Several investigations have suggested that chiropractic care can be cost-effective. A recent review of 25 studies, for instance, concluded that cost comparison studies suggest that health care costs were generally lower among patients whose spine pain was managed with chiropractic care. However, its authors cautioned that the studies reviewed had many methodological limitations. Better research is needed to determine if these differences in health care costs were attributable to the type of HCP managing their care.
Better research might come from the US ‘Centers for Medicaid and Medicare Services’ (CMS); they conduced a two-year demonstration of expanded Medicare coverage for chiropractic services in the treatment of beneficiaries with neuromusculoskeletal (NMS) conditions affecting the back, limbs, neck, or head.
The demonstration was conducted in 2005–2007 in selected counties of Illinois, Iowa, and Virginia and the entire states of Maine and New Mexico. Medicare claims were compiled for the preceding year and two demonstration years for the demonstration areas and matched comparison areas. The impact of the demonstration was analyzed through multivariate regression analysis with a difference-in-difference framework.
Expanded coverage increased Medicare expenditures by $50 million or 28.5% in users of chiropractic services and by $114 million or 10.4% in all patients treated for NMS conditions in demonstration areas during the two-year period. Results varied widely among demonstration areas ranging from increased costs per user of $485 in Northern Illinois and Chicago counties to decreases in costs per user of $59 in New Mexico and $178 in Scott County, Iowa.
The authors concluded that the demonstration did not assess possible decreases in costs to other insurers, out-of-pocket payments by patients, the need for and costs of pain medications, or longer term clinical benefits such as avoidance of orthopedic surgical procedures beyond the two-year period of the demonstration. It is possible that other payers or beneficiaries saved money during the demonstration while costs to Medicare were increased.
In view of such results, I believe chiropractors should stop claiming that chiropractic care is cost-effective.
In 2010, we published an investigation of 200 chiropractor websites and 9 chiropractic associations’ World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom, and the United States. The outcome measure was claims (either direct or indirect) regarding the eight reviewed conditions, made in the context of chiropractic treatment.
We found evidence that 190 (95%) chiropractor websites made unsubstantiated claims regarding at least one of the conditions. When colic and infant colic data were collapsed into one heading, there was evidence that 76 (38%) chiropractor websites made unsubstantiated claims about all the conditions not supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%) associations made claims about lower back pain, whereas 179 (90%) websites and all 9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated claims were made about asthma, ear infection/earache/otitis media, neck pain.
At the time, we concluded that the majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue.
Have things changed since?
I fear not! I regularly come across websites of chiropractors where they happily make bogus claims. On this website, for instance, chiropractor Karen Smith claims that muscles in the upper neck affect the ear canals. “We don’t actually treat the ear infection, or the symptoms. What we do is, we assist the body’s natural healing ability,” says Smith. “So if there’s something going on with the joints and the muscles soft tissue, the nerves coming out that supply those muscles, those muscles can’t relax, so then they’re almost tight and in spasm, so that can’t allow the drainage to happen properly.”
When fluid builds up in the ears, it’s a breeding ground for bacteria and infection. Smith says specific, gentle adjustments, can help the body drain those fluids through the nose. “What we do is we get some motion in the upper neck, with my hands, or I might use an instrument as well,” says Smith. “There’s a few other techniques that we can do. We can do some sinus drainage. We can drain some of the fluid in the ear.”
A simple ear pull technique can also help. “So what we do is, we just take the ear of the child and we do a little pull and that can actually drain the fluid as well,” says Smith. Smith says a child’s overall health and immune system impacts how quickly they see results from the treatment. In some cases, relief can be instant. “What we notice right after an adjustment is a lot of times you’ll actually see the fluid drain through the nose,” says Smith… Smith says she also treats adults who have had chronic ear issues as a child or who are experiencing pain in the ear.
When I or others expose such nonsense, the apologists say that these are just a few ‘rotten apples’, and that the chiropractic profession is fast progressing. Yet, I very much doubt this claim. For any fast progression, one would want to see the profession taking decisive and effective action against the ‘rotten apples’. This is clearly not happening, at least not to an extend that would stop such dangerous quackery.
What practical lesson can be learnt from such insights?
