If I had a pint of beer for every time I have been accused of bias against chiropractic, I would rarely be sober. The thing is that I do like to report about decent research in this field and I am almost every day looking out for new articles which might be worth writing about – but they are like gold dust!
“Huuuuuuuuh, that just shows how very biased he is” I hear the chiro community shout. Well let’s put my hypothesis to the test. Here is a complete list of recent (2013)Medline-listed articles on chiropractic; no omission, no bias, just facts (for clarity, the Pubmed-link is listed first, then the title in bold followed by a short comment in italics):
http://www.ncbi.nlm.nih.gov/pubmed/23360894
Towards establishing an occupational threshold for cumulative shear force in the vertebral joint – An in vitro evaluation of a risk factor for spondylolytic fractures using porcine specimens.
This is an interesting study of the shear forces observed in porcine vertebral specimen during maneuvers which might resemble spinal manipulation in humans. The authors conclude that “Our investigation suggested that pars interarticularis damage may begin non-linearly accumulating with shear forces between 20% and 40% of failure tolerance (approximately 430 to 860N”
http://www.ncbi.nlm.nih.gov/pubmed/23337706
Development of an equation for calculating vertebral shear failure tolerance without destructive mechanical testing using iterative linear regression.
This is a mathematical modelling of the forces that might act on the spine during manipulation. The authors draw no conclusions.
http://www.ncbi.nlm.nih.gov/pubmed/23324133
Collaborative Care for Older Adults with low back pain by family medicine physicians and doctors of chiropractic (COCOA): study protocol for a randomized controlled trial.
This is merely the publication of a trial that is about to commence.
http://www.ncbi.nlm.nih.gov/pubmed/23323682
Military Report More Complementary and Alternative Medicine Use than Civilians.
This is a survey which suggests that ~45% of all military personnel use some form of alternative medicine.
http://www.ncbi.nlm.nih.gov/pubmed/23319526
Complementary and Alternative Medicine Use by Pediatric Specialty Outpatients
This is another survey; it concludes that ” that CAM use is high among pediatric specialty clinic outpatients”
http://www.ncbi.nlm.nih.gov/pubmed/23311664
Extending ICPC-2 PLUS terminology to develop a classification system specific for the study of chiropractic encounters
This is an article on chiropractic terminology which concludes that “existing ICPC-2 PLUS terminology could not fully represent chiropractic practice, adding terms specific to chiropractic enabled coding of a large number of chiropractic encounters at the desired level. Further, the new system attempted to record the diversity among chiropractic encounters while enabling generalisation for reporting where required. COAST is ongoing, and as such, any further encounters received from chiropractors will enable addition and refinement of ICPC-2 PLUS (Chiro)”.
http://www.ncbi.nlm.nih.gov/pubmed/23297270
US Spending On Complementary And Alternative Medicine During 2002-08 Plateaued, Suggesting Role In Reformed Health System
This is a study of the money spent on alternative medicine concluding as follows “Should some forms of complementary and alternative medicine-for example, chiropractic care for back pain-be proven more efficient than allopathic and specialty medicine, the inclusion of complementary and alternative medicine providers in new delivery systems such as accountable care organizations could help slow growth in national health care spending”
http://www.ncbi.nlm.nih.gov/pubmed/23289610
A Royal Chartered College joins Chiropractic & Manual Therapies.
This is a short comment on the fact that a chiro institution received a Royal Charter.
http://www.ncbi.nlm.nih.gov/pubmed/23242960
Exposure-adjusted incidence rates and severity of competition injuries in Australian amateur taekwondo athletes: a 2-year prospective study.
This is a study by chiros to determine the frequency of injuries in taekwondo athletes.
The first thing that strikes me is the paucity of articles; ok, we are talking of just january 2013 but by comparison most medical fields like neurology, rheumatology have produced hundreds of articles during this period and even the field of acupuncture research has generated about three times more.
The second and much more important point is that I fail to see much chiropractic research that is truly meaningful or tells us anything about what I consider the most urgent questions in this area, e.g. do chiropractic interventions work? are they safe?
My last point is equally critical. After reading the 9 papers, I have to honestly say that none of them impressed me in terms of its scientific rigor.
So, what does this tiny investigation suggest? Not a lot, I have to admit, but I think it supports the hypothesis that research into chiropractic is not very active, nor high quality, nor does it address the most urgent questions.
189 Responses to Research in chiropractic seems in a dismal state
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Prof stated: ‘ but I think it supports the hypothesis that research into chiropractic is not very active, nor high quality’
No it does not. It just shows your prejudice even though you claim not to be biased. All one has to do is read your previous comments to judge.
Prof stated: ‘do chiropractic interventions work? are they safe?……..that has been established long ago. You just refuse to see the evidence. You reject any evidence that does not fit into your belief system that alt med is rubbish.
Eugen Roth said:
Do you have any Medline-listed papers that Prof Ernst forgot to include?
ER: and make sure they are from 2013.
Alan in fact I did provide some research but guess what? According to Prof’s rules the research has to be from 2013. So because no research has been published in 30 days chiropractic research is deemed to be in a dismal state. Lol
ER ok, ok ,ok: let’s not spoil the fun of this little exercise. i herewith invite you to provide us links to what you think are the 3 best articles of 2012. in turn i will invite the entire skeptic community to critically evaluate them. perhaps then we will get a better impression on the quality of chiro research.
Oooohh! Yes please!
And not just any old chiro research into, I don’t know, say, the cultural competence of chiro students, but the best evidence you believe substantiates chiropractic manipulations.
ER: what’s wrong? no appetite to take up the challenge? or perhaps there are no 3 studies that even you can approve of?
EE wrote: ‘ER: what’s wrong? no appetite to take up the challenge? or perhaps there are no 3 studies that even you can approve of?’…..Oh no, I am more than ready. But first we have to get some ground rules. Otherwise its like starting to play a game but only one side knows what the rules are, how one scores points, when the game is over, what is foul play and most important who is the referee and how the winner will be announced.
I’ll tell you what Prof lets add a little spice to the competition. Lets go head to head. I’ll choose a chiropractic study and you choose one of your studies and then we can put one against the other. Remembering that according to the BMJ only 1% of published medical research is based in science. Yeah thats sounds great! I am ready but are you Prof? As they say: ‘Lets rumble’.
The reason why chiropractic research is in a dismal state seems to be because of chiropractors’ fear for their livelihoods. Indeed, it was something that was implied in 2011 by a chiropractor author of a piece in the Journal of the Canadian Chiropractic Association:
Quote
“I was recently bewildered when colleagues and chiropractic representatives feared the possible negative consequences of good quality research and of its dissemination within and outside the profession”.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154060/?tool=pubmed
In fact, it seems that chiropractors are desperate to move the goalposts…
Quote
“The Journal of Health Services Research and Policy has just published a ‘perspective’ piece by Professor Alan Breen of the Anglo-European College of Chiropractic in which he, unsurprisingly, praises chiropractic… [Breen concludes] that “strong ontological commitment to only part of the knowledge base seems often to be the stance taken to contest the scientific basis of chiropractic” at the end of an argument where he neglects to mention any trials that test the efficacy of chiropractic for any condition. Moreover, the article does not cite a single negative study or review. Instead, politicians and committees are the preferred source of authority. Again, a preference for one side of the knowledge base is seen in the author’s focus on risks that are not balanced against benefits. Having had a look for the evidence, it appears to me that in an evidence-based biopsychosocial model for the treatment of musculoskeletal complaints: Chiropractic is, at best, unnecessary.”
http://apgaylard.wordpress.com/2009/07/03/in-praise-of-chiropractic/
More here:
Quote
“…surely a democratic and inclusive approach to muskuloskeletal practice must keep open the possibility of robust criticism – and robust examinations of the empirical and theoretical bases for chiropractic. Regrettably, it appears that what Breen is moving towards is not democracy and inclusivity. As Sackett et al argue, evidence-based medicine aims to integrate individual clinical expertise with the best available external clinical evidence from systematic research. Evidence-based medicine therefore draws on the experiences of patients, clinicians and patients. In contrast, Breen seems to be moving towards a privileging of the experiences of a small subset of medical professionals – chiropractors and associated practitioners – and he seems to be advocating this privileging at the expense of numerous other stakeholders: from patients to researchers. Evidence-based medicine is certainly not perfect – and there are important areas in which it should be improved, supplemented or superseded. However, compared to Breen’s approach – an odd kind of chiropractic-centric obligarchy – evidence-based medicine is a much more promising approach.”
http://translucentscience.wordpress.com/2009/06/27/alan-breen-in-praise-of-chiropractic-and-democracy/
In essence, the above would appear to be proof that The Scientific Method of Investigation vs The Chiropractic Method of Investigation, which was published by Chirotalk, is much closer to the reality of the current chiropractic research situation than most chiropractors would admit:
http://chirotalk.proboards.com/index.cgi?board=presentation&action=display&thread=1968
Seems to me that the chiropractic House of Cards is slowly approaching collapse.
