MD, PhD, FMedSci, FSB, FRCP, FRCPEd

chiropractic

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Amidst the current controversy of chiropractic spinal manipulation for new-born babies, the previous director of Chiropractor’s Association of Australia NSW, Alex Fielding, published an interesting article. In it, he declared:

  1. I do not condone the chiropractic treatment of children for non-musculoskeletal conditions it is simply not our place. There is little to no evidence for it and it should not be done. If a chiro is report them to AHPRA.
  2. There is no evidence for “subluxation” it simply has not been shown to exist by any credible source.
  3. Chiropractic does not equal spinal manipulative therapy (SMT) or adjustment. We are trained to assess and treat musculoskeletal conditions, use exercise rehab, various forms of manual therapy including SMT, give sound evidence based advice and refer to better suited health professionals in the appropriate circumstance. To say there is no evidence for chiropractic is an ill informed politically charged statement, if you mean SMT, say SMT.

Here I only want to comment on his last point. I think it is important, not least because we hear it ad nauseam. As soon as there emerges new evidence to show that SMT does little for back or neck pain or is ineffective for non-spinal conditions, chiropractors insist that they do so much more than just SMT, and therefore any such findings do not ever lend themselves to a verdict about chiropractic care.

In my view, this argument is a bit like ‘wanting the cake and eat it’ (chiros want to be different from physios by adhering to SMT, but they don’t want to be judged by the uselessness of SMT). It begs the following questions:

  1. What other modalities do chiros use?
  2. For which conditions do they use them?
  3. What is the evidence for or against them?
  4. In what percentage of patients do chiros use SMT?

The last question may be the most important one. I am not aware of data from ‘down under’ but, in the UK, the percentage is close to 100%. This is why I often call SMT the ‘hallmark therapy of chiropractors’. No other profession employ it more frequently. It is the treatment that defines the chiropractic profession.

If the evidence for SMT is flimsy or negative or non-existent, it seems not unreasonable to voice doubts about the profession that uses it most. The fact that chiropractors also administer other modalities – most of which, by the way, have a shaky evidence-base too – is simply a smoke-screen used to mislead us.

An example might make this a bit clearer. Imagine a surgeon who takes out the tonsils of every patient he sees, regardless of any tonsillitis or other tonsil-related condition (historically, this fad once existed; tonsillectomy was even used to treat depression). This surgeon also does all sorts of other things: he prescribes pain-killers, gives antibiotics, orders bed-rest, gives life-style advice etc. etc. Yet he is a charlatan because his hallmark intervention is not effective and even puts patients at unnecessary risks.

I know, the analogy is not perfect, but it makes the point: chiropractors refuse to be judged by the uselessness of SMT. Yet it is what defines them and they continue using SMT pretty much regardless of the evidence. Fielding pleads: To say there is no evidence for chiropractic is an ill informed politically charged statement, if you mean SMT, say SMT. I’d say there is no good evidence for SMT nor for chiropractic care that includes SMT.

My advice for chiropractors therefore is: abandon SMT and become physiotherapists. This will make you a bit better grounded in evidence, but at least you would have rid yourself of the Palmer-cult with all the BS that comes with it.

Informed consent is an essential ethical precondition for any therapeutic intervention. This obviously cannot exclude alternative medicine. Yet, one gets the impression that alternative therapists systematically ignore informed consent. Chiropractors in the UK, for instance, have been shown to often take this issue more than a little light-heartedly.

The General Chiropractic Council (GCC) has issued guidance to its members about informed consent. Here is a passage from their website which I find particularly interesting:

The information you provide to the patient must be clear, accurate and presented in a way that the patient can understand… Patients must be fully informed about their care. You must not rely on a patient to ask questions about their care, the responsibility to fully inform patients about their care lies with you.  When discussing with patients the expected outcomes of their care, chiropractors must fully discuss the risks as well as the benefits and explore with the patient what other factors they may see as relevant to making a decision.

When explaining risks, you must provide the patient with clear, accurate and up-to-date information about the risks of the proposed treatment and the risks of any reasonable alternative options, in a way that the patient can understand. You must discuss risks that occur often, those that are serious even if very unlikely and those that a patient is likely to think are important. You must encourage patients to ask questions, so that you can understand whether they have particular concerns that may influence their decision and you must answer honestly.