The only responsible advice I can think of is this: IF YOU OR YOUR CHILD IS ILL, AVOID CONSULTING A CHIROPRACTOR.
Recently, I came across a good article where someone had assessed 100 websites by UK osteopaths. The findings are impressive:
57% of websites in the survey published the ‘self-healing’ claim
70% publicised the fact they offered cranial therapy;
61% made a claim to treat one or more specific ailments not related to the musculoskeletal system;
48% of practitioners also personally offered another CAM therapy;
71% of all sites surveyed located in a setting where other CAM was immediately available.
In total, 93% of the randomly selected websites checked at least one, often more, of the criteria for pseudoscientific claims. The author concluded that quackery is far from existing only on the fringe of osteopathic practice.
In a previous article, the author had stated that “there’s some (not strong) evidence that manual therapy may have some benefit in the case of lower back pain.” This evidence for the assumption that osteopathy works for back pain seems to rely heavily on one researcher: Licciardone JC. He comes from ‘The Osteopathic Research Center, University of North Texas Health Science Center, Fort Worth‘. which also is the flag-ship of research into osteopathy with plenty of funds and a worldwide reputation.
In 2005, he and his team published a systematic review/meta-analysis of RCTs which concluded that “osteopathic manipulative therapy (OMT) significantly reduces low back pain. The level of pain reduction is greater than expected from placebo effects alone and persists for at least three months. Additional research is warranted to elucidate mechanistically how OMT exerts its effects, to determine if OMT benefits are long lasting, and to assess the cost-effectiveness of OMT as a complementary treatment for low back pain.”
This is the article cited regularly to support the statement that osteopathy is an effective therapy for back pain. As the paper is now over 10 years old, we clearly need a more up-to-date systematic review. Such an assessment of clinical research into osteopathic intervention for chronic non-specific low back pain (CNSLBP) was recently published by an Australian team. A thorough search of the literature in multiple electronic databases was undertaken, and all articles were included that reported clinical trials; had adult participants; tested the effectiveness and/or efficacy of osteopathic manual therapies applied by osteopaths, and had a study condition of CNSLBP. The quality of the trials was assessed using the Cochrane criteria. Initial searches located 809 papers, 772 of which were excluded on the basis of abstract alone. The remaining 37 papers were subjected to a detailed analysis of the full text, which resulted in 35 further articles being excluded. There were thus only two studies assessing the effectiveness of manual therapies applied by osteopaths in adult patients with CNSLBP. The results of one trial suggested that the osteopathic intervention was similar in effect to a sham intervention, and the other implies equivalence of effect between osteopathic intervention, exercise and physiotherapy.
In other words, there seems to be an overt contradiction between the conclusions of Licciardone JC and those of the Australian team. Why? we may well ask. Perhaps the Osteopathic Research Center is not in the best position to be impartial? In order to check them out, I decided to have a closer look at their publications.
This team has published around 80 articles mostly in very low-impact osteopathic journals. They include several RCTs, and I decided to extract the conclusions of the last 10 papers reporting RCTs. Here they are:
RCT No 1 (2016)
Subgrouping according to baseline levels of chronic LBP intensity and back-specific functioning appears to be a simple strategy for identifying sizeable numbers of patients who achieve substantial improvement with OMT and may thereby be less likely to use more costly and invasive interventions.
RCT No 2 (2016)
The OMT regimen was associated with significant and clinically relevant measures for recovery from chronic LBP. A trial of OMT may be useful before progressing to other more costly or invasive interventions in the medical management of patients with chronic LBP.
RCT No 3 (2014)
Overall, 49 (52%) patients in the OMT group attained or maintained a clinical response at week 12 vs. 23 (25%) patients in the sham OMT group (RR, 2.04; 95% CI, 1.36-3.05). The large effect size for short-term efficacy of OMT was driven by stable responders who did not relapse.
RCT No 4 (2014)
These findings suggest that remission of psoas syndrome may be an important and previously unrecognized mechanism explaining clinical improvement in patients with chronic LBP following OMT.
RCT No 5 (2013)
The large effect size for OMT in providing substantial pain reduction in patients with chronic LBP of high severity was associated with clinically important improvement in back-specific functioning. Thus, OMT may be an attractive option in such patients before proceeding to more invasive and costly treatments.