ER woud argue that the time window of jan 2013 is too narrow to draw firm conclusions – and that’s why i abstain from drawing firm conclusions (“So, what does this tiny investigation suggest? Not a lot, I have to admit, but I think it supports the hypothesis that research into chiropractic is not very active, nor high quality, nor does it address the most urgent questions”). yet i have to re-state that in the same period conventional medical fields like rheumatology generated hundreds of medline-listed papers and even acupuncture managed about 300% more and better articles.
SO, THE SHORTNESS OF TIME IS NOT A VALID COUNTER-ARGUMENT
ER thinks my results are false and due to the tiny time window. here are the number of hits for publications from the entire year 2012 for various disciplines:
neurology = 33082
rheumatology= 8784
herbam medicine =4751
acupuncture =2267
chiropractic = 475
CAN I NOW REST MY CASE?
no. the number of research articles is reflection of the funds available to chiropractic vs medicine. Medicine is given billions and chiropractic almost nothing. The resources made available to medicine is unlimited whereas chiropractic despite the pausity of research funds and facilities turn out excellent research. In a previous articles I have already highlighted the sad state of affairs of medical research evidenced by the BMJ stating that only 1% of medical research is based in science. I have already provided Prof with some research. Ok Prof please choose the research done in Japan on the effects on brain metabolism measured by PET after chiropractic care for you and you mates to trash. Lets see if you can come up with a constructive critism or will it just be alt med bashing as usual?
the funds are never “available” [you clearly have never applied for research grants]; you have to make them available!
if you want to nominate 3 papers from 2012, you must provide links to the articles.
I did. I have mentioned the Japanese study on brain metabolism after a single chiropractic intervention
no good sorry. we need 3 papers and the links to them
Eugen Roth said:
No. The paucity of chiro research articles is not related to the funds available for research on medicine.
Perhaps you could tell us how much this much-needed research would cost?
But I hope you don’t need reminded that while there is little research, chiropractors are making marketing claims that are not substantiated by robust evidence.
And please don’t forget to give us the three best papers that you believe currently substantiate chiropractic.
While your searches may be true, they are grossly misrepresentative of relevance. For example a Pubmed search for chiropractic and back pain in 2012 = 66
Neurology and back pain in 2012 = 36
Rheumatology and back pain in 2012 = 95
herbal medicine and back pain in 2012 = 10
Acupuncture and back pain in 2012 = 57
I think this is a more representative search in comparing the breadth of chiropractic research don’t you think?
i do not see the slightest reason why the limitation of the searches to a symptom (back pain) should make them more representative; the opposite perhaps.
Back pain is not a symptom it’s a disease. A disease which many of the aforementioned disciplines encompass within their scope of practice. These statistics show that chiropractic is amongst the leading fields of investigative research within this area.
It would be irrelevant to compare, say, the research of chiropractic for cancer (a disease not within our scope of practice) and the research of neurology for cancer (within a neurologist’s scope of practice) and yet your original search would include this.
pain is a symptom not a disease and back pain is no exception!
it can be caused by inflammation, neoplasms etc. amazing what chiros come up with!
Gosh that’s really strange because back pain is internationally classified as a disease. The ICD must be wrong. I shall write a letter immediately! Sarcasm aside, it’s a bit worrying that you don’t understand the difference between a symptom and a disease. It’s fairly simple really, a disease is a structural or function disorder that produces signs or symptoms that affects a specific location and requires a diagnosis. A symptom is a feature of disease apparent to the patient. In this way I could examine a cadaver and determine if they had back pain because of structural changes observed at dissection (degenerative osseous changes, muscle atrophy, postural adaptations). This is the difference between pain and nociception. Signs and symptoms of back pain include antalgia, muscle atrophy, edema, inflammation, nociception, muscle weakness, reduced mobility. You should read a book called the Back Pain Revolution by Gordon Waddell. It’s a core text on the Master of chiropractic syllabus.
Dear Professor Ernst,
you have a very valid point. Research in the field of chiropractic is, I despair, extremely limited when compared to those you have referred to: Neurology, rheumatology. Let us extend that list to paediatric medicine and pharmaceutical research that publishes infinitely more research than the chiropractic community.
This is a huge problem in chiropractic, the reasons for which I can only defend.
1) Money. Research is massively expensive and, in a profession of individuals in private practice mostly, impossible to fund on par with other health sciences.
2) Chiropractic dogma. The belief that chiropractic is beyond the realm of scientific research, I once again despair, hinders the progress of research in this field.
3) Publicity. Chiropractic gets bad publicity (not exclusive from the point above) which exempts it from the type of grants other health sciences have access to.
4) It’s incredibly hard to measure in a double blinded randomised controlled trial the effects of chiropractic intervention. There is no red pill – blue pill, yes – no scenario where chiropractic intervention can be studied, and incorporates the complexity of individual patient needs. In the same way that psychology cannot randomise its sample group and administer therapy based on individual analysis. If you have a better method I’d be interested to hear.
5) Standardisation. In a profession of 140 different technique systems, inter examiner (un)reliablity, cognitive bias, psychomotor skill application, subjectivity, who’s to say we can decide unanimously on a body of research?
6) Time. Chiropractic is a young, developing profession. No more could you expect the continent of Africa to conduct a sensus to the same standard as Europe than to expect Chiropractic to produce the same level of research as other developed disciplines.
None of these detract from the fact that in order to stand firm, chiropractic must step up to the standards imposed by scientific enquiry. But lets not jump ship before the oars are in the water. Chiropractic has published good solid research in the last decade, and I feel that in the next decade, more still.
As we begin to study the human brain and nervous system with better technology, fMRI, linear array EMG, mechanisms of injury and neuro-biomechanics, I foresee that we will have a better understanding of the applicability of chiropractic interventions thus forth.
I have offered to meet with you to discuss this work. That offer still stands. I’d be more than happy to demonstrate the applicability of the chiropractic we have now. I welcome the scrutiny of my work, and any flaws you can point out.
Respectfully yours
jesgol thanks for your candid comment; a few thoughts:
1) if the field of acupuncture (which is in a very similar position as chiros) can achieve a relatively reasonable research out-put, why not chiro?
2) time to de-throne the dogmatists?
3) the bad publicity is recent and entirely self-inflicted [BCA vs Singh]
4) this applies to many other fields as well.
5) there are ways around this: e.g. test the approach of 20 well-trained chiros no matter what precisely they do; this has been done in several other fields.
6) is ~120 years “young”? again the acupuncture world is a good counter-example; they only started research in the 1970s
Jesgol wrote: “Research is massively expensive and, in a profession of individuals in private practice mostly, impossible to fund on par with other health sciences.”
Strange how the chiropractic marketing group, the Foundation for Chiropractic Progress, received record financial support of over $500K in 2009
http://www.chiro.org/wordpress/?p=1151
…when only a month before, the Foundation for Chiropractic Education and Research, filed for bankruptcy:
http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=54144
Wouldn’t funnelling the money into research projects have been wiser and more ethical?