I have repeatedly written about the fact that, in alternative medicine, informed consent has remained an almost alien concept. Yet, there can be no doubt, it is an ethical imperative in ALL healthcare. The above guideline makes this perfectly clear. Essentially, it proscribes that a chiropractor has to inform each patient who is about to be treated with a spinal manipulation – virtually 100% of all patients consulting chiropractors – that:

  • this treatment has not been shown to be effective for non-spinal conditions,
  • for back and neck pain, it might help but not better than other conservative therapies,
  • in about half of all patients, it leads to mild to moderate adverse effects that typically last 2-3 days and are severe enough to interfere with the patient’s quality of life,
  • in an unknown number of patients, it might lead to severe complications, including stroke and death,
  • there are other options for your problem that are more effective and/or less harmful.

The chiropractor then has to document the patient’s consent. Only then can he start treatments.

My question to the GCC is: have you tested how many patients would consent under these conditions?

I suspect the answer is No.

And my questions to UK chiropractors is: who is actually following these guidelines?

I suspect the answer is VERY FEW. If that were true, most chiropractors would violate their own ethical guidelines and could therefore be struck of the GCC’s register. Or did I get this wrong?

For many years, I have been impressed with the high quality and originality of chiropractic research. Here is the abstract of a particularly remarkable, new investigation.

The purpose of this study was to compare characteristics, likelihood to use, and actual use of chiropractic care for US survey respondents with positive and negative perceptions of doctors of chiropractic (DCs) and chiropractic care.

From a 2015 nationally representative survey of 5422 adults (response rate, 29%), we used respondents’ answers to identify those with positive and negative perceptions of DCs or chiropractic care. We used the χ2 test to compare other survey responses for these groups.

Positive perceptions of DCs were more common than those for chiropractic care, whereas negative perceptions of chiropractic care were more common than those for DCs. Respondents with negative perceptions of DCs or chiropractic care were less likely to know whether chiropractic care was covered by their insurance, more likely to want to see a medical doctor first if they were experiencing neck or back pain, less likely to indicate that they would see a DC for neck or back pain, and less likely to have ever seen a DC as a patient, particularly in the recent past. Positive perceptions of chiropractic care and negative perceptions of DCs appear to have greater influence on DC utilization rates than their converses.

CONCLUSION:

We found that US adults generally perceive DCs in a positive manner but that a relatively high proportion has negative perceptions of chiropractic care, particularly the costs and number of visits required by such care. Characteristics of respondents with positive and negative perceptions were similar, but those with positive perceptions were more likely to plan to use-and to have already received-chiropractic care.

END OF ABSTRACT

I bet you are dying to learn who the authors of this impressive article are. Here is the full list and their affiliations:
Weeks WB1, Goertz CM2, Meeker WC3, Marchiori DM4.

  • 1Chair, Clinical and Health Services Research Program, Palmer Center for Chiropractic Research, Davenport, IA; Professor, The Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH. Electronic address: wbw@dartmouth.edu.
  • 2Vice Chancellor, Research and Health Policy, Palmer College of Chiropractic, Palmer Center for Chiropractic Research, Davenport, IA.
  • 3President, Palmer College of Chiropractic West Campus, San Jose, CA.
  • 4Chancellor, Palmer College of Chiropractic, Davenport, Iowa.

 

Not just inexperienced novices then! The authors belong to the crème de la crème of the chiropractic establishment and research!!!

In comparison, I feel like a mere beginner. But let me nevertheless try to design my own study along similar lines. It is so brilliant that I might even get the Nobel Prize for it. Here we go:

The purpose of my study would be to compare characteristics, likelihood to use, and actual use of spectacles for survey respondents with positive and negative perceptions of spectacles and opticians***. From a nationally representative survey of about 5000 adults, I would use the respondents’ answers to identify those with positive and negative perceptions of spectacles and opticians. My results would show that positive perceptions of opticians are more common than those for spectacles, whereas negative perceptions of spectacles are more common than those for opticians. Respondents with negative perceptions of opticians or spectacles were less likely to know whether spectacles were covered by their insurance, more likely to want to see a medical doctor first, if they were experiencing poor eye-sight, less likely to indicate that they would see an optician for poor eye-sight, and less likely to have ever seen an optician as a patient, particularly in the recent past. Positive perceptions of spectacles and negative perceptions of opticians appear to have greater influence on optician utilization rates than their converses. From these data, I would conclude that my sample generally perceive opticians in a positive manner but that a relatively high proportion has negative perceptions of spectacles, particularly the costs and number of visits required for getting them. Characteristics of respondents with positive and negative perceptions were similar, but those with positive perceptions were more likely to plan to use – and to have already received – care from opticians.