RCT No 6 (2013)
The OMT regimen met or exceeded the Cochrane Back Review Group criterion for a medium effect size in relieving chronic low back pain. It was safe, parsimonious, and well accepted by patients.
RCT No 7 (2012)
This study found associations between IL-1β and IL-6 concentrations and the number of key osteopathic lesions and between IL-6 and LBP severity at baseline. However, only TNF-α concentration changed significantly after 12 weeks in response to OMT. These discordant findings indicate that additional research is needed to elucidate the underlying mechanisms of action of OMT in patients with nonspecific chronic LBP.
RCT No 8 (2010)
Osteopathic manipulative treatment slows or halts the deterioration of back-specific functioning during the third trimester of pregnancy.
RCT No 8 (2004)
The OMT protocol used does not appear to be efficacious in this hospital rehabilitation population.
RCT No 9 (2003)
Osteopathic manipulative treatment and sham manipulation both appear to provide some benefits when used in addition to usual care for the treatment of chronic nonspecific low back pain. It remains unclear whether the benefits of osteopathic manipulative treatment can be attributed to the manipulative techniques themselves or whether they are related to other aspects of osteopathic manipulative treatment, such as range of motion activities or time spent interacting with patients, which may represent placebo effects.
RCT No 10
Sorry, there is no 10th paper reporting an RCT.
Most of the remaining articles listed on Medline are comments and opinion papers. Crucially, it would be erroneous to assume that they conducted a total of 9 RCTs. Several of the above cited articles refer to the same RCT.
However, the most remarkable feature, in my view, is that the conclusions are almost invariably positive. Whenever I find a research team that manages to publish almost nothing but positive findings on one subject which most other experts are sceptical about, my alarm-bells start ringing.
In a previous blog, I have explained this in greater detail. Suffice to say that, according to my theory, the trustworthiness of the ‘Osteopathic Research Center’ is nothing to write home about.
What, I wonder, does that tell us about the reliability of the claim that osteopathy is effective for back pain?
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:
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.
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?
A 2016 article set out to define the minimum core competencies expected from a certified paediatric doctor of chiropractic using a Delphi consensus process. The initial set of seed statements and sub-statements was modelled on competency documents used by organizations that oversee chiropractic and medical education. The statements were then distributed to the Delphi panel, reaching consensus when 80% of the panelists approved each segment. The panel consisted of 23 specialists in chiropractic paediatrics from across the spectrum of the chiropractic profession. Sixty-one percent of panellists had postgraduate paediatric certifications or degrees, 39% had additional graduate degrees, and 74% were faculty at a chiropractic institution and/or in a postgraduate paediatrics program. The panel was initially given 10 statements with related sub-statements formulated by the study’s steering committee. On all 3 rounds of the Delphi process the panelists reached consensus; however, multiple rounds occurred to incorporate the valuable qualitative feedback received.
The results of this process reveal that the Certified Paediatric Doctor of Chiropractic requires 8 sets of skills. (S)he will …
1) Possess a working knowledge and understanding of the anatomy, physiology, neurology, psychology, and developmental stages of a child. a) Recognize known effects of the prenatal environment, length of the pregnancy, and birth process on the child’s health. b) Identify and evaluate the stages of growth and evolution of systems from birth to adulthood. c) Appraise the clinical implications of developmental stages in health and disease, including gross and fine motor, language/communication, and cognitive, social, and emotional skills. d) Recognize normal from abnormal in these areas. e) Possess an understanding of the nutritional needs of various stages of childhood.
2) Recognize common and unusual health conditions of childhood. a) Identify and differentiate clinical features of common physical and mental paediatric conditions. b) Identify and differentiate evidence-based health care options for these conditions. c) Identify and differentiate clinical features and evidence-based health care options for the paediatric special needs population.
3) Be able to perform an age-appropriate evaluation of the paediatric patient. a) Take a comprehensive history, using appropriate communication skills to address both child and parent/ guardian. b) Perform age-appropriate and case-specific physical, orthopaedic, neurological, and developmental examination protocols. c) When indicated, utilize age-appropriate laboratory, imaging, and other diagnostic studies and consultations, according to best practice guidelines. d) Appropriately apply and adapt these skills to the paediatric special needs population. e) Be able to obtain and comprehend all relevant external health records.
