researchers is a joy to see! The collaboration shown in the research cited above is great and you should support it whole heartedly!

    • Thinking_Chiro wrote: “No, the issue of publication bias is a significant issue for everyone.”

      Of course it is, but we’re talking about chiropractic here. Why change the subject?

      • Important to provide a balance prospective

        • AN Other wrote: “Important to provide a balance prospective”

          Compared to medicine, chiropractic is a much narrower field and the robust data that are in for it show that it cannot be justified. You cannot balance it against the field of medicine which – unlike chiropractic – has been proven to have enormous, scientifically-validated benefits despite publication bias in medical research journals. IOW, bias aside, you’d think that after nearly 120 years chiropractic research would have shown impressive, favourable evidence for at least one of its unique interventions.

          • Medicine has be sub divided into narrow fields too i.e. orthopaedics, neurology etc.

            I still think the important point is to present a balanced position. Publication bias affects all aspects of research – i am sure you have read Ben Goldacre Bad science and Bad Pharma.

            Therefore medicine like chiro has it problems with the issue of publication bias.

            Personally, i think chiropractic theory is a load of junk but possibly techniques used by manual therapists have there place in the care of musculoskeletal complaints.

  • Thanks for your comment.

    Our outcome studies are only the first step. We would like to follow up with RCTs but you need some sort of evidence before leaping into an RCT. So that’s what these studies are trying to do. Is there a basis for future large scale research. We think these studies have shown it is worth going forward.

    However one point, we never say that the improvement in the symptomatic disc herniation patients is DUE to the SMT. Of course we cannot say that without a control group but we are simply describing what happens to patients with this condition that also go through a trial of SMT.

    • 1) “…you need some sort of evidence before leaping into an RCT”. are you saying that there is no published evidence on this topic? if there is, I find what you say questionable.
      2) “Our outcome studies are only the first step. We would like to follow up with RCTs…” in this case, it was a pilot study! why did call it a ‘prospective cohort outcomes study‘? isn’t this giving it a gloss of rigor that it does not observe?
      3) from what you say, your aims seem to have been different than those stated in the published paper. why?

  • 1. This was a Swiss study using Swiss patients seen by Swiss Chiropractors. Is there a theme here? To get funding from Swiss government agencies we need evidence for what we do here. Do you have a problem with that?

    2. Now let me see, the study was prospective, it was on a cohort of patients with symptomatic disc herniation and it was an outcome study. Is there something you can’t understand about that?

    3. No.

    Have a nice weekend.

    • Whenever someone says “Have a nice weekend” in circumstances where they are being scrutinised and questioned, you can guarantee it is insincere and the opposite is hoped. People who try fake well wishing don’t seem to realise how fake it appears to everyone else.

      Is it a sign of a subjective mind that has difficulty of maintaining objectivity? From my experience, yes.

  • By the way, where is all your clinical research? Nice to hide behind some cherry picking systematic reviews but how about some of this so called ‘meaningful research?’

    Do you call a 1 person systematic review you did a few years ago ‘meaningful research?’

    You need a life man!

    • NICE ONE! when you run out of arguments, resort to AD HOMINEM!
      I have published ~40 clinical studies and ~300 systematic reviews (~ 20 for the Cochrane Collaboration), the vast majority with plenty of co-worker and international collaboration. Is that not enough for you?

      • speaking od AD HOMINEM, you are in plenty [but not good] company; I just received the following email from another chiro:
        I read your article about the death rate associated with chiropractic care and came to a completely different conclusion. I concluded the author is either a complete imbecile or a muderous swindler quite possibly both. How can you sleep at night. Knowing that you have scared people away from the safest of all primary health care systems (ave 1 death/3 years) toward the medical system that kills 750,000/year. Hell holds a special place for the likes of you. Repent now for the kingdom is neigh.
        Dr. Lee D. Pierce

        • Dr. Lee D. Pierce said:

          Repent now for the kingdom is neigh.

          “A horse, a horse, my kingdom for a horse!”