*** instead of opticians and spectacles, I might also opt for other things like

  • acupuncturists and needles,
  • aroma-therapists and essential oils,
  • herbalists and herbs,
  • fast food restaurants and hamburgers,
  • politicians and politics,
  • priests and religion,
  • etc., etc.

YOU MUST AGREE, THIS DESERVES A NOBEL PRIZE!

I thank the authors of the above paper for having inspired me with their ground-breaking science. In case they receive a Nobel Prize before I do, I congratulate them on their extraordinary achievement in designing, conducting and publishing this truly cutting-edge investigation.

I just came across this article which I find remarkable in several ways. Here is the abstract:

OBJECTIVE:
The purpose of this report is to describe 2 patients with coronary artery disease presenting with musculoskeletal symptoms to a chiropractic clinic.
CLINICAL FEATURES:
A 48-year-old male new patient had thoracic spine pain aggravated by physical exertion. A 61-year-old man under routine care for low back pain experienced a secondary complaint of acute chest pain during a reevaluation.
INTERVENTION AND OUTCOME:
In both cases, the patients were strongly encouraged to consult their medical physician and were subsequently diagnosed with coronary artery disease. Following their diagnoses, each patient underwent surgical angioplasty procedures with stenting.
CONCLUSION:
Patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.

I FIND THIS REMARKABLE FOR AT LEAST 3 REASONS:

  1. I don’t remember coming across the term ‘medical physician’ before. It is clear what the author meant by it. But it is also quite clear that such phraseology is nonsensical. My Oxford Dictionary defines ‘physician’ as: “A person qualified to practise medicine, especially one who specializes in diagnosis and medical treatment as distinct from surgery.” Therefore, a ‘medical physician’ would be ‘a medical person qualified to practise medicine.’ This begs the question why this term is used in a chiro-journal. The answer is probably quite simple: they want to arrive at a point where we all accept that there are two types of physicians: medical and chiropractic. But, using again my dictionary, this would be not just a little confusing. A chiropractic physician would be ‘a chiropractor qualified to practice medicine.’ And for that you need to go not to chiro-college but to medical school.
  2. The two case reports are remarkable in themselves, I find. They show that “patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.” The remarkable thing about this is that such basic knowledge ever merited a mention and publication in a journal. It should be clear to anyone who is in healthcare! I even know shop assistants who have called an ambulance because a customer suffered from what might have been misdiagnosed as a muscular problem in the left arm but was in truth due to coronary hear disease. The fact that chiros and editors of their journals feel that it worthy of publication seems a bit worrying and begs the question: how many other elementary things about the human body (known even to shop assistants) are unknown to the average chiro?
  3. Lastly, I must praise the chiro-profession for the progress they now seem to start making. About 120 years ago, DD Palmer, the founding father of chiropractic, famously treated a man with coronary heart disease by adjusting his spine. The author of the above article did not do that! Yes, progress was painfully slow, but the above article seems to indicate that at least some chiros have come around to agreeing with real physicians that the Palmer-gospel is based on little more than wishful thinking.

On their website, the American Chiropractic Association (ACA) recently updated its members on their lobbying activities aimed at having US chiropractors recognised as primary care physicians. The president of the ACA posted the following letter to ACA members:

Last February the ACA House of Delegates passed a formal resolution directing ACA to make achieving full physician status in Medicare a top priority of the association.

For much of this past year, ACA’s staff and key volunteers have been laying the groundwork to achieve just that — quietly spending time building key support on Capitol Hill for this important legislative change. As you know, our progress advanced to the point where we were able on Oct. 27 to publically launch our grassroots campaign centered on the widespread circulation of our National Medicare Equality Petition.