4) Formulate differential diagnoses based on the history, examination, and diagnostic studies.
5) Establish a plan of management for each child, including treatment, referral to, and/or co-management with other health care professionals. a) Use the scientific literature to inform the management plan. b) Adequately document the patient encounter and management plan. c) Communicate management plan clearly (written, oral, and nonverbal cues) with both the child and the child’s parent/guardian. d) Communicate appropriately and clearly with other professionals in the referral and co-management of patients.
6) Deliver skilful, competent, and safe chiropractic care, modified for the paediatric population, including but not limited to: a) Manual therapy and instrument-assisted techniques including manipulation/adjustment, mobilization, and soft tissue therapies to address articulations and/or soft tissues. b) Physical therapy modalities. c) Postural and rehabilitative exercises. d) Nutrition advice and supplementation. e) Lifestyle and public health advice. f) Adapt the delivery of chiropractic care for the paediatric special needs population.
7) Integrate and collaborate with other health care providers in the care of the paediatric patient. a) Recognize the role of various health care providers in paediatric care. b) Utilize professional inter-referral protocols. c) Interact clearly and professionally as needed with health care professionals and others involved in the care of each patient. d) Clearly explain the role of chiropractic care to professionals, parents, and children.
8) Function as a primary contact, portal of entry practitioner who will. a) Be proficient in paediatric first aid and basic emergency procedures. b) Identify and report suspected child abuse.
9) Demonstrate and utilize high professional and ethical standards in all aspects of the care of paediatric patients and professional practice. a) Monitor and properly reports of effects/adverse events. b) Recognize cultural individuality and respect the child’s and family’s wishes regarding health care decisions. c) Engage in lifelong learning to maintain and improve professional knowledge and skills. d) Contribute when possible to the knowledge base of the profession by participating in research. e) Represent and support the specialty of paediatrics within the profession and to the broader healthcare and lay communities.
I find this remarkable in many ways. Let us just consider a few items from the above list of competencies:
Identify and differentiate evidence-based health care options… such options would clearly not include chiropractic manipulations.
Identify and differentiate clinical features and evidence-based health care options for the paediatric special needs population… as above. Why is there no mention of immunisations anywhere?
Perform age-appropriate and case-specific physical, orthopaedic, neurological, and developmental examination protocols. If that is a competency requirement, patients should really see the appropriate medical specialists rather than a chiropractor.
Establish a plan of management for each child, including treatment, referral to, and/or co-management with other health care professionals. The treatment plan is either evidence-based or it includes chiropractic manipulations.
Deliver skilful, competent, and safe chiropractic care… Aren’t there contradictions in terms here?
Manual therapy and instrument-assisted techniques including manipulation/adjustment, mobilization, and soft tissue therapies to address articulations and/or soft tissues. Where is the evidence that these treatments are effective for paediatric conditions, and which conditions would these be?
Clearly explain the role of chiropractic care to professionals, parents, and children. As chiropractic is not evidence-based in paediatrics, the role is extremely limited or nil.
Function as a primary contact, portal of entry practitioner… This seems to me as a recipe for disaster.
Demonstrate and utilize high professional and ethical standards in all aspects of the care of paediatric patients… This would include obtaining informed consent which, in turn, needs to include telling the parents that chiropractic is neither safe nor effective and that better therapeutic options are available. Moreover, would it not be ethical to make clear that a paediatric ‘doctor’ of chiropractic is a very far cry from a real paediatrician?
So, what should the competencies of a chiropractor really be when it comes to treating paediatric conditions? In my view, they are much simpler than outlined by the authors of this new article: I SEE NO REASON WHATSOEVER WHY CHIROPRACTORS SHOULD TREAT CHILDREN!
Chiropractors and osteopaths have long tried to convince us that spinal manipulation and mobilisation are the best we can do when suffering from neck pain. But is this claim based on good evidence?
This recent update of a Cochrane review was aimed at assessing the effects of manipulation or mobilisation alone compared with those of an inactive control or another active treatment on pain, function, disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without radicular symptoms and cervicogenic headache (CGH) at immediate- to long-term follow-up, and when appropriate, to assess the influence of treatment characteristics (i.e. technique, dosage), methodological quality, symptom duration and subtypes of neck disorder on treatment outcomes.