BTW, where did the Foundation for Chiropractic Education and Research get its funding for over 152 randomized, controlled trials concerning chiropractic manipulation? See
http://www.ebm-first.com/chiropractic/latest-news/1075-end-of-an-era-foundation-for-chiropractic-education-and-research-%5Bfcer%5D-decides-on-self-liquidation-and-files-for-bankruptcy.html
Why did the funding dry up if the profession is, as you claim, still young and developing?
What’s more strange, Blue Wode, is how you think that $500k will fund research equivocal to that produced by the field of neurology.
Most strange is how you chose not to mention how much funding neuroscience receives, for example: BBSRC funding for research relevant to neuroscience is £40.4 million in 2009.
And strangest of all, is that you feel that a Foundation of Chiropractic Research declaring bankruptcy is in favour of your argument.
The funding dries up when you spend all the money publishing 152 randomized controlled trials and 33,000 articles without financial backing from a multi-billion dollar pharmaceutical industry. The fact that they were able to do all that and not file for bankruptcy earlier is testament to the tenacity of those researchers.
You’ve basically highlighted my point. Why has Africa dried up in economic wealth? Because it’s young and developing and covered in leeches draining it of any chance of success.
Jesgol wrote: “And strangest of all, is that you feel that a Foundation of Chiropractic Research declaring bankruptcy is in favour of your argument. The funding dries up when you spend all the money publishing 152 randomized controlled trials and 33,000 articles without financial backing from a multi-billion dollar pharmaceutical industry.”
No, strangest of all is that after 152 randomized controlled trials and 33,000 articles (since the inception of the Foundation for Chiropractic Education and Research in 1943), chiropractors are still unable to demonstrate that chiropractic spinal manipulation is superior to taking two paracetamol.
I’d be happy to demonstrate to you first hand how chiropractic spinal manipulations are superior to taking 2 paracetamol. Or you can ask any of my patients. I’m serious. I’ll come meet with you anywhere you like, with as many as you like. I know what I do. I have nothing to hide. Unfortunately I haven’t published what I do yet. But I can demonstrate it as often as you want me to. If you can prove me wrong I’ll sign a legally binding document to never practice chiropractic again.
And…yet another chiro who just doesn’t get it.
I think we can all agree and according to Ben Goldacre the state of clinical research right across the board is pretty abysmal. I could offer a pretty lame excuse lack of funds, but having met some of the people doing chiropractic research I am not sure it would make a difference. It would appear that in health care profession those who are not very good in the clinical setting go into academia and research and have the market cornered, waiting for the day useless chiropractors cam prescribe drugs and their researchers can access some of the pharma research funds. As the saying goes if you cant do, teach. The least skillful and least experienced chiropractors are doing the research.
Your list reminds me of life as an undergraduate and you have to do a piece of research as part of the final yea assessment. Scraping around for a topic that will be accepted, finding subjects, seeking results that will be easily explained for the discussion. Then (pay back, for giving the research nerds a hard time when I was student president) they have the cheek to refuse to accept my research project because they concluded someone else wrote it for me (did not read it before the defense, too boring) so I had to take an extra year to do another one. I know enough medical doctors to know my experience of research is not restricted to chiropractic. So by all means have a laugh at the state of chiropractic research, however tell me how any of the above is relevant to what I do every day in practice with my clients. To make the research relevant go into clinics like mine (as was done with the Bolton Thiel cervical manipulation study) design the studies properly and see if we are telling lies or killing people. Alternatively dont do it, does not make any difference to me either way, I know what I can see and feel with my hands.
Richard Lanigan wrote: “To make the research relevant go into clinics like mine (as was done with the Bolton Thiel cervical manipulation study) design the studies properly and see if we are telling lies or killing people.”
Ah yes, the Bolton Thiel cervical manipulation study…
http://www.ukskeptics.com/forum/showthread.php/1610-Value-of-chiropractors-questioned?p=32759&viewfull=1#post32759
if you do not know how rigorous research is relevant to your clinical practice, you should not be let loose on any patient!
So you think every individual will respond as indicated by the conclusions of a RCT? Hardly surprising then that you gave up clinical practice. Who do you think a patient would rather see? A doctor who assumes they will respond as the majority did in a trial or a clinician who can “use their “clinical skills and past experience to rapidly identify each patients unique health state” (Sackett 2000)
I am certain I see a lot more “patients” than you do. Hardly surprising then that you gave up clinical practice. Who do you think a patient would rather see? A number cruncher who assumes they will respond as the majority did in a RCT trial or a clinician who can “use their “clinical skills and past experience to rapidly identify each patients unique health state” (Sackett 2000)
huuuuhhhh…! what is this supposed to mean? should we now count who has seen more patients in his professional life? (i think you might fail to win that one). or shall we even become more petty and call each other names such as “number-cruncher”?
have you read my post (below) on ad hominem attacks? yes? in this case, thanks for admitting that you have lost the argument.
Richard Lanigan wrote: “Who do you think a patient would rather see? A number cruncher who assumes they will respond as the majority did in a RCT trial or a clinician who can “use their “clinical skills and past experience to rapidly identify each patients unique health state” (Sackett 2000)”
You seem to be forgetting that Sackett doesn’t say that clinical expertise is a substitute for science, but that it is part of the mix. Many chiropractors, however, will add their own prejudices into the mix at the expense of their patients’ time, money, and – in some cases – lives.
Edzard “name calling”? I appreciate you having me as a guest on your blog and debating these issues, I am not in a position to insult you. This is what I said in my comment “So by all means have a laugh at the state of chiropractic research, however tell me how any of the above is relevant to what I do every day in practice with my clients”. Bearing in mind you have just listed a lot of clinical research that we both agree is irrelevant, instead of answering the question , you pose a rhetorical question; ” if you do not know how rigorous research is relevant to your clinical practice, you should not be let loose on any patient” You would like to believe that people who disagree with you are against research, I am against people drawing conclusions from rubbish research. I am more than willing as I have stated above to participate in research, if I did not think it was relevant I would not bother.
The studies you listed are irrelevant and you know that is what I was referring to. As for you being a “number cruncher”, how would you describe what you do? I am assuming you have long since retired from clinical practice and seem to spend much of your time reviewing studies on the internet and making comments on blogs and twitter. You never mention clinical experience so as you have some (“much more than me”) I would say it was relevant, so how did spinal manipulation and homeopathy, go in practice?
In relation to Blue Wodes comment suggesting I am misrepresenting Sackett; I asked Edzard if a patient had to make a choice between two types of practitioner, which would they choose? I have criticizer Edzard Ernst and Simon Singh a number of times for the way they have presented Evidence based Medicine in their book Trick or Treatment. On Page 24 they state “Evidence Based Medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients”. As we all know this is only one of Sacketts three pillars which for the “foundation of EBM, the others are the experienced practitioner which I have quoted above and the third which are the “values” each patient brings to the clinical encounter.
Again, Edzard, an ad hominem attack is not the same as an insult. It is an abbreviation and Anglification for “argumentum ad hominem”, meaning that someone’s logical position is said to be flawed based solely on the perception that they are an (add insult).
Secondly Richard’s argument is actually very valid indeed because of the one thing you seem to fail to grasp throughout your foires in the critical analysis of treatment and treatment efficacy: unfortunately (for your brand of systematic analysis of clinical efficacy) – which is probably why you are failing to see the validity of his argument: whilst no one – not even the quacks often falsely and deviously referred to in this and many other blogs like it as being representative of altmed – will argue that science has no value or place in healthcare, one has to be very careful with “how much value” one places on it.