          Anyway, if you want to bring up the number killed by conventional medicine (your number is, of course, wrong), please also detail the numbers of lives saved by conventional medicine, the number of people living longer and with a higher quality of life because of conventional medicine, the number of babies who survive birth because of conventional medicine and the number of those who are suffering less and in less pain because of conventional medicine.

          And then give the same numbers for chiropractic.

  • You have no credibility because you have done systematic reviews with you as the only author!!!!!!!!!

    Until you can answer how it is scientifically legitimate to do a systematic review with one person which you have done then how can you criticize anyone?

    This is hardly petty comment. This is a serious methodological question.

    • I suggest you stop foaming from the mouth and show me the rule/ regulation/law that forbids a single author to publish a one-author systematic review [less than 1% in my case, I estimate] or would render such a thing disreputable.

    • Prof Kim Humfreys said:

      You have no credibility because you have done systematic reviews with you as the only author!!!!!!!!!

      Until you can answer how it is scientifically legitimate to do a systematic review with one person which you have done then how can you criticize anyone?

      This is hardly petty comment. This is a serious methodological question.

      Indeed. I can’t understand why any legitimate researcher would publish a systematic review with themselves as the sole author.

      • can I detect a bit of egg on Humphreys’ face? oh, no! it’s an entire omelette!

        • The paper which reads, in part;
          “Nevertheless there are opponents of the use of Ped MT for any pediatric condition citing that it may be harmful or ineffective [9]. Others suggest the controversy is part of an organized conspiracy against CAM professions by the pharmaceutical industry [10].”
          So Prof Kim is a conspiracy theorist as well as a purveyor of junk science. Oh, it does make me laugh when the “Big Pharma” conspiracy is dragged out by someone who thinks it gives them credibility.

  • Wow, getting a bit touchy aren’t you?

    http://www.york.ac.uk/inst/crd/pdf/Systematic_Reviews.pdf

    Look under the section ‘Review TEAMS.’ It does not say Review PERSON’

    A team is used to bring in different areas of expertise or are you an expert in everything? Also to reduce bias.

    Now that you have acknowledged you have done single reviews which is poor quality research, I am wondering what other methodological problems your ‘research’ has.

    Perhaps you should fix your own problems before trying to criticize others.

    Have a nice weekend.

    • you are getting ahead of yourself; I have not acknowledged that this I POOR QUALITY RESEARCH.
      and the guideline you cite says: “The review team will manage and conduct the review and should have a range of
      skills. Ideally these should include expertise in systematic review methods, information
      retrieval, the relevant clinical/topic area, statistics, health economics and/or qualitative
      research methods where appropriate. It is good practice to have a minimum of two
      researchers involved so that measures to minimize bias and error can be implemented
      at all stages of the review.” When I do a single author paper, I have all the expertise required for it. the guideline also does not say that this is poor practice. and even if it did, this would not automatically mean that the result is inferior.
      sorry, but your repeated AD HOMINEMs do not stick – only on you, I suppose.

  • The great advantage of a single author paper is that you know who did the work.
    Only too often the “senior author” on multi-author paper has tagged his name onto the work of research students or postdocs.

    It seems to be that after the Singh affair, the evidence has been tested to death. Almost everyone who isn’t making money out of chiropractic believes that’s it’s a silly myth, born from a 19th century fairground salesman, based on preposterous made-up “principles”. More to the point, it doesn’t work.

    It sounds as though the paper you are discussing is yet another inconclusive pilot study. Almost every paper about chiropractic, and just about every other sort of quackery, ends “more research is needed”. I suggest that in future that you keep quiet until you have some good evidence.

    I’ve learned one thing from this: the University of Zürich has a chiropractic programme. Pity -I’d always assumed that it was quite a good university.

    • @ Prof Colquhoun

      I think all trials should be published whatever the results.