Review authors searched the following computerised databases to November 2014 to identify additional studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). They also searched ClinicalTrials.gov, checked references, searched citations and contacted study authors to find relevant studies.
Randomised controlled trials (RCTs) undertaken to assess whether manipulation or mobilisation improves clinical outcomes for adults with acute/subacute/chronic neck pain were included in this assessment.
Two review authors independently selected studies, abstracted data, assessed risk of bias and applied Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods (very low, low, moderate, high quality). The authors calculated pooled risk ratios (RRs) and standardised mean differences (SMDs).
Fifty-one trials with a total of 2920 participants could be included. The findings are diverse. Cervical manipulation versus inactive control: For subacute and chronic neck pain, a single manipulation (three trials, no meta-analysis, 154 participants, ranged from very low to low quality) relieved pain at immediate- but not short-term follow-up. Cervical manipulation versus another active treatment: For acute and chronic neck pain, multiple sessions of cervical manipulation (two trials, 446 participants, ranged from moderate to high quality) produced similar changes in pain, function, quality of life (QoL), global perceived effect (GPE) and patient satisfaction when compared with multiple sessions of cervical mobilisation at immediate-, short- and intermediate-term follow-up. For acute and subacute neck pain, multiple sessions of cervical manipulation were more effective than certain medications in improving pain and function at immediate- (one trial, 182 participants, moderate quality) and long-term follow-up (one trial, 181 participants, moderate quality). These findings are consistent for function at intermediate-term follow-up (one trial, 182 participants, moderate quality). For chronic CGH, multiple sessions of cervical manipulation (two trials, 125 participants, low quality) may be more effective than massage in improving pain and function at short/intermediate-term follow-up. Multiple sessions of cervical manipulation (one trial, 65 participants, very low quality) may be favoured over transcutaneous electrical nerve stimulation (TENS) for pain reduction at short-term follow-up. For acute neck pain, multiple sessions of cervical manipulation (one trial, 20 participants, very low quality) may be more effective than thoracic manipulation in improving pain and function at short/intermediate-term follow-up. Thoracic manipulation versus inactive control: Three trials (150 participants) using a single session were assessed at immediate-, short- and intermediate-term follow-up. At short-term follow-up, manipulation improved pain in participants with acute and subacute neck pain (five trials, 346 participants, moderate quality, pooled SMD -1.26, 95% confidence interval (CI) -1.86 to -0.66) and improved function (four trials, 258 participants, moderate quality, pooled SMD -1.40, 95% CI -2.24 to -0.55) in participants with acute and chronic neck pain. A funnel plot of these data suggests publication bias. These findings were consistent at intermediate follow-up for pain/function/quality of life (one trial, 111 participants, low quality). Thoracic manipulation versus another active treatment: No studies provided sufficient data for statistical analyses. A single session of thoracic manipulation (one trial, 100 participants, moderate quality) was comparable with thoracic mobilisation for pain relief at immediate-term follow-up for chronic neck pain. Mobilisation versus inactive control: Mobilisation as a stand-alone intervention (two trials, 57 participants, ranged from very low to low quality) may not reduce pain more than an inactive control. Mobilisation versus another active treatment: For acute and subacute neck pain, anterior-posterior mobilisation (one trial, 95 participants, very low quality) may favour pain reduction over rotatory or transverse mobilisations at immediate-term follow-up. For chronic CGH with temporomandibular joint (TMJ) dysfunction, multiple sessions of TMJ manual therapy (one trial, 38 participants, very low quality) may be more effective than cervical mobilisation in improving pain/function at immediate- and intermediate-term follow-up. For subacute and chronic neck pain, cervical mobilisation alone (four trials, 165 participants, ranged from low to very low quality) may not be different from ultrasound, TENS, acupuncture and massage in improving pain, function, QoL and participant satisfaction at immediate- and intermediate-term follow-up. Additionally, combining laser with manipulation may be superior to using manipulation or laser alone (one trial, 56 participants, very low quality).
Confused? So am I!