What I mean here dear Edzard (and this is part of the reason why I do agree with Richard that numbers of patients seen and treated actually IS relevant to this discussion) is that healthcare, in all its forms is about one thing and one thing only and that is the patient. Whether a clinician helps his or her patient by offering sympathy, a listening ear, placebo medication or “effective” (whatever that means) medication is irrelevant (to a point) but whether it helps the patient get better IS. Now, I say “to a point” because of course safety, and cost-effectiveness are valid and highly necessary pursuits, but NEVER (if you are a clinician held to account by your Hippocratic oath) to the detriment of the patient. This, I feel with equal fervour and passion as you feel that a patient should shun treatment which has not yet been shown to be efficacious and which has not yet been shown to be safe. I understand your point of view but fundamentally disagree with it because it does not put the potential for benefit to the patient first.
But then I am a clinician and you are not, and we therefore can theorise forever and never meet but please be astute enough to realise that it is because you are failing to see and account for “the other argument” whilst I can see yours and am quite happy to integrate into the clinical reality some of the points you make and balance some of their implications into daily use but you seem unable to take into account some of the realities of clinical life to the detriment of the efficacy of your work (ie one might have some valid points but because they’re being such a &%* about it few people are willing to listen to them). I told you before: it’s in my opinion nothing but a style and humility issue.
Regs,
Stefaan
Stefann wrote
Did you perchance mean that it doesn’t put the potential for benefit to the practitioner first?
I’m not sure how pursuing safety could be to the detriment of the patient but never mind. More confusing is that you seem familiar with the Hippocratic oath and then argue that it is worth putting a patient at risk of (1) harm and/or (2) wasting their time and money by subjecting them to an unproven therapy because it might be safe and of benefit. Doesn’t sound very Hippocratic to me.
Btw, I think Edzard knows what an ad hominem is, while you still seem a bit muddled about it.
Jesgol wrote: “Unfortunately I haven’t published what I do yet.”
Please let us know when you do.
That’s it? You’re not going to take up my offer? I’m offering to walk into the lions den and let you take your best shot, and you choose not to? How very unscientific of you.
The very fact that you are proposing what you did as if it was in some way scientifically useful shows how little you understand.
Jesgol wrote: “I’d be happy to demonstrate to you first hand how chiropractic spinal manipulations are superior to taking 2 paracetamol. Or you can ask any of my patients. I’m serious. I’ll come meet with you anywhere you like, with as many as you like. I know what I do. I have nothing to hide…I’m offering to walk into the lions den and let you take your best shot, and you choose not to? How very unscientific of you.”
You are the one who is being unscientific. As I responded to Eugen Roth on another one of Prof. Ernst’s blog posts, it is unlikely that you would be able to recognise self-serving biases. IOW, you would have to, somehow, eliminate demand characteristics (e.g. the customer is unwilling to admit to having experienced poor outcomes if a great deal of time and money has been invested); the possibility that the condition may have run its natural course (i.e. self-limiting or cyclical ailments regressing to the mean); spontaneous remission; the placebo effect (enhanced by touch); the possibility that some allegedly cured or relieved symptoms were probably psychosomatic to begin with; and misdiagnosis.
You won’t even give me a chance to demonstrate what I intend to demonstrate. You have no idea what I am going to do, and yet you’re jumping to conclusions that what I am going to tell you is subject to cognitive bias, natural history, spontaneous remission and placebo. You are the definition of dogmatic, do you know that? You’re not even willing to listen to what I have to say. Like I said, if you listen to my case and then rip it to shreds, I’ll sign an affidavit declaring never to practice chiropractic again. What have you got to lose?!
See my previous comment.
sounds like someone’s too scared to put his money where his mouth is! If you’re so confident that chiropractic “is no better than taking 2 paracetamol” you should have no problem with my proposition.
Also, you might be aware that such gatherings to discuss natural science were the founding actions of the Royal Society. Many prominent figures would engage in such discussion. But please excuse my ignorance on the matter. I forget how strict the rules are of this Old Boys’ club.
the royal society used the methods of the time! 200 years ago, they might have done what you propose; i doubt that they would do it today – but feel free and try them!
meanwhile, i would be willing to join you in a jouney backwards in time, provided we can do this on the occasion of a meeting of SKEPTICS IN THE PUB at a time and location that suits me and provided i see the protocol of what you propose before i make my final decision [i think that’s roughly how they would have done it 200 years ago]
Jesgol: your definitions of symptom and disease are correct but your interpretation is not. you write that ” I could examine a cadaver and determine if they had back pain because of structural changes observed at dissection (degenerative osseous changes, muscle atrophy, postural adaptations).” this is incorrect. you would diagnose BACK PAIN in 100% of individuals over 50 years. we all have degenerative changes in the spine and elsewhere but only some have pain – and that is one reason why BACK PAIN IS A SYMPTOM – never mind what classifications tell us; they are just that and not definitions.
I have offered many times to attend a Skeptics in the Pub meeting and explain what a subluxation is? How I locate and correct it and how it benefits an individuals wellbeing and answer questions. Could not be simpler but there have been no takers. Which is very surprising when all I here from skeptics is that a subluxation is a figment of my imagination and how I am deluded for thinking its real. I am happy to look for them in any skeptic spine, I understand skeptics may be frightened and unwilling to have their subluxations corrected. So I could bring my kids along for a demonstration of the correction if the skeptics promise to be courteous to them.
and why should they be interested in your private views? as far as i know, they are not the views of the majority of chiros.
‘they are not the views of the majority of chiros.’…..what are the views of most chiros?
RICHARD: if you have no clue what i have been doing, why do you make “assumptions” about it and even base ad hominem attacks on it. my response was not ad hominem – it was based directly on what you posted.
Richard Lanigan wrote: “I have criticized Edzard Ernst and Simon Singh a number of times for the way they have presented Evidence based Medicine in their book Trick or Treatment. On Page 24 they state “Evidence Based Medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients”. As we all know this is only one of Sacketts three pillars which for the “foundation of EBM, the others are the experienced practitioner which I have quoted above and the third which are the “values” each patient brings to the clinical encounter.”
Richard, I pointed out to you in November of last year, on this very blog, that you don’t seem to have grasped what Sackett’s “three pillars” really mean. Here’s a reminder:
http://edzardernst.com/2012/10/chiropractic-lessons-that-have-not-been-learnt/#comment-527
Snippet:
Good evidence making comes from using External Evidence AND Clinical Expertise AND Patient Values, not External Evidence OR Clinical Expertise AND/OR Patient Values. Are you advocating that your clinical ‘experience’ (which can often equate to simple prejudice) and patient wishes should be able to ignore and trump the evidence, no matter what the evidence says?
…Prof Ernst and Simon Singh did not just look at published research. Chapter 6 of Trick or Treatment?, entitled ‘Does the Truth Matter?’, addresses fully the problems of clinical experience and patient choice (the other two of Sackett’s “three pillars”) in relation to CAM.
If I have misunderstood what you do, I apologies. So what else do you do besides review scientific studies of poor quality?
and why should i do this? you are only going to take issue whith whatever i answer. i am not being examined here!
JESGOL: “You should read a book called the Back Pain Revolution by Gordon Waddell. It’s a core text on the Master of chiropractic syllabus” this is an under-whelming choice! the book is simplistic and superficial. it has ~500 pages; my textbooks on the human spine have several thousand pages and go into much greater depth.
Your attempt to discredit a text based on how many pages it has is ridiculous. ‘My books are better than yours because its got more pages’…Prof you gotta be kidding!! Lol
no you cannot read!
i criticized the book because it is “simplistic and superficial” the page-cout was merely coincidental
EUGEN ROTH: i suggested you name 3 articles of 2012 and we submit them to a critical analysis. will you do this, yes or no?
your suggestion of a head to head comparison is an entirely different approach; it sets my work against that of the entire worldwide chiro research community – hardly a fair comparison! yet i will consider it, once we have done my test outlined above.
Prof once you have addressed my concerns about ‘fair play’ I will provide you the links you require. However ‘head to head’ I believe is the way to go. Its much more exciting dont you think?
no, we do my little mini-research first!
what are your concerns?
the plan could not be more straight forward
1 you provide links to 3 full articles of your choice
2 who ever wants does a critical assessment
3 i pulish them on this blog
4 you are allowed to respond
i am not going to discuss this endlessly with you – either you do it or not.
