MD, PhD, FMedSci, FSB, FRCP, FRCPEd

It has long been argued that chiropractic spinal manipulations are mere placebo interventions. Yet few controlled trials have assessed the efficacy of spinal manipulative therapy (SMT). No high quality trials have been performed to test the efficacy and effectiveness of Graston Technique® (GT), an instrument-assisted soft tissue therapy.

The objective of this trial was to determine the efficacy of SMT and GT compared to sham therapy for the treatment of non-specific thoracic spine pain.

People with non-specific thoracic pain were randomly allocated to one of three groups: SMT, GT, or a placebo (de-tuned ultrasound). GT is a popular soft-tissue technique in the United States and becoming more popular in other developed countries. GT is an instrument-assisted soft-tissue therapy involving the use of hand-held stainless steel instruments. The promoters of the GT claim that the instruments resonate in the clinician’s hands allowing the clinician to isolate soft-tissue “adhesions and restrictions”, and treat them precisely. Each participant received up to 10 supervised treatment sessions at Murdoch University chiropractic student clinic over a 4 week period.

The two outcome measures were self-administered instruments. Participants were given blank questionnaires in a package by a research assistant following their first treatment. Participants were instructed to complete the instruments at each assessment time point. After completion of the forms the participant posted them back to the Murdoch University Chiropractic Clinic. Research assistants remained blind to the outcome data for the entire study period. The participants and treatment providers were not blinded to the treatment allocation as it was clear that the groups were receiving different treatments. Participants in the placebo group were blinded to their placebo allocation until follow-up was complete at 12 months. Participants were surveyed for the adequacy of the placebo blinding at the end of the study.

Treatment outcomes were measured at baseline, 1 week, and at one, three, six and 12 months. Primary outcome measures included a modified Oswestry Disability Index, and the Visual Analogue Scale (VAS). Treatment effects were estimated with intention to treat analysis and linear mixed models.

One hundred and forty three participants were randomly allocated to the three groups (SMT = 36, GT = 63 and Placebo = 44). Baseline data for the three groups did not show any meaningful differences. Results of the intention to treat analyses revealed no time by group interactions, indicating no statistically significant between-group differences in pain or disability at 1 week, 1 month, 3 months, 6 months, or 12 months. There were significant main effects of time (p < 0.01) indicating improvements in pain and disability from baseline among all participants regardless of intervention. No significant adverse events were reported.

 

12998_2016_96_Fig3_HTMLThe authors concluded that this study indicates that there is no difference in outcome at any time point for pain or disability when comparing SMT, Graston Technique® or sham therapy for thoracic spine pain, however all groups improved with time. These results constitute the first from a fully powered randomised controlled trial comparing SMT, Graston technique® and a placebo.

Some people claim that there is little wrong with placebo therapy, as long as it helps patients. This is not what I think, but even the proponents of this argument would agree that the placebo used in this way has to be safe. As SMT is by no means free of adverse effects, the argument cannot be applied here.

Other people will argue that this is about SMT and not chiropractic implying that I am conducting a vendetta against the poor chiropractors. I would disagree: we have just learnt that 93% of chiropractors consider SMT as their primary treatment. Yes, osteopaths and physiotherapists also use SMT but certainly not to this extent. Thus this discussion is mostly about chiropractic, and the onus is on chiropractors to demonstrate beyond doubt that SMT does more good than harm.

The true significance of this study is, I think, that the chiropractic profession now must convince us that spinal manipulation has any usefulness at all. They will have to conduct rigorous trials along the lines of this study to test for which condition these interventions generate outcomes that are significantly better than those achievable by sham.

Until such data are available, it would be wise, I think, to consider all therapeutic claims made for chiropractic unproven and bogus.

WATCH THIS SPACE!

138 Responses to Chiropractic treatments are placebos

  • An excellent analysis.
    I feel it would be possible to have a placebo controlled trial by all groups being told “you will receive one of three types of treatment: GT, SMT,or ‘de-tuned ultra sound’.”

    IMHO, treatment with a placebo is still ‘treatment’, not a sham treatment (even if it uses sham procedures – in this case, detuned ultra-sound).
    This is not semantic sophistry, but the reality of medical practice.
    Nothing wrong with TLC, providing patients give fully informed consent to what is involved.
    Which most chiropractors are disinclined to obtain.

    My book, Real Secrets of Alternative Medicine (just published on Amazon and Kindle), reveals more!

  • No doubt the usual suspects will be right along to tell you that this is all a fraud perpetrated by pharma shills, but to me this looks entirely unsurprising. There are no really effective therapies for this pain, but even that misses the point, which is that virtually every therapeutic intervention turns out to be less effective than its original proponents claim. Even if we ignore the obvious nonsense of innate and subluxations, it is no surprise at all to find that a treatment invented by one man in isolation over a century ago turns out to be weak to the point of ignorable.

  • “Until such data are available, it would be wise, I think, to consider all therapeutic claims made for chiropractic unproven and bogus.”

    That’s interesting since the last Job Analysis reported that:

    98.8% of chiropractors give advice on posture and ergonomics.
    98.5% promote exercise and fitness
    97.3% advise changing unhealthy habits

    But perhaps EE made an error and meant to say “…all claims made about SMT”?

    But then again, one has to question regarding the research paper…what percentage of chiropractors only do SMT or only use Graston (R) since apparently that’s what this project really studied?

    • You can get advice about posture and diet from a reality-based health practitioner. The fact that not *everything* they say is abject nonsense does not excuse the fact that most of what they actually *do* is based on nonsense.

      • thanks Guy – you were faster than I to answer this.
        reminds me of the German joke where the secretary teaches the doctor to not say ‘good bye’ to his patients leaving his office, but to say ‘take good care’. this way, she can claim an extra payment from the insurance system for ‘medical advice given to patient’.

      • So you disagree with Ernst statement…good.

        • Typical SCAM proponent: everything must be boiled down to either supporting or opposing the enemies of SCAM. No, I do not disagree with Prof. Ernst’s statement, I read it and interpret it in the way I stated.

          In much the same way that A vs. A+B trials can never yield a negative result, X vs X+Bullshit comparisons will always appear to favour the SCAM proponent. In reality, the question is:

          1. Does this person promote bullshit or do they stick to the facts?
          2. Do they know and accept their limitations?
          3. Are equivalent benefits available from providers who have a better track record in the above two criteria?