      With regards low back pain research – there has probably been too much repetition of research and maybe there needs to be a view that conditions that do not have a clearly defined cause are at risk of being over researched and over treated

    • The Zurich medical faculty says this about it:
      “Chiropractic is, as a science-based treatment method, an alternative and / or complementary approach to the medical, surgical and physical therapy treatments of many diseases and disorders of the musculoskeletal system. Since autumn 2008, it is possible to study chiropractic at the Medical Faculty of the University of Zurich. The Department of chiropractic is affiliated to the Balgrist University Hospital”
      They has also recently appointed Claudia Witt as Professor (Full) and Chair of Natural Medicine. I was on the appointment panel and left in protest. Witt happens to be an ex-homeopath and has published more research in homeopathy than anyone else in recent years; practically all her conclusions are favourable for homeopathy. I published an analysis of her work here: http://www.csicop.org/si/show/homeopathy_a_critique_of_current_clinical_research/

  • There are nö advantages to a 1 person systematic review. That is why all standards for Systematic reviews have the Team approach. Please find me one quality refernce saying a 1 person review is Even acceptable.

    Weren’t you at Exeter a Long Time ago? Nö comparrison to UZH.

  • Most chiropractors have moved on from that myth! Few colleges and universities teach it except in its historical context.
    Every profession needs its critics both internal and external as this fosters reform and best practice. Attacking the critic is an anathema and goes against the philosophy of critical thinking! I enjoy my exchanges with the critics and it pushes the reform process. The only frustration is the carpet bombing of the profession as the chiropractic reformers become unacceptable collateral damage!

    In reply to Prof. B. Kim Humphreys:
    When I first started reading Edzards research and blogs I was very angry and thought “more of the usual attacks from one of the high priests of the medical temple”, but as I read more and more of his articles my initial anger changed as I had to agree with much of what he said! Reform or lack there of needs its critics and I have come to appreciate his work! You put a huge amount of work into your research and become very protective and attachecd to your babies, but you must expext to be examined and criticised. If a critic fires a paper at me I fire a paper back and it is a thoroughly enjoyable process. Accept the criticism in good grace.
    Thankyou for your research and I look forward to reading more!

  • AN Other wrote: “Medicine has be sub divided into narrow fields too i.e. orthopaedics, neurology etc.”

    But those narrow fields have good, scientifically proven evidence for them whereas chiropractic hasn’t.

  • But that doesn’t address the issue of publication bias affecting all fields – it is important to present the full picture.

    So, medicine does have proven evidence and chiro doesn’t – they are still both affected by publication bias.

  • What you say is true. But not the whole picture. If you do not state the same issues occur in other professions, people will not know that it does.

    • AN Other wrote: “If you do not state the same issues occur in other professions, people will not know that it does.”

      If there was good, scientific evidence for chiropractic, then comparing bias in chiropractic with bias in medicine would be fair comment (balance). However, let’s have some decent evidence for something that’s uniquely chiropractic before we make any comparisons with medicine’s shortcomings.

  • In reply to Blue:
    “But those narrow fields have good, scientifically proven evidence for them whereas chiropractic hasn’t.”
    This depth of evidence is assumed. The college of surgeons puts the percentage of surgical procedures backed by research at optimistically 20%, they are deeply concerned about this as the accountants move in. They put this low figure down to lack of funding, difficulty recruiting surgeond and difficulty recruiting patients. Some areas are highly researched but the malority is a case of this is how we have always done it and it works. Unfortunately, that is anecdote!

  • In reply to Blue Wode:
    “why don’t chiropractors start doing meaningful research?”
    There are Blue you are just dismissive of it. One of my favourite researchers is Charlotte Leboeuf-Yde
    http://www.researchgate.net/profile/Charlotte_Leboeuf-Yde
    http://www.ncbi.nlm.nih.gov/pubmed/?term=leboeuf-yde+c

  • Gibley Gibley wrote: “BW, let me get this right? A researcher with a PhD in neurophysiology, with an prestigious award from the University of Auckland, is doing research into spinal dysfunction and the effects on the body does not have enough “science”, in your opinion.”

