MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Do chiropractors even know the difference between promotion and research?

Probably a rhetorical question.

Personally, I have seen them doing so much pseudo-research that I doubt they recognise the real thing, even if they fell over it.

Here is a recent example that stands for many, many more such ‘research’ projects (some of which have been discussed on this blog).

But first a few sentences on the background of this new ‘study’.

The UD chiropractic profession is currently on the ‘opioid over-use bandwagon’ hoping that this move might promote their trade. Most chiropractors have always been against using (any type of) pharmaceutical treatment and advise their patients accordingly. D D Palmer, the founder of chiropractic, was adamant that drugs are to be avoided; he stated for instance that Drugs are delusive; they do not adjust anything. And “as the Founder intended, chiropractic has existed as a drug-free healthcare profession for better than 120 years.” To this day, chiropractors are educated and trained to argue against non-drug treatments and regularly claim that chiropractic is a drug-free alternative to traditional medicine.

Considering this background, this new piece of (pseudo) research is baffling, in my view.

The objective of this investigation was to evaluate the association between utilization of chiropractic services and the use of prescription opioid medications. The authors used a retrospective cohort design to analyse health insurance claims data. The data source was the all payer claims database administered by the State of New Hampshire. The authors chose New Hampshire because health claims data were readily available for research, and in 2015, New Hampshire had the second-highest age-adjusted rate of drug overdose deaths in the United States.

The study population comprised New Hampshire residents aged 18-99 years, enrolled in a health plan, and with at least two clinical office visits within 90 days for a primary diagnosis of low-back pain. The authors excluded subjects with a diagnosis of cancer. They measured likelihood of opioid prescription fill among recipients of services delivered by chiropractors compared with a control group of patients not consulting a chiropractor. They also compared the cohorts with regard to rates of prescription fills for opioids and associated charges.

The adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower among chiropractic compared to non-chiropractic patients. Average charges per person for opioid prescriptions were also significantly lower among the former group.

The authors concluded that among New Hampshire adults with office visits for noncancer low-back pain, the likelihood of filling a prescription for an opioid analgesic was significantly lower for recipients of services delivered by doctors of chiropractic compared with nonrecipients. The underlying cause of this correlation remains unknown, indicating the need for further investigation.

The underlying cause remains unknown???

Really?

Let me speculate, or even better, let me extrapolate by drawing an analogy:

Employees by a large Hamburger chain set out to study the association between utilization of Hamburger restaurant services and vegetarianism. The authors used a retrospective cohort design. The study population comprised New Hampshire residents aged 18-99 years, who had entered the premises of a Hamburger restaurant within 90 days for a primary purpose of eating. The authors excluded subjects with a diagnosis of cancer. They measured the likelihood of  vegetarianism among recipients of services delivered by Hamburger restaurants compared with a control group of individuals not using meat-dispensing facilities. They also compared the cohorts with regard to the money spent in Hamburger restaurants.

The adjusted likelihood of being a vegetarian was 55% lower among the experimental group compared to controls. The average money spent per person in Hamburger restaurants were also significantly lower among the Hamburger group.

The authors concluded that among New Hampshire adults visiting Hamburger restaurants, the likelihood of vegetarianism was significantly lower for consumers frequenting Hamburger restaurants compared with those who failed to frequent such places. The underlying cause of this correlation remains unknown, indicating the need for further investigation.

Daaaahhhhhhh!

 

11 Responses to Chiropractors do not seem to know (or ignore) the difference between research and promotion

  • And they have their conclusion:
    Choosing to consult someone who advises against pain medications results in a higher chance of not taking pain medications.

    This must be one of the most useless studies ever having seen the light of day, the authors must have been really bored, or out of marketing ideas… there is short-circuitry all over this thing! The analogy is a perfect comparison. It’s like asking yourself whether you decided to ask yourself (or worse).

  • Dr Kazal, the last author listed on this paper and therefore the supervising author is a board certified family medicine physician and not a chiropractor. Never the less your comments are well noted.

  • The fact that someone managed to get through medical school and specialist board certification is no guarantee of a sound mind and scientific rigour, not any more than chiropractor school.

    By the way Mister Epstein. When are you going to respond to our questions regarding your management of acute abdominal complaints? We are so looking forward to hearing your explanations.

    • Is my question regarding abdominal complaints of interest only to you or is your question regarding abdominal complaints of interest to a larger unknown pro evidence based group? Please advise.

      • @Mr. Epstein

        The layout and nature of this blog may give a false impression that it is viewed and read only by a handful of individuals who regularly make comments solely on a one-to-one basis. You may rest assured that there are plenty of readers who never post comments. Your response to Bjorn Geir’s question about your management of abdominal complaints is most definitely of interest to this larger ‘unknown’ readership.

        In August last year you wrote: “Stay tuned to my publication of this procedure next month or in October in the Chiropractic Journal of Australia. It’s not a case report about abdominal pain management but the mechanism of the procedure itself. I look forward to your critique of this published paper. Remember, publish or perish.”

        But no such paper has appeared in the <Chiropractic Journal of Australia. However, I note your comment about “Publish or perish”. Does this explain why you published the same paper twice in the last two issues of the <Chiropractic Journal of Australia? Double publication of a single study is regarded as a major sin in the world of scholarship and research, but this is the first time I’ve ever come across someone with the chutzpah to do it in the same journal!

        The <Chiropractic Journal of Australia purports to be peer-reviewed and it lists a Chief Editor on its website. Either this guy is exceptionally dumb or in the pay of Big Backcracking.