          Chiropractors almost all promote bullshit; they show no signs of accepting their limitations; and the evidence very clearly shows that at least equivalent benefit can be obtained from other providers.

          So: chiropractors can get in the sea.

          • Actually you did disagree with Ernst. He wrote “all”, you wrote “not everything.”

            Granted I suspect you will try to spin it by “your interpretation” but it’s above for all to see.

          • As a True Believer, obviously you see the need to view tax world in black and white, with all nuance totally invalidating any critical opinion you don’t like.

            The problem is your end.

          • @ Guy…”As a True Believer, obviously you see the need to view tax world in black and white, with all nuance totally invalidating any critical opinion you don’t like.”

            No, I understand the limitations of the research as it applies to how these therapies are usually being utilized in a clinical setting.

            What we need to know is if SMT has an additive (or synergistic) effect within a multimodal approach and for which subgroups. Some well designed pragmatic studies would give us insight. I’ve been calling for such studies for years.

          • Here is a list of all the research which unambiguously establishes chiropractic theory and practice as a valid distinct intervention for any health condition:

            I didn’t miss any.

          • Guy: Here is a list of all the research which unambiguously establishes chiropractic theory and practice as a valid distinct intervention for any health condition:”

            I love how you guys set up your position…nice use of word qualifiers.

    • Doc Dale, What percentage advise their clients to make another appointment?

    • It matters none the percentage of chiropractors who utilize SMT or Graston. What this study clearly shows is that both are either placebos or no better than placebos.

      I’d like to see a follow-up study that compares these outcomes to no formal treatment at all (i.e. bed rest, OTC meds, heat/ice packs, stretching, mild exercise, etc.). No, wait…. I wouldn’t–it won’t change the outcome one iota.

      • “It matters none the percentage of chiropractors who utilize SMT or Graston”

        Your right, it matters not.

        “What this study clearly shows is that both are either placebos or no better than placebos.”

        Uh, did you even read the authors view on the limitations of the study?

        • Doc Dale – I’m just wondering if that “Doc” is a medical qualification, or are you a quack? I’m wondering mainly because your approach to evidence seems to be the classic quackery apologist’s MO.

          Like the study results? It’s incontrovertible.
          Don’t like the study results? Look for limitations on methodology, attack the authors for bias or conflict of interest, assert some other study you *d* like as completely invalidating the results, and if all else fails attack the person citing the study.

          • Nope…a study can stand or fall on its own regardless of the results. Its the clinical interpretation that skeptics seem to struggle with.

            The OP study…with its high drop out rate, students do some of the adjusting and soft tissue work, mixture of acute, subacute and chronic conditions, symptom directed care, nonspecific diagnosis, etc…the most surprising thing is that it even got published.

          • I notice you didn’t answer the question. Are you a practising quack? A chiropractor perhaps?

            Your objections to this study are spurious. Prof. Ernst is not suggesting it is the final definitive answer (that’s what quacks do, they pretend every single positive result is definitive regardless of any contradictory studies). This study stands on its merits as one more data point in the body of evidence that clearly shows chiropractic to be a clinical dead end.

          • hear, hear!

          • Guy: “This study stands on its merits as one more data point in the body of evidence that clearly shows chiropractic to be a clinical dead end.”

            It’s not a good study. Trying to tout the study as good evidence, well, it makes skeptics look silly. So be it.

          • it’s better than the average chiro study, in my view.

          • EE: I have no doubt you believe that.

          • It appears no worse (and a lot better) than most other studies in this area. As with most quackery, it is a field beset by atrocious studies designed to support belief rather than test a hypothesis.

          • Guy: “It appears no worse (and a lot better) than most other studies in this area.”

            It makes skeptics look desperate, I guess that’s their choice.

          • Thank you, Guy, for taking the words right out of my mouth. Nicely expressed.

        • Acknowledgment of limitations are a necessary part of any well-structured and responsible research. However, the irrefutable results of this study put any observed limitations in proper, irrelevant perspective.

          This study that you are so tenaciously attempting to refute is the first of what I hope are many nails in the coffin of this ubiquitous quackery.

          I advocate insurance companies dropping this shameful practice as a covered procedure… sooner than later.

          • @Norman. A true skeptic is one that remains objective when evaluating evidence. It appears you have lost that ability, assuming you ever had that ability. Hence it appears you are a pseudo-skeptic and not a very good one at that and thus a waste of my time. You can have the last word if you like.

          • A true skeptic is one that remains objective when evaluating evidence

            You have to love lessons in skepticism from a member of a 19th Century cult.

          • Dale (no, I won’t acknowledge your moniker “Doc”): Ah, yes. Yet ANOTHER attack on the integrity of the person rather than a cogent rebuttal. But I digress…

            The bigger picture here is that you continue your diatribe against others on this thread, yet choose to end your interaction with me without even once providing a sensible rebuttal. All the while I kept personal attacks out of the discussion.

            I take that as the ultimate compliment. Thank you!

            And, yes, thank you for letting me have the last word. I feel so…. grateful.

            P.S. Please respond to earlier requests to actually tell us your credentials. I’ll be eagerly watching and waiting.

  • Odd the study hasn’t been published in a peer reviewed journal

  • So interesting…

    One skeptic says “chiropractic treatments are placebos”

    Another skeptic says “… at least equivalent benefit can be obtained from other providers.”

    • The two statements are not incompatible. The benefits of chiropractic treatment are, as far as the best evidence shows, small, possibly even negligible as this study says, and transient. Temporary relief is also obtainable through reality-based treatments. Thus there is no reason to go to a chiropractor, with the attendant dis benefits of indefinite courses of unnecessary treatment, adverse effects up to and including death, which are met with outright denial, anti-vaccine activism, failure to understand the legitimate scope of practice and so on.

      Why go to a witch doctor for an aspirin rather than a pharmacist? There is no potential upside, other than for the witch doctor.

    • @Doc Dale

      Where’s the inconsistency? You don’t have to go to a chiropractor and thereby swallow all the underlying quasi-mysticism about how the body works to benefit from placebo treatments. A massage, a heat treatment, even a friendly word from an empathetic doctor or nurse can sometimes work apparent miracles by the placebo effect.