    It’s how the science is being applied that’s the problem.

  • In reply to Blue:
    “I don’t see much of her work being published in respected journals, and none of it has – as far as I know – been accepted by medical science as robust evidence for ‘chiropractic’.”
    Respected journals:
    C&MT
    Trials
    Best Practice and Research: Clinical Rheumatology
    BMC: Musculoskeletal Disorders (Where she is also an editor)
    European Spine Journal
    Arthritis research and therapy
    BMC Medicine
    Journal of Clinical Epidemiology
    Spine
    BMC Medical Research Methodology
    Scandanavian Journal of Rheumatology
    Arthritis and Rheumatism
    Acta Radiologica
    The Spine Journal
    Clinical Rehabilitation
    Journal of the Canadian Chiropractic Association
    JMPT
    That is a sample from her first four pages of PubMed only. These are leading peer reviewed journals in Orthopaedics, medicine, neurology, rheumatology, radiology, rehabilitation, trials, chiropractic and physiotherapy. For a chiropractor to be published in highly regarded medical journals is to be applauded, not dismissed!

    I agree with your comment on standardization as Edzards latest blog on the lack of it in the USA is relevant. Having said that, I have local GP’s doing homeopathy, naturopathy, acupuncture (he has 8 rooms going at once and a queue out the door for free acupuncture) which are definitely non-standard for medicine, yet they claim it on the public purse!

    • Thinking_Chiro wrote: “These are leading peer reviewed journals in Orthopaedics, medicine, neurology, rheumatology, radiology, rehabilitation, trials, chiropractic and physiotherapy.”

      I was thinking more along the lines of theNew England Journal of Medicine, theJournal of the American Medical Association, and the British Medical Journal.

  • BW, you must be exhausted from shifting the goal posts all the time to suit your restricted and limited argument. Stop, please stop!!!! You have lost.

  • In reply to Blue Wode:
    Lynton Giles
    http://www.ncbi.nlm.nih.gov/pubmed/?term=Giles+LG
    BMJ and Lancet among others.
    He has also had some interesting exchanges with Edzard over the years!
    Another chiropractor I admire!

    • Hopefully Giles is a truly rational chiropractor (essentially a physiotherapist), unlike Heidi Haavik who appears to have strong chiropractic philosophy leanings, and who, as far as I know, hasn’t been published in the BMJ or the Lancet or similar.

      • BW, when you have to resort to tired sarcasm like that, in an attempt to denigrate an argument, you have lost it. Give up now as you are just making a fool of yourself. Quite frankly, you do not know what you are talking about.

  • Lynton Giles is now retired. His body of work is impressive and essentially chiropractic dating back to the 1970’s! Another chiropractic leader and reformer worthy of your support!

  • Speaking of chiro’s who are published in British Medical Journal…. here you go….. Aron Downie…. http://www.ncbi.nlm.nih.gov/pubmed/24335669

    • @ Alex, Chiro

      Whilst it is commendable to see a chiropractor published in the British Medical Journal, it has done nothing to further the quest for robust evidence for ‘chiropractic’. What’s more, I see that Aron Downie is on the staff of the Chiropractic Department at Macquarie University, New South Wales. That is hardly a ringing endorsement of his academic prowess when you consider that Macquarie is set to drop its chiropractic degree because it wants to build on the university’s recent major strategic investments in *research-intensive* areas of biomedical science and engineering:
      http://www.announcements.mq.edu.au/others/proposed_changes_to_chiropractic_at_macquarie

      Additionally, I believe that this is Aron Downie’s Facebook account:

      QUOTE
      “Downie Chiropractic is a family practice that focuses on musculoskeletal conditions of the spine and entire body. Specific areas of interest include rehabilitation, sports and paediatric care.
      http://www.facebook.com/pages/Downie-Chiropractic/130873700305207?sk=info

      In the wake of the unsuccessful British Chiropractic Association v. Simon Singh libel case, is there now good evidence for chiropractic for children?