So its my way or the highway. Already showing signs that it will not be a fair contest. I am not going to bullied into something if there is any kind of coercion. ‘
Any progress on finding those three papers yet? All you have to do is tell us what they are and provide a link to them.
and this morning, a new chiro-article had appeared on Medline: http://www.ncbi.nlm.nih.gov/pubmed/23369818
to save you the bother of looking it up, here is the abstract
In this article, we describe the case of a 44-year-old secretary who developed neck pain. Without first having consulted her general practitioner, she visited a chiropractor who concluded that she had ‘irritation of the nerves’, which the patient interpreted as a herniation of a cervical disc. She believed an MRI to be necessary. She underwent a total body scan at a commercial facility which revealed degenerative changes of the cervical and lumbar spine and an arachnoid cyst in the brain. We could not reassure this patient; however, unnecessary investigations and treatment in a different patient could be prevented. Additional investigations for neck pain without neurological signs on examination are only necessary for a few patients. Chiropractic may have serious side effects. Confusing information about neck pain appearing on the Internet and in medical journals should be contested with information based on the solid, critical appraisal of studies
This article is written by a neurologist. The question arising is: Was the chiropractor negligent? Did he miss obvious signs and symptoms that should have made him refer this patient to a medical facility for further investigations? For instance pituitary gland adenomas can be asymptomatic and could be a co-incidental finding that in no way would contra indicate chiropractic care for a mechanical joint dysfunction in the cervical spine. To try make some kind of association between the two and therefore to suggest that the patient would have found herself in a life threatening situation had she taken up chiropractic care is ridiculous.
ER, you will notice that i omitted all the insulting statements in this post – in future, i will just not post such comments altogether; it takes too much time to edit them. so please abstain from insults, ad hominem etc.
Now you know why I want guarantees of ‘fair play’.
you have my guarantee of fair play
Eugen
Why are you having such a problem telling us what you believe to be the three papers that you believe are the most compelling?
i think it would be fair to conclude that he chickened out. coersion??? we only want to critically assess the 3 articlesfrom 2012 which he thinks are top quality. no room for coersion whatsoever – even if we wanted to.
Indeed. And such a simple task too.
While we’re waiting for Eugen to come up with his three most convincing trials, it might be interesting to look at an update to the last Cochrane Review of chiro for LBP that’s just been published: Spinal manipulative therapy for acute low back pain: an update.
This isn’t a Cochrane Review, of course, but it concluded:
It’s worth noting that it also said:
I dont take issue with anything you say because you are drawing your conclusions from what we both agree is poor quality research. You tell me I am being unfair to you because you do more than trawling the internet searching for CAM research to blog about, nevertheless you refuse to tell me what else you do. You say you have written a textbook on the human spine far superior to Gordan Wadells, Back pain Revolution, which you describe as as “simplistic and superficial” because it only has 500 pages. I would like to read your book on the spine but it does not seem to be on Amazon, where can I get it?
i wrote “my textbboks on the human spine….”this was not supposed to mean “the textbooks which i have published”. my textbooks are the books i consult and they cover most areas of medicine. it would be a very tall order to write them.
so you think my job is/was to blog about studies i find on the internet. let me tell you what my team and i did in the last 20 years:
we conducted ~ 40 clinical trials, ~ 10 surveys, ~ 20 other investigations, ~ 200 systematic reviews/meta-analyses and published them in peer-reviewed medical journals [not on blogs]. in addition, i gave ~ 600 lectures worldwide, wrote and edited ~ 20 books, wrote grant applications,acted as expert witness in ~10 cases for the GMS and the courts, supervised Phd students, examined Phd studentsin ~20 different countries, taught med students in exeter and many other unis, acted as peer-reviewer for ~ 3000 jounal submissions for most leading med journals, reviewed about 1000 grant-applications, served on various gov committees, created 2 med journals and acted as their editor in chief – and YES!!! – i also wrote a few blogs for the times, the guardian, the independent, pulse, BMJ, 21st floor and now this one [i am sure i forgot a few things]
Here are my 3
McCormack, JR. (2012). Use of thoracic spine manipulation in the treatment of adhesive capsulitis: a case report.. Journal of Manipulative and Physiological Therapeutics. 20 (1), 28-34.
Huisman PA, Speksnijder CM, de Wijer A. (2013). The effect of thoracic spine manipulation on pain and disability in patients with non-specific neck pain: a systematic review.. Disability Rehabilitation.
Saavedra-Hernández M, Arroyo-Morales M, Cantarero-Villanueva I, Fernández-Lao C, Castro-Sánchez AM, Puentedura EJ, Fernández-de-Las-Peñas C.. (2012). Short-term effects of spinal thrust joint manipulation in patients with chronic neck pain: a randomized clinical trial.. Clinical Rehabilitation.
Really? Those three? You’re given the opportunity to choose the three most compelling articles of 2012– and one of your three is a single case report? And another is a “systematic review”— no new information, just a rehash of what’s already been published? So, only one of the three that you yourself chose is actually a clinical trial. Wow.
I think, rhetorically, it’s a better strategy to try to argue your own side of an argument, rather than hand the other guy more ammunition. But maybe there’s a more-subtle strategy here.
Anyway: despite your not posting a link, I’ll take a look at that third ref, the “clinical trial”. Let’s see what it showed….
That didn’t take long. The article itself is behind a paywall. Here’s the abstract: http://www.ncbi.nlm.nih.gov/pubmed/23129812
82 patients randomized to either cervical OR full-spine manipulation (note no placebo group). There was no attempt at blinding the patients, and it’s unclear whether observers were blinded. Of the outcomes, one was significantly different (disability, as rated on some kind of scale); but pain nor range of motion was not different between the groups.
This is impressive?
Does Jesgol’s ‘plethora’ of evidence for chiropractic remind anyone of anything?
1) a case-report; interesting perhaps but without any consequences: case reports never prove anything.
2) a systematic review, quite well-made but shows that “there is insufficient evidence that TSM is more effective than control interventions in reducing pain and disability in patients with non-specific neck pain”; hardly convincing.
3) roy commented already on the RCT
this begs the question: were you trying to pull our leg?
Edzard said:
He must have been – that’s the only possible explanation.
Either that or chiros still don’t understand the basic concepts behind robust scientific evidence…
Here are some more
von Heymann WJ Dr Med, Schloemer P Dipl Math, Timm J Prof Dr Rer Nat, Muehlbauer B Prof Dr Med.. (2012). Spinal HVLA-Manipulation in Acute Nonspecific LBP: A Double Blinded Randomized Controlled Trial in Comparison With Diclofenac and Placebo.. Spine.
Muth S, Barbe MF, Lauer R, McClure PW.. (2012). The effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy.. Journal of Orthopaedics and Sports Physical Therapy. 42 (12), 1005-16.
Dunning JR, Cleland JA, Waldrop MA, Arnot CF, Young IA, Turner M, Sigurdsson G. (2012). Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial.. Journal of Orthopaedics and Sports Physical Therapy. 42 (1), 5-18.
I’m not sure how relevant the year is. The number of revolutions the earth performs around the sun has nothing to do with the quality of research. Although I have no double blinded randomised controlled trial to confirm this.
Jesgol
Prof Ernst didn’t ask for a Gish Gallop, just the three studies that you believed were the best evidence for chiropractic manipulation.
Which three is it to be?
No that is not what he asked for. He asked for 3 publications from 2012 that substantiate quality evidence in the field of chiropractic.
Here are my 3 for review.
von Heymann WJ Dr Med, Schloemer P Dipl Math, Timm J Prof Dr Rer Nat, Muehlbauer B Prof Dr Med.. (2012). Spinal HVLA-Manipulation in Acute Nonspecific LBP: A Double Blinded Randomized Controlled Trial in Comparison With Diclofenac and Placebo.. Spine.