      • There is, in any case, no inconsistency between a study that finds outcomes to be consistent with placebo and studies that find outcomes to be no better than reality-based treatments, because as far as I can tell most reality-based treatments for chronic back pain are also no better than placebo. We are, bluntly, shit at treating chronic back pain. And chiropractors have noticed that this is a little gold mine, people will present when it hurts, receive treatment, regress to the mean as they would have done anyway, credit the treatment due tot he usual cognitive biases, and thereby become potential converts tot he cult, ripe to be sold subluxation theory, chiropractic “wellness” treatments, supplements sold from the office and all the other paraphernalia of SCAM.

        • @Guy…”because as far as I can tell most reality-based treatments for chronic back pain are also no better than placebo. We are, bluntly, shit at treating chronic back pain.”

          And this is probably why…

          Smudging of the Motor Cortex is related to the Severity of Low Back Pain
          http://www.researchgate.net/…/55397aa00cf226723aba1a87.pdf

          ISSLS Prize Winner: Smudging the Motor Brain in Young Adults With Recurrent Low Back Pain http://corebalancetherapy.com/wordpress/wp-content/uploads/2013/03/Hodges-Smudging-the-motor-brain-CLBP-Spine-2011.pdf

          Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain http://brain.oxfordjournals.org/content/131/8/2161.full

          Driving plasticity in the motor cortex in recurrent low back pain http://www.pilatesinstitute.com.br/site/aluno/aluno-restrito/conteudo/paul_hodges/plugin-Driving%2520plasticity%2520in%2520the%2520motor%2520cortex%2520in%2520recurrent%2520low%2520back%2520pain.pdf

          Cortical changes in chronic low back pain: Current state of the art and implications for clinical practice http://cdn.bodyinmind.org/wp-content/uploads/Cortical-changes-in-chronic-low-back-pain-Current-state-of-the-art-and-implications-for-clinical-practice.pdf

          I can’t find it! Distorted body image and tactile dysfunction in patients with chronic back pain http://www.bodyinmind.org/wp-content/uploads/Moseley-2008-PAIN-i-cant-find-it.pdf

          Disrupted Working Body Schema Of The Trunk In People With Back Pain. http://cdn.bodyinmind.org/wp-content/uploads/Bray-Moseley-2009-BJSM-left-right-body-rotation-stuff.pdf

          SMUDGING THE MOTOR BRAIN IN RECURRENT LOW BACK PAIN: P55 http://journals.lww.com/spinejournalabstracts/Fulltext/2011/10001/SMUDGING_THE_MOTOR_BRAIN_IN_RECURRENT_LOW_BACK.312.aspx

          • I don’t think the scientific community is anywhere near getting to the bottom of this yet. Those papers represent some interesting results but are a very long way from being definitive. This is true of a lot of disorders that lack objective quantifiability. And some of those fields – especially neurological research – are prone to what I think could charitably be described as flights of fancy.

            One thing is close to certain, though: the correct role of “subluxation” and “innate” in back pain management is the same as the role of unicorns in transport policy. This will remain the case until the chiropractors show said things actually exist. A chiropractor who does not believe in subluxation or innate is not actually a chiropractor.

          • “A chiropractor who does not believe in subluxation or innate is not actually a chiropractor.”

            We Hear that all the time from the straight group….it’s their security blanket. I suppose some skeptics need to cuddle up to it as well.

          • “A chiropractor who does not believe in subluxation or innate is not actually a chiropractor.”

            We Hear that all the time from the straight group….it’s their security blanket. I suppose some skeptics need to cuddle up to it as well.

            You hear it because it is actually true. Subluxation theory and innate are the things that make chiropractic what it is. If you are a back-cracker and you don’t believe in those things then you are a manual therapist not a chiropractor, and you should be proud of that. Anybody who uses the chiropractic brand is associating themselves with dangerous charlatans.

          • Guy: “Subluxation theory and innate are the things that make chiropractic what it is.”

            The majority of chiropractors do not hold onto those antiquated beliefs and definitions espoused by DD Palmer on subluxation and innate. The majority have moved on, it seems some skeptics have not (there are several papers published on the beliefs and practices of current chiropractors, skeptics should familiarize themselves with those papers to reduce the risk of looking foolish).

          • Guy: “Subluxation theory and innate are the things that make chiropractic what it is.”

            The majority of chiropractors do not hold onto those antiquated beliefs and definitions espoused by DD Palmer on subluxation and innate. The majority have moved on, it seems some skeptics have not (there are several papers published on the beliefs and practices of current chiropractors, skeptics should familiarize themselves with those papers to reduce the risk of looking foolish).

            You should try reading my comment again, this time focusing on the actual words and not the potential implications for the brand on which you base your livelihood.

            Subluxations and innate are the definition of chiropractic. That is simple historical fact. Now obviously as medicine evolved out of the dark ages the practitioners retained the title, but that was a reasonably coherent community all moving along an evidence-based path: chiropractic was invented from whole cloth by one man, and was operated more or less as a cult by his son.

            Those who are moving away from the cult of subluxation are not evolving chiropractic, they are simply splitting the difference between outright quackery and the reality-based practice of manipulative therapy. Many mixers still offer bullshit like supplements and cranial osteopathy, still claim to treat colic in infants. It is possible for someone who was once indoctrinated into chiropractic to drop *all* bogus treatments, but at that point they are no longer a chiropractor.

            If you don’t provide treatment for colic and other conditions unrelated to the musculoskeletal system, if you don’t sell supplements from your office, if you don’t offer “wellness” or maintenance “adjustments” then sure, you’re no longer a quack – but you’re also no longer actually a chiropractor because you have discarded practically everything that is taught by the chiropractic schools.

          • No, it’s more like telling a Catholic priest who has abandoned the doctrines of transubstantiation and virgin birth and is instead promoting just being nice to people, that he is no longer a Catholic.

          • Guy: “No, it’s more like telling a Catholic priest…”

            The comparison to osteopathy is the better example.

          • You may find other comparisons more ideologically acceptable, but a glance at the history of chiropractic shows that what defines chiropractic is its signature bullshit: subluxations and innate. If you don’t believe in these, and stick strictly to evidence-based treatments, then you’re not a chiropractor – and you should be proud of that and distance yourselves from a cult which includes such dangerous lunacy as the McTimoney crowd.