Since the launch of our campaign, through very public and transparent means, ACA has received the support of various organizations and individuals within the profession. These supporters fully understand the importance of eliminating any and all provider discrimination by CMS. Further they fully understand and agree with the soundness of the strategic and tactical decisions we have made and continue to make an effort to achieve the desired reformation in Medicare.

Towards building a unified consensus within the profession for our objectives and plans to accomplish them, we have engaged in prolonged discussions, mostly via the Chiropractic Summit Steering Committee and Roundtable process that includes ACA, COCSA, ACC, ICA, NBCE, FCLB and CCE. Throughout this process we have provided for them written legal opinions and analyses relative to the precise legislative language needed to achieve the full-physician status we seek. We have outlined our strategy numerous times; have shared our materials and updates with any group wishing to review them; and have repeatedly urged state chiropractic associations, chiropractic colleges, corporate partners and individual DCs to join with us and enthusiastically support this reformation campaign.

While there was high consensus on the objective of Medicare reform during the Summit Roundtable process, there was much discussion surrounding the proposed legislative language. Specifically, whether or not “detection and correction of subluxation of the spine through manual manipulation” would need to be eliminated and replaced with language simply designating DCs as physician level providers on the same level as MDs and DOs who report/bill services to Medicare based on their individual state laws.

ACA is of the opinion that nothing less than removal of the “subluxation” language in the definition of physician section will accomplish our objectives. Historically, the facts are that this language has proven to be the major barrier within HHS and CMS when we advocated for regulatory remedies expanding our reimbursement and coverage for the full range of services provided by a DC. ACA (and our profession) has expended massive resources over the past decade or longer to no avail through regulatory channels (HHS, CMS). Based on these experiences, the only reasonable recourse to eliminate 40+ years of Medicare discrimination is through a thoughtful profession-wide legislative effort.

During the Roundtable discussions, compromise language was reached placing the current “subluxation language” into the preamble of a proposed law stating that DCs must continue to have the ability to detect and correct subluxations of the spine for Medicare beneficiaries. Six of seven Summit Roundtable organizations voted in favor of this language that was offered by the Association of Chiropractic Colleges.

ACA`s intent on removing the “subluxation” reference in the Social Security Administrative statute is in no way an attempt to quash our ability to perform those services that so many of the Medicare population need and deserve. Rather, the ultimate goal of this historic effort is to gain the privilege to manage our Medicare patients within state scopes of practice and allow reimbursement for all those services that the Medicare beneficiaries are currently forced to pay out of pocket. ACA supports fully our continued ability to correct subluxations through appropriate active care and, in fact, achieve coverage for manipulation of all areas, not simply limited to the spine.

Expanding Medicare scope reimbursement will allow our profession to practice contemporary chiropractic and to potentially increase utilization of our services to the ever-increasing aging population. Expansion and reformation will also place DCs in a position to participate in alternative payment models, quality healthcare initiatives, community health centers, hospitals and other integrated settings which are vital to professional growth.

In conclusion, should you as an HOD member be questioned on our intent you should be able to answer unequivocally that ACA supports the right to manage our patients as dictated by our training and competencies based on state scopes of practice. Further, we support those who wish to provide necessary active subluxation care for the Medicare population. Please support this initiative and let’s join together to encourage your state association, colleges and universities, corporate partners, patients and individual DCs to become true partners in order to make this a success for our patients and for our grand profession.

A list of talking points will be distributed in the coming days.

Sincerely, Tony Hamm, DC President, ACA

Do I read this correctly?

The term subluxation is a hindrance to business. Therefore chiros need to do something about it. Never mind that the principle of subluxation as used in the realm of chiropractic is nonsense!

This might throw an entirely different light on those chiros who want to get rid of the term ‘subluxation’.

And what about chiros as primary care physicians?