      • ” is there now good evidence for chiropractic for children?”
        I think I can answer this one: no!
        what follows, I think, is that chiros who continue to treat paediatric conditions are outside the boundaries of evidence-based practice [to put is politely].

  • In response to Blue Wode:
    Have a look at the other authors Blue, they include Prof Chris Maher who was recently ranked No 2 pain researcher in the world.
    Aaron and the other MQU chiro PhD’s are doing their research at the George institute at Sydney Uni due to lack of support at MQU.
    As for stated investment in research intensive Engineering and Medicine, the private hospital is in trouble and I hear through the medical grapevine that it is in the process of being bailed out by Ramsay Health. As for their Advanced specialist training; when I discussed this with an extremely highly placed surgeon he rolled his eyes and said “so they think they are better than the major teaching hospitals!” As for engineering, I have talked to friends, two who are very senior, and they are unimpressed.
    As for Aaron’s FB page have you gone through it? It is solid how to play safely, posture , musculoskeletal etc for children. Zero BS!

    • zero BS and Zero connection to chiropractic, I’d say.

      • Thinking_Chiro wrote: “Have a look at the other authors Blue”

        I have. Please explain what they’ve added to the evidence base for ‘chiropractic’.

        Thinking_Chiro wrote: “As for Aaron’s FB page have you gone through it? It is solid how to play safely, posture, musculoskeletal etc for children. Zero BS!”

        But that’s not true chiropractic. Further, it helps to lend an air of legitimacy to ‘paediatric’ chiropractors, nearly all of whom continue to base their practices on pseudoscientific concepts. Here’s the problem:

        QUOTE
        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.”

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

  • We’ve had this discussion in regards to “Bait and Switch” before. As for standard PT and Sports Med masquerading as chiro, the core text used by both chiro’s and physio’s for rehab of the spine is written by a chiropractor (Craig Liebenson) with chapters fron McKenzie and Bogduk among others. Much of the work used comes from work done at the Prague school of medicine by Janda and Co. Liebenson has done a lot of work with them. You have physio’s adopting more and more chiropractic techniques. If you look at how a physio in private practice 25 years ago compared to now, they have shifted more towards chiropractic than you realise especially in regards to the spine! They even have manipulative therapists now who are as bad as the worst evangelical vitalistic chiropractors. To assume that the traffic is all one way is naive to say the least!

    “But that’s not true chiropractic.”
    You need to make the distinction between outdated and modern chiropractors Blue, my doctors do, my patients do and so should you. That is what helps the reform process.

    • Thinking_Chiro wrote: “You have physio’s adopting more and more chiropractic techniques…They even have manipulative therapists now who are as bad as the worst evangelical vitalistic chiropractors.”

      Do you have any good citations to show that physiotherapists are ‘adjusting’ spines to correct ‘subluxations? If so, can you show that their numbers as high as chiropractors (i.e. the majority)?

      Thinking_Chiro wrote: “You need to make the distinction between outdated and modern chiropractors Blue, my doctors do, my patients do and so should you.

      How do your doctors and patients make that distinction? Is the method they use widely available (advertised) to other MDs and patients? What part do the chiropractic regulators and trade bodies play in making the distinction clear to everyone?

      • Tiresome bait and switch, BW. Up to your old tricks again. Unless you have something constructive to add, please do not bother making any posts.

  • But there are 4,500 physios in the UK who practice acupuncture!

    • @ AN Other

      There are over 47,000 physios in the UK, so that is less than 10% of them. A greater concern is the 76% of UK chiropractors who deem traditional chiropractic beliefs (chiropractic philosophy) to be important, and the 63% who admit that the (mythical) chiropractic subluxation is central to chiropractic intervention. Ref:
      http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1188-the-scope-of-chiropractic-practice-a-survey-of-chiropractors-in-the-uk.html

      • Checking again it is actually 6000 physio who practice acupuncture – so that is two times the amount of chiros and about the same number of osteos. So there is more physios who are practicing woo than the 2 other professions.