Huisman PA, Speksnijder CM, de Wijer A. (2013). The effect of thoracic spine manipulation on pain and disability in patients with non-specific neck pain: a systematic review.. Disability Rehabilitation.
Saavedra-Hernández M, Arroyo-Morales M, Cantarero-Villanueva I, Fernández-Lao C, Castro-Sánchez AM, Puentedura EJ, Fernández-de-Las-Peñas C.. (2012). Short-term effects of spinal thrust joint manipulation in patients with chronic neck pain: a randomized clinical trial.. Clinical Rehabilitation.
Enjoy
ok, i did not invite you to do this but i am entirely happy to do it with anyone who plays by the rules; please select 3 articles of 2012 and provide links to the full articles for our assessments.
Only some chiropractic research (that is, research performed by chiropractic professionals) is actually on the topic of spinal manipulation. I think it is an important distinction. Your observation is accurate, certainly about research on chiropractic manipulation, but I think there is progress being made in the breadth of research from chiropractors, as well as integration in universities in Canada.
Visiting the Canadian Chiropractic Research Foundation website (www.canadianchiropracticresearchfoundation.com) (I hope I spelled that right) and reading the article topics in the Journal of the Canadian Chiropractic Association can give one an idea to the types of research performed.
You may find an article interesting that is in the December issue of the CCA Journal (you have probably read it already) called: “Commentary – Legitimizing chiropractic clinical research Dr. David J. Brunarski, DC, MSc, FCCS(C)”
Regards:)
I dont think any chiropractic would guarantee a cures for anything, what is not in dispute is that dysfunction of synovial joints will affect the articular surfaces of the joints and the surrounding soft tissues. There are 48 facet joints in the spine. In each spinal joint there are mechano receptors and restriction of joint movement will affect sensory input to the CNS, motor output and pain transmission. Then there is the affect of joint dysfunction on the sympathetic chain which runs down the spine, It interacts with the spinal nerves by way of rami communicantes.The superior end of it is continued upward through the carotid canal into the skull, and forms a plexus on the internal carotid artery. Baroreceptors in the carotid artery regulate blood pressure.
None of this is in dispute, what is disputed is how spinal dysfunction affects specific conditions. Medical doctors treat conditions, I restore function to dysfunctional spinal joints thats all I do, I dont call myself a “doctor”, I see myself providing a service to clients, just as a personal trainer would and I am in no doubt clients are better off free from spinal dysfunction as they are if they take regular exercise, brush their teeth and eat healthy.
So every day I am happy to palpate spines for spinal dysfunction/subluxation and correct the subluxation. The consumer decides whether whether the feel better after an adjustment and whether and when they need it again. The study below describes local effects of subluxation on a joint as you seem to believe subluxation is a figment of my imagination. Medical people only use the term in relation to hypermobility of a spinal joint, chiropractors use the term in relation to the joints full range of motion. I would love somebody to do research into the effects of what I have described, I have done three research studies in my life, its time consuming and stressful and having just recovered from stage three cancer my kids get my undivided attention when they are not at school. If you want to come into my practice to conduct a study you are more than welcome.
http://www.ncbi.nlm.nih.gov/pubmed/3581580
the onus to sow evidence for the assumptions of a profession lies squarely within this profession.
Cant disagree with that. Unfortunately the chiropractic profession lacks leadership and cant decide whether it wants to be a branch of manual medicine or a separate and distinct profession. If the politicians can decide on the kind of profession they want, they may start producing more relevant research, for you and your colleagues. In the mean time, I like the vast majority of chiropractors will continue to help our clients deal with the problems caused by spinal joint dysfunction.
so it is the politicians who have to decide?
i thought that a mature profession should be in charge of its own destiny!?!
So, essentially, chiropractors are charging their customers *as if* good research evidence for their interventions already existed. That’s hardly ethical.
No chiropractor disputes that more research is necessary to better understand the mechanisms of chiropractic care. Nobody can deny that research plays a vital role in developing the chiropractic profession further. Prof you are trying to create the idea in the reader’s mind that chiropractic is not based on scientific principles but to quote you ‘the make believe world of chiropractic’. This is a misrepresentation. Chiropractic is based on scientific principles that is a fact. I have given you many examples of this in the past. Richard has also described this very clearly in his recent comment. It also is a fact that the chiropractic research is lacking not being able to turn these scientific principles into evidence. However the unsatisfactory state of research in general (BMJ states only 1% of medical research is scientifically sound) and in chiropractic especially does not mean that chiropractic is woo-woo, pseudo science, make believe, bogus and all the other derogatory terms that you have used. It is an undeniable fact that research funds are extremely limited for chiropractic research. Why? Its simple because the monetary gain from chiropractic research for investors in minimal. The financial incentive to invest in medical research on the other hand is HUGE…..billions of $$$$$$.
You see Prof you could become an even greater urban myth by collaborating with chiropractors in research that would provide the scientific evidence that would verify the scientific principles and theories that chiropractic is based on. Imagine that.
AND GUESS WHAT? I HAVE CO-OPERATED WITH CHIROS!
why don’t you give us the link to your regularly cited claim “only 1% of med evidence is sound”?
if i remember correctly, it was richard who denied that evidence matters for him!?!
“It also is a fact that the chiropractic research is lacking not being able to turn these scientific principles into evidence.”….could it be that they are pseudo-principals which cannot be converted into evidence?
could it be that chiros do not really know what evidence is? see the above test! was that not a telling result?
Yes, please Eugen. A link to that would be good. Not that it’s relevant to the paucity of good evidence for chiro, of course.
THe evidence you had listed in your posting was “irrelevant” to me. Scientific evidence is just information, individuals interpret it differently. Its not a truth or guarantee of outcome.
I would not describe the “Chiropractic profession” as being “mature” the fact they need 4 associations to represent the views of 2,500 of them would suggest a lack of maturity and you have been well able to take advantage of those political divisions down the years.
Professor Ernst wrote: “AND GUESS WHAT? I HAVE CO-OPERATED WITH CHIROS!”
I remember one particular instance where Prof. Ernst co-operated with the chiropractic profession, but it was far from reciprocated: In 2004, the General Chiropractic Council (GCC) claimed that Prof. Ernst “…refuses to engage in any meaningful dialogue with the UK chiropractic profession.”
http://www.gcc-uk.org/files/link_file/Press_HSJ_260704.pdf
(That link is now dead, presumably having been de-activated after the GCC lost the ‘promoting the profession’ aspect of its remit around four years ago.)
Nevertheless, just over a year after the GCC’s assertion, Prof. Ernst attended one of the GCC’s meetings, and the following is what the GCC chose to write about his visit in its open minutes of that meeting:
Quote
Presentation by and discussion with Professor Ernst
A copy of Professor Ernst’s presentation is attached as Appendix A to these Minutes. Questions to Professor Ernst in the subsequent debate included:
• Are you familiar with the work of Herzog et al regarding the physical characteristics of cervical spine manipulation and its effect on the vertebral artery?
• How do you rationalise your view of the chiropractic profession as responsible for most serious adverse affects when osteopaths, some physiotherapists and other professionals also engage on a global basis in manipulation of the cervical spine?
• Why do you say that osteopaths use mobilisation, which is inherently safer and chiropractors only manipulate, which carries more risk?
• Where is your evidence of “serious adverse events, such as stroke (sometimes fatal) are regularly reported”?
Ref C-040805-8 here: http://www.gcc-uk.org/files/link_file/C-040805-Open1.pdf
What’s disgraceful about the above is that Appendix A, and the minutes of the ensuing debate, seem to be for chiropractors’ eyes only as they were *never published online* despite the GCC priding itself on being a transparent regulatory body…
http://www.gcc-uk.org/files/link_file/Press_GCCTakesLead_171299.pdf
‘.could it be that they are pseudo-principals which cannot be converted into evidence?’……..what pseudo principles are you referring to?
You see Prof there you go again using terms like ‘pseudo principles’ when referring to chiropractic. And you claim that you have to edit my comments because of insults. Yet again you are showing that you are not interested in getting into a constructive discussion but that you are more interested in ‘chiro bashing’.