          • Guy: “If you don’t believe in these, and stick strictly to evidence-based treatments, then you’re not a chiropractor – and you should be proud of that and distance yourselves from a cult…”

            There is much discussion within chiropractic circles on how to distance themselves from the “cult”. The current desire is for the EB crowd to maintain the title chiropractor and the “cult” to call themselves something else…like spinology. However, that presents many ego-based issues.

            The most feasible option is to create an advanced program with a different title or add on. This is currently underway in some areas.

            Regardless, there are several camps under the umbrella of chiropractic and for someone to claim that those who currently use that title must belong to just one camp based solely on historical content, well, it’s just silly and ill-informed dribble.

          • There is much discussion within chiropractic circles on how to distance themselves from the “cult”. The current desire is for the EB crowd to maintain the title chiropractor and the “cult” to call themselves something else…like spinology. However, that presents many ego-based issues.

            First among the ego based issues is that the reality based people have dropped everything that makes chiropractic what it is, and if they want to hold on to the title then they will have to fight off a substantial majority who promote quackery to some degree or other. The 99% of charlatans do give the 1% of ethical practitioners a bad name.

          • Well, that gets into how one defines quackery and a modality from a profession

            http://dictionary.cambridge.org/us/dictionary/english/quackery

          • While there may be dispute at the margins, there are a few things that can be unambiguously identified as quackery. These include:

            * Supplements sold with structure and function claims
            * Anti-vaccinationism and other wedges used to sow distrust of doctors and science
            * Intravenous vitamins
            * The chiropractic subluxation and Innate
            * Spinal manipulation for colic or any other disorder unrelated tot he musculoskeletal system
            * Cranial osteopathy
            * Applied kinesiology, skin resistance, hair analysis and other fraudulent diagnositc techniques
            * Manipulation of infants (actually this is also child abuse)
            * Full spine X-rays to diagnose “subluxation”
            * Maintenance adjustments and other “wellness” treatments
            * Diagnosing purported imbalances using two scales, plumb lines, leg measurments and so on

            All these have been observed in chiropractic offices. The list is, I am sure, incomplete.

            And if you don’t do any of those things which are quackery then you are not a chiropractor, and should rejoice in the fact.

          • Well, that gets into how one defines quackery and a modality from a profession http://dictionary.cambridge.org/us/dictionary/english/quackery

            Guy: “While there may be dispute at the margins, there are a few things that can be unambiguously identified as quackery.”

            The point raised was how one defines quackery. That determines the identifiers.

          • I wonder if anyone determine to what mode of therapy these descriptions refer (without searching for the words)?

            X is a system of diagnosis and treatment for a wide range of medical conditions. It works with the structure and function of the body, and is based on the principle that the well-being of an individual depends on the skeleton, muscles, ligaments and connective tissues functioning smoothly together. To Xs, for your body to work well, its structure must also work well. So Xs work to restore your body to a state of balance, where possible without the use of drugs or surgery. Xs use touch, physical manipulation, stretching and massage to increase the mobility of joints, to relieve muscle tension, to enhance the blood and nerve supply to tissues, and to help your body’s own healing mechanisms. They may also provide advice on posture and exercise to aid recovery, promote health and prevent symptoms recurring.

            A Y will treat both the symptoms and the root cause of a condition with aim to alleviating symptoms and preventing reoccurrence whenever possible. Because the body is treated as a whole, treatment for long-term and repetitive problems is particularly effective. Y encourages the skilled use of a variety of techniques and exercise advice to affect an improvement and to reduce symptoms. Not all Ys will use all of these techniques, only those with the relevant qualifications. When necessary, an Y will refer you to other professionals including your GP and Consultant specialists.

            Zs are concerned with the framework of bones and muscles that support the body (the ‘musculoskeletal system’). Some problems of the musculoskeletal system can be caused by accidents, stress, lack of exercise, poor posture, illness and everyday wear and tear. These problems may cause pressure on the nerves in the body. Depending on your condition, the Z may manipulate parts of your spine or joints and give you advice on exercise, selfhelp, diet and lifestyle. Some Zs also offer rehabilitation programmes. Manipulation involves precisely handling or moving joints, or parts of the spine, sometimes moving them further than they would normally move.

          • @Alan Henness

            I got 1 and 3 right (I checked by googling the text). I’d never heard of no. 2.

            Osteopathy, from these quotes. actually comes over as slightly more loopy than chiropractic. The problem (as others have pointed out on this blog) is that, in the USA, osteopaths are first fully trained in medicine before they choose to incorporate the lunacy. Elsewhere in the world anyone with a string of sausages as a tool can set themselves up as an osteopath.

            I guess that setting oneself up as an Osteopath or a Chiropractor (or an Acupuncturist or a Homeopathist, etc. etc.) is the SCAM equivalent of specialists in real medicine. We tend to value any specialist title — e.g. Gynaecologist, Radiologist, Oncologist, Surgeon, even — as somehow ‘better’ than a mere ‘Doctor’ (mostly assumed top refer to a GP).

  • @Alan (on Monday 23 May 2016 at 16:23)
    Brief excerpt from the Wikipedia article on “Religion”:

    Religion is a cultural system of behaviors and practices, world views, sacred texts, holy places, ethics, and societal organisation…

    It doesn’t really matter which of the different developmental branches of the archaic Bonesetter cult you cite.
    All the modern branches of religion that have derived from it (osteopathy, osteomyology, chiropractic, naprapathy, kinesiology etc.) share very similar scriptures, rites and business concepts. They all have their deities and prophets and all pretend to be able to work miracles by manhandling the body and its appendages in various ways. Chiropractic is no novelty, only a commercialised rebranding of age old practices.

    The indignant, sometimes belligerent knee-jerk type reactions we observe here in response to rational critique are yet another manifestation of the religious nature of the modern bonesetter cultures.

  • Has anyone on this thread actually looked into Graston Technique? It is primarily used by physiotherapists and is also calles Instrument Assisted Soft Tissue Mobilization (IASTM). Perhaps honesty in tagging Edzard:
    “Posted in alternative medicine, chiropractic, clinical trial, critical thinking, medical ethics”
    In reply to Doc Dale:
    This is the site for Carpet Bombing! All chiro’s here are rabbid subluxationists! I have had this conversation with the regulars on many an occasion!

  • Critical_Chiro

    There are several issues in the original blog, I only pointed out a couple before getting side tracked with Guy.

    Chiropractic does not own spinal manipulation. The words are not synonymous. It’s misleading to treat them as such.