Recently Dave Newell posted on this blog: “chiropractors in the UK … are primary care clinicians”. I objected and he insisted to be correct because “Primary Care is defined as a clinician that is the first port of call for patients seeking help.” Frank Odds then countered: “This business of “primary care provider” is becoming enervating! Edzard has now spelt out the meaning of the term as defined by Wikipedia. You are quite right that a dentist is a primary care provider: people go to a dentist when they have symptoms affecting their mouth in general — more often their teeth and gums in particular. They know that’s what dentists deal with. A general practitioner is a primary care provider: people go to a GP when they have symptoms anywhere. They know that’s what GPs deal with. A chiropractor is indeed a primary care provider: of chiropractic. ”

I think that primary care physicians are doctors who are capable of handling everything or at least most of what primary care may present to them. Chiros do not fulfil this criterion, I think.

I would be interested what you feel on this important issue.

‘Megalomania’ of a clinician is (for the purpose of this blog-post) defined as a practitioner claiming to cure everything. It seems to me that this dangerous condition is endemic in the realm of alternative medicine, and particularly in chiropractic. Perhaps they catch it at chiro school, I don’t know, but an awful lot of them seem to suffer from it.

We all had to get used to this fact, and there is nothing remarkable about it anymore. But recently I came across a website where an extraordinarily severe case is being disclosed. Let me share some of the text (including its grammatical and other errors) with you:

How many of the 10,000 patients Dr. Del Monte has – upon whom he has performed one million spinal adjustments – with his hands – healed themselves?

The woman who could not get pregnant. Doctors told her she would never conceive.

She came to Dr. Del Monte, got adjustments and soon after, somehow – she got pregnant and gave birth to a healthy child.

The person with the brain tumor that went away. Science can’t prove it – no more than you can X- Ray for a headache and prove it. Maybe he would have healed his tumor without spinal adjustments.

The two year old that couldn’t speak who suddenly opened her mouth and babbled one hour after her first adjustment.

Asthmatics, bedwetters, people in pain, their back and neck, indigestion, earaches.

Cured.

People set for surgery because they couldn’t bear the pain – who went to Dr. Del Monte and never met the surgeons’ knife.

Dr. Del Monte is an apostle – and I use the word advisedly – for chiropractic is not religion – although its founder D.D. Palmer thought of making it a religion – because it seems to unleash God’s healing power.

Chiropractic can open up impossible doors, unlock the door to free-flowing, “Innate Intelligence” – the natural tendency of the body to seek and maintain a condition of balance or equilibrium.

You don’t believe in Innate Intelligence?

One chiropractor explained it this way: “At the moment of your conception, 23 chromosomes from your mother and 23 chromosomes from your father combined to form one cell, the unique ‘You’.

“Barely the size of a pinhead, that one cell began to divide into what is now an estimated 80 quadrillion cells that make up your body. This process is driven by something – call it an Innate Intelligence, an inborn wisdom, which knows how tall you will be, the length of your fingers, where your nose should be on your face, and where your vital organs belong.

“This Innate Intelligence stays with you after you are born and guides every function of your body until your last breath of life.

“The master control system for this is your nervous system which consists of your brain, spinal cord and nerves that go to every cell, tissue and organ. Nerves control your heartbeat, respiration, hormone balance, digestion, immune system, muscle contraction and every other function that is necessary for you to live.

“Your Innate Intelligence is ‘wise’ to the importance of this system. Fully encased in bone, your skull protects your brain and your spinal column protects your spinal cord.”

While no chiropractor can guarantee that your Innate Intelligence will self cure any specific symptoms or diseases, they can guarantee that when your body is free of nerve interference it will work better.

Some have regained eyesight.

Several threw away their canes.

You will often hear people say, when they leave Dr. Del Monte’s office “My back is so much better, I can stand up straight; My migraines are gone; My blood pressure is down; My heartburn is gone; Menstrual cramping went away; My digestion is better; I haven’t had a cold in years.”

Dr. Del Monte explains: “Anything that could be effected by the nervous system can be improved by chiropractic manipulation, and the nervous system controls and coordinates almost every function of the body.

“Why would you mask the symptoms with drugs, when you could allow your own body to heal?”

“Sick cells makes sick tissues which make sick organs. Then there are sick people. Symptoms are the last to show up. If the spine is healthy, the body needs no help in healing. It does the healing.”

The main procedure is “spinal manipulation,” or “adjustments” which restore mobility by applying force into joints that became restricted – as a result of injury — caused by a traumatic event or through repetitive stresses – causing inflammation, pain, and diminished function.