          • @ AN Other

            Your new figure indicates that around 12% of UK physiotherapists use acupuncture. Considering that acupuncture is likely to be one of many interventions used by them, the figure of 60%-70% for UK chiropractors who *base* their practices on spinal manipulation/adjustment pseudoscience remains a far greater concern.

            It’s also important to look at the global picture. I note that there are around 184,000 physical therapists in the U.S. and around 60,000 chiropractors. I’m not sure how many U.S. physical therapists use acupuncture, but if the figure was similar to the UK, then that would put the number at around 22,000. However, we know that nearly 90% of U.S. chiropractors view chiropractic as a panacea, so that means that the number of pseudoscientific chiropractors in the U.S. stands at around 54,000 – potentially more than twice the number of U.S. physical therapists who use acupuncture as an adjunct intervention.

            Anyway, I don’t know what highlighting the minority of physiotherapists who perform acupuncture has got to do with the topic at hand – i.e. the enormous reluctance of chiropractors to conduct meaningful research.

          • So you don’t mind physios using acupuncture?

          • What would you define as meaningful research?

          • for instance, studies that rigorously address the questions of efficacy or safety

          • Thank you Prof Ernst.

            How do you feel about professions using non-evidence based techniques?

          • if it’s in my area of expertise, I feel like educating them.

  • In reply to Blue:
    “How do your doctors and patients make that distinction?”
    Its called the referral network Blue. Its the doctors and also my bread and butter and its based around professional reputation. It took me years to develop my reputation and gain the trust of my local doctors and patients. When I first started practice I got a lot of anti-referrals (Don’t see a chiro), this changed to quiet tolerance and finally into open dialog and referrals. I now get referrals from doctors who I have had no previous interaction, but they know about me and they know how I practice.

    “What part do the chiropractic regulators and trade bodies play in making the distinction clear to everyone?”
    Good question! Here we have COCA who are very proactive on all the important issues. AHPRA and the chiropractic board are also becoming far more active as I have noted previously. CAA is being dragged kicking and screaming in the right direction, but have a ways to go!
    The piecemeal, non standardized, variable regulation in the USA is source of facepalms to us all.
    This makes the critics and reformers within the profession a valuable resource that must be supported!
    Well written external criticism is also vital to the reform process!

    “Do you have any good citations to show that physiotherapists are ‘adjusting’ spines to correct ‘subluxations?”
    They have not adopted the “S” word, they use the “V” and “W” words, Vitalism and wellness which is just another way to justify overtreating!

    • Thinking_Chiro wrote: “CAA is being dragged kicking and screaming in the right direction, but have a ways to go! The piecemeal, non standardized, variable regulation in the USA is source of facepalms to us all.”

      IOW, the regulation of chiropractors continues to be largely useless due to the regulators’ apparent approval of the pseudoscience that underpins the industry.

      Thinking_Chiro wrote: “They [physiotherapists] have not adopted the “S” word, they use the “V” and “W” words, Vitalism and wellness which is just another way to justify overtreating.”

      Citations re their numbers, please.

  • Every other time I tell people what I have learned about the chiropractic pseudoscience and switch-and-bait tactics, up pops someone who knows someone who was miraculously saved from an incapacitating bout of lower back pain by a chiro.
    Maybe there is something to it?
    The question is whether the specific and professional looking manipulations of vertebrae as exemplified by the chiro in the above linked video is doing constitute a theatrical or a therapeutic part of his performance.
    Is it just smoke and mirrors as they simply soothe, reassure and massage and get the patient to relax and start moving as in this video? To me it does not look very miraculous as it took a couple of hours and I have myself gotten over the worst spasms in similar situations with a good painkiller, massage, ice and forcing myself to get moving.

    Since we are at the movies you will also enjoy this glittering, 6 minute promotional presentation of a chiropractic that reminds me very much of my (former) chiro’s. No wheelchairs, ambulances or grimacing faces but a lot of impressive looking machinery, enticing catchphrases and theatrical moves. He even seems to be able to diagnose a bulging disc from foggy plain-films. That’s what I call x-ray eyes.