    Chiropractors typically use a multimodal approach. SMT is a common tool. It is not a “chiropractic treatment”.

    Poor research is poor research. An unwillingness to acknowledge it as such just because it provides confirmation bias is, well, in this case, ironic.

    To use the above approaches indicates a strong bias against an entire profession and will most likely cloud their ability to objectively analyze new evidence….at least that’s the pattern I’ve seen over the past 20 years.

  • Dale said:

    Chiropractic does not own spinal manipulation. The words are not synonymous. It’s misleading to treat them as such.

    Chiropractors typically use a multimodal approach. SMT is a common tool. It is not a “chiropractic treatment”.

    GPs typically uses a multimodal approach. What makes a chiro?

  • Edzard you wrote :

    “Edzard on Thursday 26 May 2016 at 06:10
    and you think that really happens?
    in which country do you live?
    any evidence?”

    Please check this website : https://projects.propublica.org/docdollars/
    After checking I know my MD , dentist ..etc.. goes on seminars payed by big pharma… and don’t tell me they get payed travel expenses and what not for free…

    Check this :
    http://www.nbcwashington.com/investigations/Does-Your-Doctor-Cash-in-on-Drug-Company-Money-197059261.html

  • Edzard
    Having performed your critical appraisal on this paper, would it meet your selection criteria standards for inclusion into a systematic review on SMT?

    • my SR would most likely be about the clinical effects of acupuncture; they were not a primary endpoint for this study, and the trial was underpowered and quantified them by non-validated instruments. so [depending on the exact text of my protocol] the answer would most likely be NO.

      • Thank you Edzard, I assume this is a reply to my question regarding a SMT/chiropractic SR and you made a slip with the word acupuncture?

        So you did pick up on the modified ‘Low Back’ Oswestry Disability Questionnaire and the lack of validity, sensitivity and reliability of such when measuring ‘Thoracic Disability’.

        I am curious, considering the above renders 50% of the measured outcomes as unreliable and that there are a number of other issues with this study:
        underpowered (as you say), process of randomisation, unequal group size, limited baseline measures, inclusion of ‘overwhelming’ number of long term pain (>3months) subjects, high loss to follow up, students performing assessment and treatment under supervision… why did you NOT include this in your summary above?

        More importantly why did you offer this paper up to your readers as a ‘rigorous trial’ as though it has something to add to the evidence base for SMT or chiropractic?

        • I AM SO SORRY!
          I was completely elsewhere [I was thinking about one of the acupuncture posts above], please disregard my previous answer.
          I try again: yes, this trial would be considered for a SR.

          • Thank you for the apology.
            My original question was about inclusion in an SR not consideration. So would you mind trying again?

          • I would consider it for inclusion, and most likely it would get included; but it all depends on the exact wording of the protocol.

        • For folks to parade the paper as good evidence, well, it says more about those folks than the actual paper.

          How did one person here put it? It’s not as bad as the average bad paper.

          I guess in their minds that makes the paper good evidence?

          Tsk, tsk.

          • “For folks to parade the paper as good evidence, well, it says more about those folks than the actual paper.”
            no, it says a lot about chiro studies; I doubt that you can show us many that are of better quality – please try!!!

  • Actually, it says a lot about those who want to use this paper as some type of good evidence.

    EE: “The true significance of this study is, I think, that the chiropractic profession now must convince us that spinal manipulation has any usefulness at all.”

    • evidence in medicine is not an absolute; it often is about the ‘best available’ – and that study belongs in this category, don’t you think?

      • There is a lack of high quality research on SMT for non-cardiac chest pain. Adding another low quality paper into the mix doesn’t really help answer the question.

        Using a low quality paper to claim “Chiropractic treatments are placebos”, well, tells me more about the author than the paper.

        • and the defence of chiropractic by a chiropractor tells us what?

          • Calling a paper for what it is is not defending chiropractic. Pretending it is something that it is not is what is revealing.

          • it is one of the better studies in this area! are you deaf?

          • Thanks for the exchange…it’s been very revealing regarding your ability to objectively do, uh, views and reviews.

          • there is not much objectivity needed to realise that this study is not amongst the worst chiros have been publishing.

          • EE: “there is not much objectivity needed to realise that this study is not amongst the worst chiros have been publishing.”

            Based upon the many issues that are apparent and surfaced within this study, the study design needs some serious modification.

            Personally, I wouldn’t be so bold (or foolish) as to make a declaration that this study shows, “chiropractic treatments are placebos”.

            I doubt any objective and qualified reviewer would make such a statement based upon this study.

            You appear comfortable doing so, that falls upon you.

          • “Personally, I wouldn’t be so bold (or foolish) as to make a declaration that this study shows, “chiropractic treatments are placebos”.”
            Yes, of course, you are a chiro!

        • The lack of high quality research is easy to understand. No ethics board worthy of the name would approve human trials where there is no remotely plausible reason to expect any benefit other than to the practitioner’s wallet.

          • A better study would be to see if SMT has an additive effect…as utilized by most chiropractors.

          • Doc Dale,

            There is no need for “a better study”: an A + B versus B trial will always produce a positive result (an additive effect), which is why this study design is so popular within the sCAM empire.

          • @Doc Dale

            “A better study would be to see if SMT has an additive effect…as utilized by most chiropractors.” Great idea. Another A vs A+X trial… which has been explained ad nauseum on this blog can only produce positive results for X!

          • Pete and Frank:

            Nah, that’s not what I was thinking. More like:

            ABC+D
            vs
            ABC+E

            Where ABCD is usual chiropractic care
            D is SMT
            E is a sham

            Of course, parameters would be set on what constitutes ABC. Personally I’d stick with more evidence based stuff like exercise, stretching, Ergonomics, rehab, etc… That stuff most chiropractors do.

          • When you say “usual chiropractic care”, do you mean manipulation plus bullshit (I.e. usual care as practiced by most Chiros) or do you mean something you claim to be distinct from manipu,action despite there being no difference which is either provable or evident to onlookers?

          • Guy: “When you say “usual chiropractic care”, do you mean manipulation plus bullshit (I.e. usual care as practiced by most Chiros) or do you mean something you claim to be distinct from manipu,action despite there being no difference which is either provable or evident to onlookers?”