Manipulation, or adjustment of the joint and tissues, alleviates pain and muscle tightness, and allows tissues to heal.

“It should be tried first ahead of drugs and surgery,” Dr. Del Monte says.

The focus is therefore on spotting and curing “vertebral subluxations”, said to be the cause of many diseases. Sometimes chiropractic assumes the sole cause of an individual’s health problems are subluxations.

These subluxations, commonly caused by birth trauma, childhood falls, accidents and all types of stress, reduce the function of the areas supplied by these nerves.

Nerve pressure can affect areas that are directly supplied by those nerves: muscles, bladder, prostate or heart; they can affect the entire body because of the relationship that each cell, organ and system share…

The list of ailments Dr. Del Monte has seen his patients cured of – self healed – are nearly endless: Bowel/bladder problems, chronic colds, allergies, ringing in the ears, earaches, bed wetting, sciatica, colds, fevers…

“So many times people come in with a cold or fever. We see an almost instant response- within hours. It’s not like you are waiting days.

“Ninety percent of the time patients get favorable results. Rarely does a patient go to a Chiropractor and say ‘it didn’t work for me’…

“I don’t need a referral. I don’t need a script. People do refer patients here, but I am primary healthcare. They don’t have to go through their medical doctor. They just come and see me. They just call the office, “ said Dr. Del Monte.

END OF QUOTE

THE ONLY CONDITION THAT CHIROPRACTIC MANIPULATION CANNOT CURE IS MEGALOMANIA!

On a good day, I can heartily laugh at this sort of thing (of which this article is merely one of hundreds of example available on the Internet). On a not so good day, however, I ask myself questions:

  • Where does such idiocy come from?
  • Do chiropractors ever learn anything about medical ethics?
  • Why is this chiropractor still allowed to practice?
  • What happens to the poor patients who fall for it?
  • Why is nobody stopping it?
  • Where are the protests of chiropractors who boast of being reformed and evidence-based?

On this blog, I have repeatedly pleaded for a change of the 2010 NICE guidelines for low back pain (LBP). My reason was that it had become quite clear that their recommendation to use spinal manipulation and acupuncture for recurrent LBP was no longer supported by sound evidence.

Two years ago, a systematic review (authored by a chiropractor and published in a chiro-journal) concluded that “there is no conclusive evidence that clearly favours spinal manipulation or exercise as more effective in treatment of CLBP.” A the time, I wrote a blog explaining that “whenever two treatments are equally effective (or, in this case, perhaps equally ineffective?), we must consider other important criteria such as safety and cost. Regular chiropractic care (chiropractors use spinal manipulation on almost every patient, while osteopaths and physiotherapists employ it less frequently)  is neither cheap nor free of serious adverse effects such as strokes; regular exercise has none of these disadvantages. In view of these undeniable facts, it is hard not to come up with anything other than the following recommendation: until new and compelling evidence becomes available, exercise ought to be preferred over spinal manipulation as a treatment of chronic LBP – and consequently consulting a chiropractor should not be the first choice for chronic LBP patients.”

Three years ago, a systematic review of acupuncture for LBP (published in a TCM-journal) concluded that the effect of acupuncture “is likely to be produced by the nonspecific effects of manipulation.” At that time I concluded my blog-post with this question: Should NICE be recommending placebo-treatments and have the tax payer foot the bill? Now NICE have provided an answer.

The new draft guideline by NICE recommends various forms of exercise as the first step in managing low back pain. Massage and manipulation by a physiotherapist should only be used alongside exercise; there is not enough evidence to show they are of benefit when used alone. Moreover, patients should be encouraged to continue with normal activities as far as possible. Crucially, the draft guideline no longer recommends acupuncture for treating low back pain.

NICE concluded that the evidence shows that acupuncture is not better than sham treatment. Paracetamol on its own is no longer recommended either, instead non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin should be tried first. Talking therapies are recommended in combination with physical therapies for patients who had no improvement on previous treatments or who have significant psychological and social barriers to recovery.

Professor Mark Baker, clinical practice director for NICE, was quoted stating “Regrettably there is a lack of convincing evidence of effectiveness for some widely used treatments. For example acupuncture is no longer recommended for managing low back pain with or without sciatica. This is because there is not enough evidence to show that it is more effective than sham treatment.”