In my view, these analyses show that the quality of most studies is wanting and the evidence is weak – much weaker than chiropractors and osteopaths try to make us believe. It seems to me that no truly effective treatments for neck pain have been discovered and that therefore manipulation/mobilisation techniques are as good or as bad as most other options.
In such a situation, it might be prudent to first investigate the causes of neck pain in greater detail and subsequently determine the optimal therapies for each of them. Neck pain is a SYMPTOM, not a disease! And it is always best to treat the cause of a symptom rather than pretending we know the cause as chiropractors and osteopaths often do.
The authors of the Cochrane review seem to agree with this view at least to some extent. They conclude that although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.
The call for further research is, of course, of no help for patients who are suffering from neck pain today. What would I recommend to them?
My advice is to be cautious:
- Consult your doctor and try to get a detailed diagnosis.
- See a physiotherapist and ask to be shown exercises aimed at reducing the pain and preventing future episodes.
- Do these exercises regularly, even when you have no pain.
- Make sure you do whatever else might be needed in terms of life-style changes (ergonomic work place, correct sleeping arrangements, etc.).
- If you are keen on seeing an alternative practitioner for manual therapy, consult a osteopath rather than a chiropractor; the former tend to employ techniques which are less risky than the latter.
- Avoid both chiropractors and long-term medication for neck pain.
Much has been written on this blog and elsewhere about the risks of spinal manipulation. It relates almost exclusively to the risks of manipulating patients’ necks. There is far less on the safety of thrust joint manipulation (TJM) when applied to the thoracic spine. A new paper focusses on this specific topic.
The purpose of this review was to retrospectively analyse documented case reports in the literature describing patients who had experienced severe adverse events (AE) after receiving TJM to their thoracic spine.
Case reports published in peer reviewed journals were searched in Medline (using Ovid Technologies, Inc.), Science Direct, Web of Science, PEDro (Physiotherapy Evidence Database), Index of Chiropractic literature, AMED (Allied and Alternative Medicine Database), PubMed and the Cumulative Index to Nursing and Allied Health (CINHAL) from January 1950 to February 2015.
Case reports were included if they: (1) were peer-reviewed; (2) were published between 1950 and 2015; (3) provided case reports or case series; and (4) had TJM as an intervention. The authors only looked at serious complications, not at the much more frequent transient AEs after spinal manipulations. Articles were excluded if: (1) the AE occurred without TJM (e.g. spontaneous); (2) the article was a systematic or literature review; or (3) it was written in a language other than English or Spanish. Data extracted from each case report included: gender; age; who performed the TJM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the TJM; as well as type of severe AE that resulted.
Ten cases, reported in 7 articles, were reviewed. Cases involved females (8) more than males (2), with mean age being 43.5 years. The most frequent AE reported was injury (mechanical or vascular) to the spinal cord (7/10); pneumothorax and hematothorax (2/10) and CSF leak secondary to dural sleeve injury (1/10) were also reported.
The authors point out that there were only a small number of case reports published in the literature and there may have been discrepancies between what was reported and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the TJM, published the cases.
The authors concluded that serious AE do occur in the thoracic spine, most commonly, trauma to the spinal cord, followed by pneumothorax. This suggests that excessive peak forces may have been applied to thoracic spine, and it should serve as a cautionary note for clinicians to decrease these peak forces.
These are odd conclusions, in my view, and I think I ought to add a few points:
- As I stated above, the actual rate of experiencing AEs after having chiropractic spinal manipulations is much larger; it is around 50%.
- Most complications on record occur with chiropractors, while other professions are far less frequently implicated.
- The authors’ statement about ‘excessive peak force’ is purely speculative and is therefore not a legitimate conclusion.
- As the authors mention, it is hardly ever the chiropractor who reports a serious complication when it occurs.
- In fact, there is no functioning reporting scheme where the public might inform themselves about such complications.
- Therefore their true rate is anyone’s guess.
- As there is no good evidence that thoracic spinal manipulations are effective for any condition, the risk/benefit balance for this intervention fails to be positive.
- Many consumers believe that a chiropractor will only manipulate in the region where they feel pain; this is not necessarily true – they will manipulate where they believe to diagnose ‘SUBLUXATIONS’, and that can be anywhere.
- Finally, I would not call a review that excludes all languages other than English and Spanish ‘systematic’.