            I briefly covered this topic earlier. But based upon the latest Job Analysis (2015) this is what I consider “usual chiropractic care” (one can argue at what percentage one requires for it to be considered “usual”)

            Health promotion utilization on a daily basis:

            Ergonomics postural advice. 98.8%
            Physical fitness/exercise promotion 98.5
            Changing unhealthy behavior 97.3
            Nutrition dietary advice. 97.0
            Stress reduction 97.5
            Self care strategies 98.1
            Disease prevention 92.5

            Passive adjunctive:

            Cryotherapy 89.9%
            Trigger point therapy. 86.8
            Bracing 83.1
            E stim 76.6
            Moist heat 71.3

            Active adjunctive (2009)

            Correct therapeutic exercise 96.8%
            Rehab exercise of spine 92.3
            ADL advice 84.6
            Rehab exercise extremities 84.3

          • I am still siting for you (or indeed any other chio) to identify any element of chiropractic which us both unambiguously valid, and distinct from non-chiropractic practice.

            The list you provided includes things like posture advice which have been entirely mainstream and offered by real medical professionals for my entire working life. The few things we see which are distinct to chiropractic, smell strongly of duck and do not appear to gave a sound evidence base.

            It is almost as if all real research is done by orthopaedic specialists, sports medicine researchers and so on, and chiropractic innovates only in ways of charging people more money.

          • Guy: I am still siting for you (or indeed any other chio) to identify any element of chiropractic which us both unambiguously valid, and distinct from non-chiropractic practice.

            DD: I guess one could say that chiropractic “takes” the various applicable elements from other “distinct” professions and puts them together into one office package (and yes, some take from the wacky side of things). If one goes to a PT one most likely won’t get nutrional advice. If one goes to a MD one most likely won’t get a manual muscle release. If one goes to a dietician one most likely won’t get postural advice, etc, etc, etc. If one goes to a chiropractor they may get a package centered around a more wholistic and more natural approach. (I suspect you know all of this already but I’ll play along for now).

            Guy: It is almost as if all real research is done by orthopaedic specialists, sports medicine researchers and so on…

            DD: I spend a lot of time on PubMed doing searches. I’ve probably shared over a 1000 research papers on FB for discussion over the past year or two. Many papers that I have share were with the intent of giving us insight of the NMSK system and related systems as it relates to what we do. Yes, most research I have shared was not done by chiropractors. I consider that unfortunate.

          • Many chiros hire out one of their rooms to an acupuncturist and/or other sCAM practitioners so, yes, chiros are offering A+B+chiropractic+D…, which is more effective than chiropractic alone. Placebo_A + Placebo_B + Placebo_C + Placebo_D… versus Placebo_C will always produce a positive result.

            Similarly, providing dietary advice + exercise advice + a recommendation to smoke cigarettes + ergonomics advice, versus smoking cigarettes, will always produce a positive result. However, this does NOT lead to the logical conclusion that a practitioner who is providing all of this advice is providing efficacious health care. It leads to the conclusion that such a practitioner is nothing other than a quack.

          • Pete: “yes, chiros are offering A+B+chiropractic+D…, which is more effective than chiropractic alone. Placebo_A + Placebo_B + Placebo_C + Placebo_D…”

            Do you understand that there is a chiropractic model of healthcare? That is not just SMT? That my approach included a sham? That there is evidence that things like exercise and rehab have evidence of being effective for some spinal conditions? That we clearly don’t know if adding SMT to a combined approach of exercise, ergonomics, lifestyle changes, rehab, etc (which a majority of chiropractors do) if it improves outcomes and if so for which conditions/subgroups? That within 3 different professions, DCs, PTs and DOs, that many seem to think/find that adding SMT to those other approaches appears to improve clinical outcomes? That in all my searches of research that I have done that I have yet to find one quality research paper that properly investigates that primary question? That most human based research on SMT really only applies to the small, and often quacky group, that says, “I only adjust the spine, nothing else”?

          • @Doc Dale

            “Personally I’d stick with more evidence based stuff like exercise, stretching, Ergonomics, rehab, etc… That stuff most chiropractors do.” You don’t have to be a chiropractor to do that stuff.

            I’ve asked the following question twice before and no-one has deigned to reply. Perhaps you will do the honour. What is it that chiropractors do that makes chiropractic distinct from other medical support services, particularly physiotherapy and osteopathy? If you leave aside nonsense like subluxations, which many chiros tell us are passé, if you don’t support the concept of vitalism and you’re not anti-vaccination, precisely what is it that underpins the status of chiropractic as a separate ‘profession’?

          • Frank: What is it that chiropractors do that makes chiropractic distinct from other medical support services, particularly physiotherapy and osteopathy?

            For the most part, nothing in what chiropractors “do” separates themselves from those professions. PTs can “do” what DCs can “do” and vice versa (there is some limitation in scope that separates the two professions, but PTs are moving forward). Of course, DOs have pharmaceutical rights whereas most DCs and PTs do not and most DOs shy away from manual therapy, but more are becoming interested in adding it into their practices (so says researchers anyway).

            The separation comes mainly from how chiropractors view the body (particularly the NMSK system, but for some they also include the visceral system and cognitive aspects) as a unit, not a bunch of unconnected parts. DOs had this view historically (perhaps it’s still taught), PTs are beginning to grasp it, at least I am seeing hints of it within their research publications.

            Is the realty-based chiropractic profession obsolete/risk of becoming so? Yep, I’ve been telling them that for years. Those that I hang with are looking at refinement of the profession to find/fill a niche. Whether they can do so before time runs out we will have to wait and see (I say they have 10-15 years before the bubble completely bursts, longer if they can significantly distance themselves from the wacky doodles within the profession).

            Of course, the above is mostly just my opinion and personal view of the status.

            Does that answer your question?

          • Doc Dale,

            I understand both its business model and its ‘health care’ model. I also understand the difference between “effective” [for the practitioners] and “medically efficacious” [for the clients].

            Thanks for asking.

          • Pete: well, I have my doubts that you understand based upon your response.

          • Doc Dale

            Thank you for answering my question. I understand you’re speaking for yourself and your view of things, not for other chiros.

            You acknowledge you are doing nothing particularly different from physiotherapy then say: “The separation comes mainly from how chiropractors view the body (particularly the NMSK system, but for some they also include the visceral system and cognitive aspects) as a unit, not a bunch of unconnected parts.” Wow! That’s deep thinking!