AND GUESS WHAT? I HAVE CO-OPERATED WITH CHIROS!….tell me more.
i do not quite see why!
but anyway,for instance, i was an advisor on Thiel’s safety study.
If you were advising them, how come they got the design of the follow up in the study so wrong. Did they ignore your advice?
advice is just that – i did not design the investigantion. also i think the design was not too bad; i more object to the interpretation of the findings etc.
I presume you mean you object to their conclusions from the findings. I was one of the chiropractors who provided the findings. We had to report on any adverse events after 100 consecutive adjustments to the cervical spine. I reported there were none which is normal for me.
asking a polite question “could it be that…” is not bashing anything; you could even see it as a constructive suggestion to think about your concepts differently.
…or did you only say that to distract from the fact that you did not provide the link i asked for?
My post from today: chiros know nothing about children’s health either– a conclusion from their own literature.
http://pediatricinsider.wordpress.com/2013/02/06/chiropractors-know-almost-nothing-about-child-health/
Well said, Roy.
“Chiropractic professionals need to decide: Is treating children part of our practice? If so, they should insist on quality information to guide their practice to effectively help pediatric patients. Until they have that knowledge, they ought to tell parents that, honestly, they have no idea what they’re doing”
I would have to say I am from the Robert Mendelsohn school of thought when it comes to pediatrics. Keep away from medical doctors, give a fever three days to run its course and temperature is the bodies way of dealing with bacteria and virus. My 4 children have never had antibiotics the eldest is 26 the youngest is 6. Dont you think thats unusual, surely you view that as a good thing. It may be down to a difference in approach.
How would you manage a case of Otitis Media in a five year old boy and a case of colic in a ten week infant and what evidence would you base your decision on. These are two cases that presented at my practice recently and according to you I should have referred them out, so what would you have done? Then I will tell you what I did.
Richard, you’ve posted that identical comment here and on the original post in my own blog. I will respond there.
I can tell you, as a board certified pediatrician that the management of a case of otitis media in a five year old boy would depend on the specifics of the case and the findings on physical exam. I can also attest that a well done examination of the tympanic membrane and correct interpretation of that exam, does take skill that even many adult medicine (internists) may lack ( I know this because I am also board eligible in internal medicine). Clinical pediatricians look in ears all day long and it took me a couple years of such before I felt confident in my approach. So what would I do. Well, in the case of an obvious case of OM (red, bulging TM, decreased TM movement) in a previously healthy child with a non-contributory past medical history, I would probably do absolutely nothing except perhaps some topical analgesia, parental reassurance and and follow up in 2-3 days for reassessment.
With regard to colic. I would reassure myself based on careful history and physical exam that no other, more concerning process is present, then reassure the parents that this is nothing that requires specific treatment.
Another rate limiting step may be the number of journals dedicated to chiropractors. Edzard may be more aware of this number than I am. The JCCA is published only quarterly (perhaps more submissions would raise this number). Furthermore, a lack of quality in the scientific research submitted by the working chiropractor may result in that research not being accepted at all by a mainstream medical journal.
Another point I would like to make is that if you are referring to chiropractic as a treatment, you may wish to compare it to research of other treatments, not specialties. As I mentioned before, only a small proportion of chiropractic research is on manipulation. It may be more appropriate to compare, say, studies about acetaminophen, and then scale it down to the number of chiropractors to medical professionals (I am guessing about 5-10 percent).
No matter what, no excuses, we need more and better research about chiropractic. It is a known issue.
Gary said:
Yes, a very quick search brings up just 17 journals dedicated to chiropractic and a further five that seem to take articles on chiropractic:
Annals of Vertebral Subluxation Research
Chiropractic & Manual Therapies
Chiropractic History – The Journal
Chiropractic Journal of Australia
Chiropractic Report
Clinical Chiropractic
Dialogues – The Journal of Philosophy, Principles & Practice of Chiropractic
Journal of Chiropractic Education
Journal of Chiropractic Humanities
Journal of Chiropractic Medicine
Journal of Clinical Chiropractic Pediatrics
Journal of Manipulative and Physiological Therapeutics (JMPT)
Journal of Pediatric, Maternal & Family Health – Chiropractic
Journal of the Academy of Chiropractic Orthopedists
Journal of the American Chiropractic Association
Journal of the Canadian Chiropractic Association
Manual Therapy
Musculoskeletal Disorders
Spine
Spine Journal: Official Journal of the North American Spine Society
The Chronicle of Chiropractic
The Journal of Upper Cervical Chiropractic Research
Is that enough?
Back pain is not a distinct disease entity but a symptom. This means that one back pain is not necessarily like another back pain.
There can be no “golden rules” and each treatment plan has to be highly individualized. It must take into account the nature of your particular back problem. Your signs and symptoms. Your entire life situation, worries and hopes. Your previous experiences with certain forms of treatment. The prognosis for your condition. The possibility of preventing further episodes of back pain. A comprehensive plan will often need more than one therapeutic approach. Educating yourself together with a combination of conventional and complementary treatments, is the best strategy.
How can that be put into a RCT?
the answer is:
WITHOUT MAJOR PROBLEMS -i think you might need to read up about research methodology.
Surely everybody aims to get as symptom free as soon as possible and to keep out of trouble in the future.
But Prof Ernst that whole piece was from one of your books. Please let us know the research you have done that can explain the “golden rule” or the valuable research you have participated in that shows that “one back pain is not necessarily like another back pain”
Do you no longer believe that “each treatment plan has to be highly individualized”? If you now think your own words were wrong what research has changed your mind?
i do not doubt the need for individualisation of the treatment of back pain.
what i said is that it is possible to scientifically test any individualised approach.
individualisation is fine, i never denied that – however, i deny that it defies scientific testing
Again, Prof Ernst if each person has an individual problem and there is no “golden rule” (your words) how would you test this scientifically? How would you develop a RCT to cover individual problems? And why haven’t you bothered to develop a research project to test this theory, why haven’t you researched individual treatments for individual problems? You seemed to identify back pain as a problem that is difficult to deal with so why haven’t you done some worth while research into it? Obviously the chiropractic research isn’t up to your standard so where is your work?
we did develop a trial design which allows a maximum degree of individualisation http://www.ncbi.nlm.nih.gov/pubmed/8617415 this is not specifically for chiro nor for back pain – here a simple 2 parallel group design might evenn suffice: x pts are randomised to see chiros ot docs [ the chiros then can individualise as they see fit] and after 3 months or so, we compare the results.
why have we not done such a trial; as it happens, we did design one and applied for funding anout 12 years ago – and failed to be successful.
the fact that i have not done such trials does not disqualify me from criticising chiro-research.
THE ONUS TO SUPPORT CLAIMS WITH EVIDENCE RESTS ON THE SHOULDERS OF THOSE WHO MAKE THEM
Have you offered this trial you devised to any chiro associations? If not why not.
at the ime, we submitted it to funding bodies with an interest in the subject. i do not think there were chiro-organisations that offered funding for research; i am not even sure whether there are any tody – are there???
lol thats a good one 😉
when you have stopped laughing, please list the chiro-funding organisations which, 12 years ago, funded trials.
If you agree that back pain and treatment for back pain needs to be individual do you think rct is the best way of measuring outcome? How can standardise problems or treatment?
RCTs do not measure outcomes they compate the results of two different treatments.
for that purpose, there is no method that is more reliable in establishing cause and effect
You still haven’t answered the question Prof. If back problems and treatment for back problems are individual, how can you standardise a problem or a treatment then compare using an RCT? I have to keep going back to this as you seem to feel the only way to establish cause and effect is by RCT but you are unwilling or unable to explain how it could be done.
So please explain it to me like I’m an 8 yr old. If each episode of back pain is individual and each treatment plan is individual (remembering this is from your book) how can an RCT compare these episodes and treatment?
who says that RCTs have to include only standardised treatments? they mostly do, and life is easier in such cases, but it is not mandatory – see trials of homeopathy, to name just one example.