    My impression is that a very large part of the clientele of chiropractic the world over are happy, smiling, worried well and healthy children who have no use of such services whatsoever but mesmerised by the professional air and the fancy “Dr.” before the name.

    • @ Bjorn

      What is a good painkiller? Are there bad ones?

      What does massage do? – another theatrical placebo?

      I agree that chiropractic philosophy / theory is rubbish. But are all the techniques used by chiros ineffective. If they same techniques are used by physios are they still ineffective?

      Maybe back pain is a condition that just occurs from living. Do you know that the more developed a country becomes the more people report to physicians with low back pain! It could be that people learn to go to a physician with their pain – but because low back pain doesn’t fit nicely into a biomedical model, it becomes over-treated, poorly treated and misunderstood.
      In this void, professions have stepped in to provide treatment – maybe it is time for professions to step out. However, in a society used to a quick fix by a pill, this may be easier said than done.

      • The world would be filled with wheelchair-riders if chiropractic manipulation was essential for lumbago and sciatica.

        – What is a good painkiller?
        Short answer: A good painkiller is one that works.
        A painkiller that works has side effects. That is to be expected and can be dealt with.
        If you are preoccupied, as so many friends of alternate realities are, with the perceived evils of authentic medicine and choose to emphasise on the negatives and deplore the goods of effective medicines. If that is your preference, so be it. We are not talking about prolonged, unnecessary use of analgesics here.

        As I have on numerous occasions related here before, I used to have bad bouts of lumbago once or twice every year until I realised it was my own fault due to an excessively sedentary lifestyle. The eye-opener was being leg-pulled by a useless, income-driven chiropractor who tried to convince me I would remain a pain-riddled, immunocompromised weakling if I did not pay him for weekly or at least semi-weekly 2-minute theatrical performances including wringing my neck, which had never given me problems.

        – Massage…?
        Good massage has nothing in common with the chiropractic antics that I have seen. My chiro never massaged or suggested such. Massage (properly energetic massage, not cranio-, Bowen or similar pathetic light fondling) has a few important components.
        1. Massaging out of oedema from muscles affected by prolonged inactivity and/or spasm.
        2. The soothing, relaxing, reassuring effect of a good massage, aided by the dimmed lights and candles so often utilised as reinforcing agents.
        3. Last but certainly not least: TOUCH! Many modern people are touch- and hug-depleted. Humans and animals alike need the benefit of touch and warmth. A family physician laden with experience once called it ‘Skin hunger’ when a person exhibits stress-like symptoms due to lack of human touch, an all too common deficiency 🙂

        – Do the chiropractic-specific manipulations do anything more useful than physiotherapy?
        Shitty x-rays, back-thumping, hip-hopping, neck wringing and clicker-prodding peculiar to the chiropractic ‘Theatre de l’absurde’ is amply demonstrated in the second promotion video I linked to in my prior post. Considering all the available evidence, repeatedly drawn up here in EE’s blog, these antics cannot provide anything useful for the hordes of smiling worried-well who frequent the chiropractic waiting room, excitedly getting their bi-weekly attention to an imaginary problem no-one but chiropractors can diagnose or define. And probably neither for the occasional acute sufferer even if they are led to believe in a miracle, as I reasoned in the previous comment.
        My question in the previous comment was whether the chiro’s perhaps could have one particular trick in their sleeve that enabled them to perform a miracle for acute lumbago/sciatica. My own evaluation is that they have not.

        – Why so many people in western/modern societies seek medical/alternative attention for back pain?
        Simple. The keyphrase is of course ‘sedentary lifestyle’. Hard working people of less privileged societies mostly keep their backs active.
        Also, it is to some extent a neo-cultural phenomenon where the demands of the overprotected offspring of generation-X for physical perfection and flawless health are not met by busy physicians with 10-15 minutes per visit, a boring attitude and meeger powers of persuasion.