            I view my car as a unit, and drive it as a unit, but if something goes wrong with it I expect my garage to diagnose which part or parts have malfunctioned. For some malfunctions I expect to refer to a specialist mechanic. That might give particularly dim-witted people the impression that all mechanics view a car as “a bunch of unconnected parts”. Such an impression would, of course, be inaccurate. Every mechanic, even those who only ever deal with transmissions, carburettors, or exhausts, knows perfectly well they’re working on part of a functioning whole.

            But, hang on a minute, you said: “chiropractors view the body (particularly the NMSK system, but for some they also include the visceral system and cognitive aspects) as a unit.” That bit in the brackets means you or some of your colleagues don’t really view the body as a unit. Just the NMSK system. But the definition of a ‘system’ is “a set of things working together as parts of a mechanism or an interconnecting network; a complex whole”. However you look at it, your answer is trying to say something meaningful, but it’s really pure dissembling and evasion. When you try to differentiate (your view of) chiropractic as treating the body as a ‘unit’ you refer to a ‘system’, which is per se built up from units.

            I’m sorry, Doc Dale. I hoped for an answer that might persuade me there is some substance to differentiate chiropractic from a misguided, unsubstantiated faith. I appreciate your willingness to post prolifically on this blog, but you are failing to do chiropractic any favours.

          • The bit in brackets indicates that some of them are probably dangerously delusional. We can tell easily enough: ask them about subluxations, innate, or treatment of conditions other than musculoskeletal pain.

          • Frank: You acknowledge you are doing nothing particularly different from physiotherapy

            DD: therapeutically there is not much difference. Regarding scope of practice there is a difference. For example, last I saw only 2 states in the USA allow PTs to order X rays. I don’t think any state allows a PT to read the X rays. I don’t think reading X rays is even a part of the DPT program yet. They must rely on an MD. DCs do not need an MD for those services. So in that sense, there is a big difference.

            Frank: then say: “The separation comes mainly from how chiropractors view the body (particularly the NMSK system, but for some they also include the visceral system and cognitive aspects) as a unit, not a bunch of unconnected parts.” Wow! That’s deep thinking!

            DD: comes down to acknowledging, understanding and addressing compensation patterns.

            Frank: But, hang on a minute, you said: “chiropractors view the body (particularly the NMSK system, but for some they also include the visceral system and cognitive aspects) as a unit.” That bit in the brackets means you or some of your colleagues don’t really view the body as a unit. Just the NMSK system.

            DD: some have taken an approach of just dealing with the NMSK system and referring out for other issues. Most, from my conversations, accept a relationship between the spine and the visceral system but don’t hold to the traditional view that subluxations cause disease.

            Frank: But the definition of a ‘system’ is “a set of things working together as parts of a mechanism or an interconnecting network; a complex whole”. However you look at it, your answer is trying to say something meaningful, but it’s really pure dissembling and evasion. When you try to differentiate (your view of) chiropractic as treating the body as a ‘unit’ you refer to a ‘system’, which is per se built up from units.

            DD: I’m not sure of your point.

            Frank: I’m sorry, Doc Dale. I hoped for an answer that might persuade me there is some substance to differentiate chiropractic from a misguided, unsubstantiated faith.

            DD: I wouldn’t assume that anything I write is going to persuade you to change your thinking.

            Frank: I appreciate your willingness to post prolifically on this blog, but you are failing to do chiropractic any favours.

            DD: my posting here is not with the intention of doing chiropractic “any favours”.

          • I am certainly still no closer to understanding what differentiated a chiro from an osteo and a physio. ISTM that how they ‘view the body’ is an empty phrase.

          • Has more to do with stuff like this…

            Individuals with CAI appear to have altered diaphragm contractility, which may be an illustration of diaphragm dysfunction and central nervous system changes in CAI population. The association between CAI and altered diaphragm contractility provides clinicians a more comprehensive awareness of proximal impairments associated with CAI.

            http://www.ncbi.nlm.nih.gov/pubmed/27232242

          • And stuff like this…

            Cervical positive sagittal alignment in adult patients with thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach MCID at 2-year follow-up despite having similar baseline HRQOL to patients without CD.

            http://www.ncbi.nlm.nih.gov/m/pubmed/26360147/?i=2&from=%2F25978077%2Frelated

          • Doc Dale wrote: “Health promotion utilization on a daily basis:… Nutrition dietary advice 97.0[%]”

            I can’t be bothered to point out all of the bullshit terms in your lists, but the above is worthy of mention: There is no such thing as “Nutrition dietary advice”.

            “A registered dietitian (RD) or registered dietitian nutritionist (RDN), is a dietitian who meets all of a set of special academic and professional requirements, including:

            – the completion of a bachelor’s degree with an accredited nutrition curriculum;
            – satisfactory performance on the registration exam;
            – an internship at an approved health-care facility, foodservice organization, or community agency” — Wikipedia, retrieved 2016-05-30.

            In many countries, including the UK, the term “dietitian” is a legally protected title. Anyone and everyone can call themselves a “nutritionist”, and sell dietary supplements at inflated prices.

          • Pete, you seem to be lost in the purpose of the discussion. This seems to be a recurrent issue with you. When you get caught up I may consider any points you wish share…until then…

          • Dale said:

            Has more to do with stuff like this…

            and…

            And stuff like this…

            Sorry, what question did you think you were answering?

          • Doc Dale, The topic of this discussion is: Chiropractic treatments are placebos.

          • Pete:Doc Dale, The topic of this discussion is: Chiropractic treatments are placebos.

            Kind of, depends on where in the string one jumps in. The topic has become what constitutes a chiropractic treatment. You seem to be stuck on chiropractic treatment=SMT. I’ve shared what I think that is false.

  • Edzard I am sorry for the new thread but I did not have a reply button from your last post.

    Given my above mentioned issues with this study (mostly all mentioned in the studies discussion) that are absent in your summary above, I would be grateful if you could provide an example of the type of protocol where you would ‘definitely’ include this study for a systematic review, that meets your standards for inclusion?

    • I am trying to tell you since a while: there cannot be a ‘standard for inclusion’ – it depends on the research question which determines the protocol which determines the inclusion/exclusion criteria.