Good news for us all, I would say:

  • good news for patients who now hear from an accepted authority what to do when they suffer from LBP,
  • good news for society who does no longer need to spend vast amounts of money on questionable therapies,
  • good news for responsible clinicians who now have clear guidance which they can show and explain to their patients.

Not so good news, I admit, for acupuncturists, chiropractors and osteopaths who just had a major source of their income scrapped. I have tried to find some first reactions from these groups but, for the moment, they seemed to be stunned into silence – nobody seems to have yet objected to the new guideline. Instead, I found a very recent website where chiropractic is not just recommended for LBP therapy but where patients are instructed that, even in the absence of pain, they need to see their chiropractor regularly: “Maintenance chiropractic care is well supported in studies for controlling chronic LBP.”

NEVER LET THE TRUTH GET IN THE WAY OF YOUR CASH-FLOW…they seem to conclude.

You have to admit, quacks had a difficult time recently:

  • homeopathy has been disclosed as humbug,
  • chiropractic is not much better,
  • ‘acupuncture awareness week’ left acupuncturists bruised…

Need I go on?

One has to pity these guys; their income is dwindling; they have no pensions, no unions to protect them etc., they know nothing other than quackery…what can they do? They are clearly fighting for survival.

I suggest we all focus, use our imagination and come up with come constructive ideas to help them.

Alright, I start: HOLISTIC DOPING

The fate of the poor (not in a monetary sense, of course) tennis star Sharapova gave me that brainwave.

Our elite athletes are in a pickle: they feel the need to enhance their performance but more and more ways of achieving this with cleverly administered drugs are becoming illegal. Their livelihood is at stake almost as much as that of our dear quacks.

What if the two groups jointed forces?

What if they decided to help solve each others’ problems?

This could be a classical win/win situation!

I am sure homeopaths, chiropractors, acupuncturists etc. could design holistic program for improving athletic performance. It would be highly individualised and embrace body, mind, spirit, sole and anything else they can think of. It could include the newest concepts in quantum healing, energy field, qi, vital force, etc. The advantages are obvious, I think:

  • none of these interventions will ever be found on a list of forbidden drugs,
  • the program will work perfectly well because it will generate large placebo responses,
  • performance will therefore increase (as always in alternative medicine, anecdotal ‘evidence’ will suffice) ,
  • and so will the quacks’ cash flow.

Is there a downside? Not really…oh, hold on…yes there is!

My idea is not that original; others have had it already. In fact, there are quite a few quacks offering alternatives to good old-fashioned doping.

THAT’S THE AWFUL THING ABOUT QUACKERY: ALL THE GOOD IDEAS TURN OUT TO BE ALREADY TAKEN!

Recently, I came across this website. I think it is worth having a good look because it is just too funny for words. Amongst other things, it offers 5 tips for finding a ‘wellness chiropractor’. I could not resist the temptation of reproducing these 5 tips here – and for good measure, I added some footnotes of my own; they appear in the otherwise unaltered text as numbers in square brackets referring to short comments at the bottom:

  1. Does the practice focus on vertebral subluxation [1] and wellness? Physical, biochemical, and psychological stress may result in spinal subluxations [1] that disrupt nerve function [2] and compromise your health [3]. If you’re looking for a wellness chiropractor, it’s essential that this be the focus. Some chiropractors confine their practice to the mechanical treatment of back and neck pain, and this is something you need to be aware of beforehand.
  2. Does the doctor “walk the talk”? If he or she is overweight, looks unhealthy, or does not live a healthy lifestyle, this speaks volumes regarding their commitment to wellness [4].
  3. Do the two of you “click”? Do you like each other? Do you communicate well? Avoid a doctor [5] who seems rushed, talks down to you, or seems disinterested in listening to your concerns [6].
  4. Does the doctor use objective assessments of nerve function? Since your care is not based just on addressing pain, your chiropractor should be using some form of objective assessment of your nerve function, as spinal subluxations [1] can sometimes be asymptomatic [7]. Non-invasive instruments that measure the electrical activity in your muscles, and/or a thermal scanner [8] that evaluates the function of your autonomic nervous system can be used, for example.
  5. What treatment techniques are used? Chiropractic techniques include low-force adjustments by hand, and more forceful adjustments using instruments [9]. Ask which technique would be used on you [10], and if you have a preference, make sure the doctor [5] is willing to use it.