And my conclusion from all this? THORACIC SPINAL MANIPULATIONS CAN CAUSE CONSIDERABLE HARM AND SHOULD BE AVOIDED.
Regular readers of this blog will be aware of the many bogus claims made by chiropractors. One claim, however, namely the one postulating chiropractors can effectively treat low back pain with spinal manipulation, is rarely viewed as being bogus. Chiropractors are usually able to produce evidence that does suggest the claim to be true, and therefore even most critics of chiropractic back off on this particular issue.
But is the claim really true?
A recent trial might provide the answer.
The purpose of this study was to compare the effectiveness of chiropractic spinal manipulative therapy (cSMT) to a sham intervention on pain (Visual Analogue Scale, SF-36 pain subscale), disability (Oswestry Disability Index), and physical function (SF-36 subscale, Timed Up and Go) by performing a randomized placebo-controlled trial at 2 Veteran Affairs Clinics.
Older veterans (≥ 65 years of age) who were naive to chiropractic were recruited. A total of 136 who suffered from chronic low back pain (LBP) were included in the study – with 69 being randomly assigned to cSMT and 67 to the sham intervention. Patients were treated twice per week for 4 weeks. The outcomes were assessed at baseline, 5, and 12 weeks post baseline.
Both groups demonstrated significant decrease in pain and disability at 5 and 12 weeks. At 12 weeks, there was no significant difference in pain and a statistically significant decline in disability scores in the cSMT group when compared to the control group. There were no significant differences in adverse events between the groups.
The authors concluded that cSMT did not result in greater improvement in pain when compared to our sham intervention; however, cSMT did demonstrate a slightly greater improvement in disability at 12 weeks. The fact that patients in both groups showed improvements suggests the presence of a nonspecific therapeutic effect.
Hold on, I hear you say, this does not mean that cSMT is a placebo in the treatment of LBP! There are other studies that yield positive results. Let’s not cherry-pick our evidence!
Absolutely correct! To avoid cherry-picking, lets see what the current Cochrane review tells us about cSMT and chronic LBP. Here is the conclusion of this review based on 26 RCTs: High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain.
In the realm of alternative medicine, we encounter many therapeutic claims that beggar belief. This is true for most modalities but perhaps for none more than chiropractic. Many chiropractors still adhere to Palmer’s gospel of the ‘inate’, ‘subluxation’ etc. and thus they believe that their ‘adjustments’ are a cure all. Readers of this blog will know all that, of course, but even they might be surprised by the notion that a chiropractic adjustment improves the voice of a choir singer.
This, however, is precisely the ‘hypothesis’ that was recently submitted to an RCT. To be precise, the study investigated the effect of spinal manipulative therapy (SMT) on the singing voice of male individuals.
Twenty-nine subjects were selected among male members of a local choir. Participants were randomly assigned to two groups: (A) a single session of chiropractic SMT and (B) a single session of non-therapeutic transcutaneous electrical nerve stimulation (TENS). Recordings of the singing voice of each participant were taken immediately before and after the procedures. After a 14-day wash-out period, procedures were switched between groups: participants who underwent SMT on the first occasion were now subjected to TENS and vice versa. Recordings were assessed via perceptual audio and acoustic evaluations. The same recording segment of each participant was selected. Perceptual audio evaluation was performed by a specialist panel (SP). Recordings of each participant were randomly presented thus making the SP blind to intervention type and recording session (before/after intervention). Recordings compiled in a randomized order were also subjected to acoustic evaluation.
No differences in the quality of the singing on perceptual audio evaluation were observed between TENS and SMT.
The authors concluded that no differences in the quality of the singing voice of asymptomatic male singers were observed on perceptual audio evaluation or acoustic evaluation after a single spinal manipulative intervention of the thoracic and cervical spine.
There is nevertheless an important point to be made here, I feel: some claims are just too silly to waste resources on. Or, to put it in more scientific terms, hypotheses require much more than a vague notion or hunch.
To set up, conduct and eventually publish an RCT as above requires expertise, commitment, time and money. All of this is entirely wasted, if the prior probability of a relevant result approaches zero. In the realm of alternative medicine, this is depressingly often the case. In the final analysis, this suggests that all too often research in this area achieves nothing other than giving science a bad name.