      • Mr. Epstein

        The question is mine, not yours.
        I refer to your comment of Sunday 20 August 2017 at 09:21, where you stated the following:

        If I was confronted with a patient with acute abdominal pain, which I have and resolved very quickly after palpating its severity and determining that the pain was manageable after performing SMAT

        SMAT appears to be an impromptu, unrealistic method of attempting to correct lumbar spine deformities by placing a heavy load (e.g. sandbag) on a persons abdomen in the suppine position for short periods.

        To me as an abdominal surgeon your statement clearly indicates that you took upon yourself to diagnose and treat a person with acute abdominal pain. In my part of the world this is not only unlawful practice without the appropriate medical education, training and certification. It also places the subject at grave risk for serious consequences when untrained individuals think they can diagnose or treat acute abdominal problems.

        You have repeatedly in the months since you made his statement, avoided responding to my iterated question, by which I intended to elicit whether my understanding of said statement is accurate.
        Seeing that you have recently been arrested in Indonesia for unlawfully playing doctor, my question is perhaps redundant.

        Your response to my question is perhaps by now only of empirical interest to the audience here. But it is of critical importance for the medical authorities in your region of residence as such behaviour of someone entitling himself as “Dr.” and pretending to have the training and qualification of a medical doctor, may constitute a public health hazard.

        I hope no one is injured by what appears to be conduct inspired by grandiose delusions.

        • I don’t know if you did skim through the actual text Björn, but there is something that does astound me.

          If I understand correctly from the text (“interventions performed”), the following imaging procedures were performed:

          1) Lateral lumbar x-rays with 5 kg on abdomen.
          2) Lateral lumbar x-rays with 10 kg on abdomen.
          3) Lateral lumbar x-rays with 15 kg on abdomen.
          4) Lateral lumbar x-rays with knees flexed, without weight on abdomen.
          5) Lateral lumbar x-rays with knees straight, without weight on abdomen.
          6) Lumbar CT scan with bent legs and weight on abdomen.
          7) Lumbar CT scan with bent legs without weight on abdomen.
          8) CT angiography of the abdominal/pelvic region.

          Because the paper is more than a mess, it is not clear when each of these were performed, but it seems that those were performed together. Besides, the 3-year case story is based on other x-ray images only shown in the beginning. Also, I am not very sure whether these were carried out on a subject, or the participant/patient/subject was the author himself, as there is a couple of pictures depicting him with weight on his abdomen in the proposed stances by the machinery.

          Now, I am going to overlook for a moment the fact that hundreds-of-thousands’ worth of imaging devices was set at the disposal of someone in such a meaningless study scenario. From a couple of studies around, I managed to see that a low-dose abdominal aortic angiography leads to an effective dose of ~4 mSv (source), and an abdominal/pelvic CT scan lies at about 10 mSv (source). Then, another 1.5 mSv (source) for lateral lumbar x-rays.

          If we just naively sum up these typical values, this makes up (5*1.5) + (2*10) + ~4 = 31.5, or ~30 mSv. In comparison, the worldwide average radiation exposure (both natural and artificial) is about 3 mSv.

          So, naively speaking, this is 10 years’ worth of background radiation in one sitting. I don’t really know if any ethics committee would approve such an experiment for the sole purpose of …drawing semi-accurate lines on pictures and measuring angles for no obvious reason. And, instead, an armamentarium of expensive devices is dedicated to this? Am I missing something? Please, tell me I’m wrong in thinking that this (hocus) opus borders on misconduct and demonstrates gross irresponsibility on behalf of all (executive producers and production managers) participants; the author, his accomplices at the labs, the (magazine) journal and the reviewers.

          This is a lot of resources AND radiation just for the sake of a fantasy.

          • I have to admit that I only read this abomination through once and hastily jotted down a few of the many concerns that came to mind in this comment. The unreasonable radiation was way down on my list of nauseating notions.

            You are right James, this parody of science only serves to support the picture we already have of mister Epstein as a person severely lacking the knowledge and skill-set necessary for professional scientific or medical work. He also seems to lack the ability to recognise the boundaries between mastery and make-believe, fact and fiction. The Dunning-Kruger phenomenon is strong with our friend Epstein 🙂

          • I went back and went through the thread a bit. Indeed, I had missed this comment (but I remembered all the attempts to bring reason to that Mr…). Reading your concerns, I really cannot help but say that you really gave it a try in very good faith. This (excuse for a paper) not-even-a-draft looks more like a hoax… it’s almost completely unformatted, just interleaved text with images (without images, I really would find it hard to believe this story actually took place) and the part with the relieved bloating is hard to swallow.

            The man draws lines on semi-articulated spines and measures angles as if these are not at all dependent on the posture of the moment (spine), stage of inhalation/exhalation (ribs) and motion in general. The big bucks are on one of the images where the drawn line simply runs vertically (i.e. is not even remotely a relatively proper tangential extrapolation of the bone shape) so that the corresponding angle ends up being significantly different to the control angle. This is like playing with your new computer after a trip to an amusement park with medical devices. It’s horrifying that so much ground is available for someone to defame science so badly!

            After a while, it seems that the only thing he got right is that bloating reduces if you lie supine for a while with 10 kgs on your belly. He just didn’t write how, and did not provide a good enough description of the experience, say, a 10 minute follow-up… perhaps a few good farts, an untimely trip to the toilet… 10 kgs work wonders for a troubled stomach or intestine, provided the loading is done on the right position. Punches work just as well!

            I guess this parody never ends… 🙁

    • But getting through Chiropractic “school” and getting certified in one of it’s specialities e.g. neurology, orthopedics pediatrics or gynecology….is actually an excellent means of determining an unsound, unsophisticated and insolvent mind. I give you Dr. of Fraud Epstein.

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