MY COMMENTS:

  1. ‘Spinal subluxation’, as used in chiro-lingo, is a non-entity that has no place in reality; it is merely a tool for making money.
  2. I am not aware of any evidence to suggest that this is true .
  3. As subluxations do not exist, it is safe to say that this is pure fantasy.
  4. The assumption seems to be that only a healthy chiro is a good chiro!?!?
  5. Chiros were just promoted to doctors – obviously much better for generating a health income.
  6. There are qualities that are required from everyone – your waiter, bus-conductor, butcher etc. – even from your chiro.
  7. Non-existent entities are always asymptomatic.
  8. Test with lousy reliability.
  9. Very misleading statement; manual ‘adjustments’ can also be forceful and are often more forceful than those using instruments.
  10. This statement makes it very clear that informed consent is not what patients can regularly count on with chiros. This leads me to suspect that chiros frequently breach one of the most important ethical rules in clinical practice.

Yes, I do think the chiro fraternity often is completely hilarious – unwittingly perhaps but surely hilarious [if we would not laugh at them, we would need to get angry with them which is to be avoided at all cost, as they tend to sue for libel]. Without the chiros regularly making themselves ridiculous, my life would certainly be far less droll.

Elsewhere on this intriguing post, the author informs us that where I think chiropractic shines is that we address the cause of the problem. Personally, I think, where chiropractic shines brightest is in amusing us with their continuous flow of humorous bovine excrement.

WE SHOULD BE THANKFUL!

Cervical spine manipulation (CSM) is a popular manipulative therapy employed by chiropractors, osteopaths, physiotherapists and other healthcare professionals. It remains controversial because its benefits are in doubt and its safety is questionable. CSM carries the risk of serious neurovascular complications, primarily due to vertebral artery dissection (VAD) and subsequent vertebrobasilar stroke.

Chinese physicians recently reported a rare case of a ‘locked-in syndrome’ (LIS) due to bi-lateral VAD after CSM treated by arterial embolectomy. A 36-year-old right-handed man was admitted to our hospital with numbness and weakness of limbs after receiving treatment with CSM. Although the patient remained conscious, he could not speak but could communicate with the surrounding by blinking or moving his eyes, and turned to complete quadriplegia, complete facial and bulbar palsy, dyspnoea at 4 hours after admission. He was diagnosed with LIS. Cervical and brain computed tomography angiography revealed bi-lateral VADs. Aorto-cranial digital subtraction angiography showed a vertebro-basilar thrombosis which was blocking the left vertebral artery, and a stenosis of right vertebral artery. The patient underwent emergency arterial embolectomy; subsequently he was treated with antiplatelet therapy and supportive therapy in an intensive care unit and later in a general ward. After 27 days, the patient’s physical function gradually improved. At discharge, he still had a neurological deficit with muscle strength grade 3/5 and hyperreflexia of the limbs.

The authors concluded that CSM might have potential severe side-effect like LIS due to bilaterial VAD, and arterial embolectomy is an important treatment choice. The practitioner must be aware of this complication and should give the patients informed consent to CSM, although not all stroke cases temporally related to CSM have pre-existing craniocervical artery dissection.

Informed consent is an ethical imperative with any treatment. There is good evidence to suggest that few clinicians using CSM obtain informed consent from their patients before starting their treatment. This is undoubtedly a serious violation of medical ethics.

So, why do they not obtain informed consent?

To answer this question, we need to consider what informed consent would mean. It would mean, I think, conveying the following points to the patient in a way that he or she can understand them:

  1. the treatment I am suggesting can, in rare cases, cause very serious problems,
  2. there is little good evidence to suggest that it will ease your condition,
  3. there are other therapies that might be more effective.

Who would give his or her consent after receiving such information?

I suspect it would be very few patients indeed!

AND THAT’S THE REASON, I FEAR, WHY MANY CLINICIANS USING CSM PREFER TO BEHAVE UNETHICALLY AND FORGET ABOUT INFORMED CONSENT.

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