        Just my two eurocents worth… 😛

  • AN Other wrote: “So you don’t mind physios using acupuncture?”

    I mind physiotherapists using acupuncture as much as I mind MDs using homeopathy – i.e. I’m not happy about it, but expect that they will discard the interventions eventually. On the other hand, I am not at all confident that chiropractors will ever reform in an acceptable way.

  • What would be an acceptable way for chiropractors?

    Also why do you think that MDs and physios will discard these interventions – they decided to use them in the first place?

  • AN Other wrote: “What would be an acceptable way for chiropractors?”

    I think this quote lifted from the ‘Spine Salesmen’ chapter of the book, The Health Robbers: A Close Look At Quackery In America, answers that:

    “If a chiropractor limited his practice to musculoskeletal conditions such as simple backaches, if he were able to determine which patients are appropriate for him to treat, if he consulted and referred to medical doctors when he couldn’t handle a problem, if he were not overly vigorous in his manipulations, if he minimized the use of x-rays, and if he encouraged the use of proven public health measures, his patients would be relatively safe. But he might not be able to earn a living.”

    The entire chapter can be read here:
    http://www.chirobase.org/12Hx/hr76.html

    AN Other wrote: “Also why do you think that MDs and physios will discard these interventions – they decided to use them in the first place?”

    Because the robust, recent data are beginning to show conclusively that both interventions are placebos. As that awareness grows, I think we’ll witness physiotherapists and MDs gradually discarding them – not least because they don’t have to rely on quackery for their livelihoods.

    • They seem to be using them to improve their income otherwise they wouldn’t be using them. What would be an appropriate amount of time for Physios and MDs to discard these techniques?

      If they are practicing EBM – they should be able to do it immediately, especially if they don’t have to rely on them for their livelihoods. The same standard should apply to chiros and their overuse of SMT.

  • In Reply to Blue:
    “If a chiropractor limited his practice to musculoskeletal conditions such as simple backaches, if he were able to determine which patients are appropriate for him to treat, if he consulted and referred to medical doctors when he couldn’t handle a problem, if he were not overly vigorous in his manipulations, if he minimized the use of x-rays, and if he encouraged the use of proven public health measures, his patients would be relatively safe. But he might not be able to earn a living.”
    Thanks Blue, you just described my practice and I am very busy. I help more patients, get more medical referrals, see each patient less and transition them onto active care (where they help themselves) as soon as possible. I help the 90% that doctors see, not the 10% most chiropractors see! I like the fruit at the top of the tree!

    In reply to Björn Geir:
    Weekly treatments are totally unwarranted and make the patient dependant on chiropractic instead of making them independant. As for chronic difficult backs, I have the reputation with my doctors as the go to guy for challenging backs, but I set treatment goals and time frames to achieve them and if these are not met then I refer on. Doctors respect this attitude and it generates referrals. Chiropractors who think they are a universal panacea is one of the major complaints I hear from doctors, and I agree with them! I work with local doctors, physio’s, personal trainers, remedial masseurs, exercise physiologists and specialists. The neurosurgeon I refer to the most often refers them back telling me he is not ready and to continue managing the patient. He is very conservative!

    The medical acupuncture society is very politically active here with a growing membership. A GP near me has 8 rooms running at once and bulk bills it to the public purse! Very lucrative and the patiients are queued out the door!

  • In reply to Blue:
    This gem from your neck of the woods. Sounds familiar!
    http://www.energymedphysio.org.uk/index.asp
    Or my nech of the woods:
    http://www.acnem.org/
    400+ doctors into homeopathy etc!

  • In Reply to AN:
    “Where are you practicing and how did you get to the position you are in now?”
    Sydney, Australia.
    Years of sending reports to doctors and a long relationship with the medical centre in the office suite next to me. Then when they bought a shopfront and expanded they invited me to join them. Additionally, doctors gossip like old women, so the doctors I work with also became my advocates within the medical profession.

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