  • Years ago there was a blog on this site that discussed research. I emailed Prof Ernst and asked him “What makes a good study?”. The reply has stuck with me ever since and I call it “Edzards Rule” that I apply to every paper I read and has been very helpful!
    “A good study answers one question!” – E Ernst

  • Oh, and Frank. There is some interesting research coming out from orthopedic surgeons. If I recall, they are finding that with lumbar orthopedic surgery for low back issues that the status of the cervical spine has an significant effect on the outcomes (think it was with regards to cervical anterior translation). This is unique as most research in this area tends not to pass the adjacent joints. This Doesn’t directly apply to chiropractors but chiropractors have acknowledged this relationship really since its inception…the spine (NMSK) is a unit and better outcomes occur when it’s addressed as such (someone posted something here about the appropriateness of cervical manipulations).

    Anyway, gotta run.

  • Prof Ernst.

    could you confirm that you believe all research performed by chiropractors, about chiropractic or spinal manual therapy is bogus?
    Have you seen any research or publications by chiropractors that you believe reaches a standard of excellence?

    • 1) no
      2) yes

      • We all know what bad research looks like. An example of bad and deceitful research about chiropractic can be seen in the NZMJ, performed by your research colleague, Shaun Holt. I am sure you can list numerous examples of bad research published by chiropractors (as well as many other health care disciplines).
        Can you please give us several examples of good research performed by chiropractors. Perhaps other commentators in this site e.g. the Franks, could also answer the request?

        • @ GibleyGibley on Monday 30 May 2016 at 21:11,

          If you can’t nominate any research that will withstand scrutiny, why bother continuing in the witchcraft? That is, of course, a rhetorical question because we all know why you still do it. >$$$$$$$$$$$$$$$$$$

          Real medicine subjects itself to scrutiny so why are alt-meds (the clue is in the title) so reluctant?

          (p.s., how is UnZud at this time of the year? Is it hard to get camel-turd breath fresheners?)

          • Prof. Ernst. This reply by Frank Collins is offensive and detracts from the tenure of the discussion. Previously you have asked for comments to be fair and inoffensive. This comment does neither.

          • @ GibleyGibley on Wednesday 01 June 2016 at 00:03

            “Prof. Ernst. This reply by Frank Collins is offensive and detracts from the tenure of the discussion. Previously you have asked for comments to be fair and inoffensive. This comment does neither.”

            Firstly, my post was clearly intended to offend you, in the same way your posts are offensive in their abstruseness and continued failure to any reasonable requests made of you.

            Secondly, the word is “tenor”, as in tone, not “tenure”, as in duration. Don’t they teach you anything in chiro school?

        • Prof. Ernst. You have not answered my question. It cannot be that difficult. Please give an example or two of good research performed and published by chiropractors.

  • The data in this post from ‘Doc’ Dale, a chiropractic job analysis, appear to come from this survey, which provides interesting insights into (US) chiropractors and their patients.

    Most impressive to me was Table 8.2, which lists joint conditions and their frequency of diagnosis. Top of the list came “Spinal subluxation/joint dysfunction”, which was the initial diagnosis in 80.3% of cases. Please, those chiros who repeatedly tell us the ‘profession’ is reforming and that ‘subbies’ are a vanishing minority: don’t bother any more. The survey was done in 2014 and published last year.

    • Frank: Most impressive to me was Table 8.2, which lists joint conditions and their frequency of diagnosis. Top of the list came “Spinal subluxation/joint dysfunction”, which was the initial diagnosis in 80.3% of cases. Please, those chiros who repeatedly tell us the ‘profession’ is reforming and that ‘subbies’ are a vanishing minority: don’t bother any more.

      That’s a problem you skeptics have in analyzing the data and the profession…black and white doesn’t apply to the chiropractic profession.

      One could say..80.3% of those presenting to chiropractors with joint pain and/or dysfunction the initial diagnosis was sprain/strain…or something like that…depends on how the survey was worded.

      “Subluxation” as a word carries a lot of garbage which some have abandoned the historical garbage but acknowledge the word.

      • “black and white doesn’t apply to the chiropractic profession.” Or even the simple definition of words it uses. Sorry Mr. Dale, you shift the sands and move the goalposts too frequently for sensible further debate.

        • DD: “black and white doesn’t apply to the chiropractic profession.”

          Frank: Or even the simple definition of words it uses.

          DD: Yep. You applied one definition whereas the paper used a different one. Common mistake.

          Frank: Sorry Mr. Dale, you shift the sands and move the goalposts too frequently for sensible further debate.

          DD: Most of my efforts have been to try and get you folks to understand how to properly interpret this stuff. Perhaps it’s beyond some to do so. Anyway, take care.

          • Most of my efforts have been to try and get you folks to understand how to properly interpret this stuff

            Odd, then, that everything you said came across as trying to wave away the cult of Palmer and its pervasive influence on the chiropractic trade.

          • Guy: Odd, then, that everything you said came across as trying to wave away the cult of Palmer and its pervasive influence on the chiropractic trade.

            DD: perhaps because you made assumptions about me along the way. Skeptics tend to do that.

            If you go back to my original comments above they centered around two points:

            1. This study isn’t good enough to draw any conclusions (which Ernst seems to have done)
            2. This study does not represent a “chiropractic treatment” (which Ernst said it did in the title)

            My points have nothing to do with which side of the fence I may or may not fall on but rather the proper interpretation, presentation and application of such research and its findings.

    • Frank: This is the definition they used in the Job Analysis of subluxation:

      subluxation
      The alteration of normal biomechanical
      or physiological dynamics of contigu-
      ous articular structures; it is essentially
      a functional entity.

      Now compare that with a “subbies” uh, definition.

      http://www.chiropractic.org/subluxations

      A vertebral subluxation is the result of spinal bones with improper motion or position affecting nerve communications between your brain and your body.

      A vertebral subluxation is a stress response. Muscles go into spasm. Spinal bones lock up. And adjacent nerves are choked or chafed. This interferes with the control and regulation of your body. This garbles communications between the brain and parts of your body.

      Distorted nerve communications can be an underlying cause of many health problems beyond just headaches and back pain. For example. Interfere with nerve impulses going to or from your stomach: stomach problems.

      • @ Doc Dale on Tuesday 31 May 2016 at 00:41

        A so-called profession that can’t even decide on a definition of what constitutes its primary raison d’etre? What next, definitions localised to the specific chiro’s office? (Actually, that is what happens now. 🙂 )

        • Frank: “..profession that can’t even decide on a definition of what constitutes its primary raison d’etre?”

          It does tend to confuse the skeptics.

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