When you consider the cost of back pain to the economy, why do you think your design was turned down?. Did you apply to the chiropractic or osteopathic professions for funding?
I think Fed Up raises a relevant point about this type of research and the confounders that may effect results (or is this a point you raised in a book?). When someone gets a pill as a clinical intervention the pill is always the same, when someone gets “spinal manipulation therapy SMT”, like surgery its dependent on the skill of the practitioner, how does one account for the level of skill in a RCT, and isnt this a difficulty in assessing surgery .
Then in using the generic term “chiropractic” are you aware not all chiropractors use joint manipulation involving cavtation of the joint. Dont you think researchers should focus on assessing techniques and make sure the technique is executed by a skilled experienced practitioner. Not doing this may account for poor results dont you think?
you need to employ several therapists who fullfill certain quality criteria for such trials; nothing new her; this has been done in many other areas of research as well.
Hi. I’m just looking for general information about where I can locate ANY research about the effectiveness of Chiropractic to the individual. I don’t want to add to any arguments, I would just like some links that can lead me to information about whether going into the Chiropractic field is worth the time and money that I would have to invest in the endeavor. Not only that, but I want to see if the career can stand behind their promises of promoting a healthy way of living, without breaking any ethics and having a clear conscience. It seems that everyone on this page is fighting for the betterment of human health, but the way that is achieved cannot be agreed upon. The bottom-line- to both DC’s and non-DC’s, is whether or not there is a definite answer to the effectiveness of chiropractic. If so, please provide links. If not, links would be great too. Thanks! I look forward to expanding my knowledge-base of the profession, both good and bad.
lol. Aneta you have produced a response from 2 of the most anti chiropractic skeptics you are likely to ever come across on a blog run by a third. All you now need is a response from the black duck and you’ve got a full house. They have never and will never have a positive thing to say about chiropractic.
I know you probably won’t post this Prof, but you still havent answered the question about what you did with the trial you devised.
1) it seems to me that anyone capable of critical analysis is called “anti-chiro” by chiros [they would say that, wouldn’t they]
2) so sorry to not have answered one of your questions [with >1400 comments on this blog, i might be excused for forgetting some]; the answer is NOTHING.
I think you will find my comment was sound. Anti just means “against, opposite, instead of” is that not a description of your perception of chiropractic? please point me to ANY comment written by the 4 people I have mentioned that is positive about chiropractic.
ok, may i suggest you make a few suggestions?
please formulate a few key sentences which, in your view, critical thinkers might agree with about the positive sides of chiropractic.
subsequently, we will see whether we can subscribe to them.
@ Aneta
See here http://www.ebm-first.com/chiropractic.html (there’s a UK section)
And here http://chirotalk.proboards.com/index.cgi (mainly relates to the U.S.)
Aneta said:
You will find lots of information on the effectiveness of chiro (mostly anecdotal and poor quality research) – and vast swathes of stuff all about chiro marketing and sales techniques – but very little good quality evidence. However, if you look at the best quality and most independent evidence, it shows very little indication of effectiveness indeed – certainly not a good basis for making any career choice.
If you’ve not already done so, I also suggest reading what Prof Ernst has written here on his blog:
Chiropractic: lessons that have not been learnt?
Chiropractic manipulation for infant colic?
On the other side of the coin, why not go visit Richard Lanigan in London. I’m sure he’d be delighted to have you spend the day observing his practice. I’d take you but I’m in Luxembourg. I can recommend a variety of chiropractors who would be happy to have you observe. This way you could develop an idea of clinical practice and if it’s something you’d enjoy. It’s 4 years of grueling study, practical skills and it’s even tougher once you graduate. But it is an incredible profession to be part of as it’s dynamic and challenging. As for the research, there is enough evidence to include spinal manipulative therapy for non-specific LBP in the NICE guidelines.
http://pathways.nice.org.uk/pathways/low-back-pain-early-management#content=view-node%3Anodes-choice-of-physical-treatments
Here is the BEAM trial published in the BMJ (2004) http://www.ncbi.nlm.nih.gov/pubmed/15556955
And the Bronfort report (2010) in Chiro & Osteo http://www.ncbi.nlm.nih.gov/pubmed/20184717
You’re doing the right thing by asking these questions. It’s important you are informed about this commitment. There is a mine field of bureaucracy in the profession and plenty of skeptics out there who point out we need more research in chiropractic. They’re not wrong, but I’m not willing to throw the baby out with the bath water.
Feel free to ask me questions privately: [email protected]
Jesgol
What were the Bronfort Report studies about?
Jesgol wrote: “As for the research, there is enough evidence to include spinal manipulative therapy for non-specific LBP in the NICE guidelines.”
That may be true, but a responsible risk/benefit assessment suggests that chiropractors shouldn’t provide it:
http://www.ebm-first.com/chiropractic/the-meade-report-criticism/551-spinal-manipulation-for-the-early-management-of-persistent-non-specific-low-back-pain-mdash-a-critique-of-the-recent-nice-guidelines.html
Jesgol wrote: Here is the BEAM trial published in the BMJ (2004)”
And here is valid criticism of it…
http://www.ebm-first.com/chiropractic/the-meade-report-criticism/1368-the-beam-trial.html
As for the Bronfort Report, I’m very interested in how you are going to answer the question above asked by Alan Henness.
The Bronfort report is a systematic review of the literature of the effectiveness of manual therapies for musckuloskeletal and non-musculoskeletal conditions.
So is manipulation done by a chiro the same as that done by an osteo, a physio or a doctor?
Spinal manipulation is an umbrella term for a high velocity low amplitude thrust delivered by a skilled practitioner of manual therapy. Chiropractors and osteopaths have similar proficiency in, but not limited to, spinal manipulation.
Physiotherapists are skilled practitioners of manual therapy and many are proficient, but not limited to, spinal manipulation however the undergraduate training in HVLA spinal manipulation is significantly less, and many undergo post graduate education to achieve proficiency.
Doctors (medical doctors such as a GP) are not proficient in manual therapy. There is no undergraduate training in spinal manipulation and the emphasis is on diagnosis and treatment of disease not limited to the musculoskeletal system.
Are you sure you know what chiropractic is?
Jesgol: You’ve told me about their relative proficiencies in HVLA thrusts, but I asked whether (spinal) manipulation done by a chiro are the same as done by an osteo, etc.
They are similar yes. Spinal manipulation is spinal manipulation. But what does differ is where it is applied and with what degree of force, direction, speed etc. but that is entirely case dependent, so to all intense and purposes they are the same – osteo and chiro SMT.
Jesgol said:
What are the parameters of these differences and why are there two entirely separate statutory regulators for two occupations that are ‘to all intense [sic] and purposes’ the same?
Intents* sorry my iPad auto spelling prefers intense. I don’t see what you’re getting with this point, but ill give you the benefit of the doubt. Chiropractic and osteopathy have different origins. They are separate forms of spinal manip. Typically osteopaths use long level techniques, chiros use short lever. Both aim to achieve the same thing – spinal health. The EU degrees are similar, but not identical. In the same way a BMW is different from a Mercedes Benz. but no one is arguing that one is more of a car than the other. We have separate regulatory bodies because of the nature of statutory regulation in the UK. The requirements of each are the same as with any regulatory body.
I’m not sure if this comment will be posted. Some of my previous comments have been omitted without explanation. I think it has something to do with the administrator selecting which comment(s) suit his/her argument.
Jesgol said:
Yes, we all know that. But that doesn’t answer the questions.
You previously said:
So they are similar, yet different is all we seem to have so far. In an attempt to understand the differences, I asked what the parameters were, so what’s the distinction between a long and an short lever; what differences in force, direction and speed are there and why?
perhaps. But aiming to achieve something isn’t the same as achieving ‘spinal health’, whatever that is.
I’m interested in the UK: why are there two separate statutory regulatory bodies, with different rules, etc, when both chiros and osteos both do spinal manipulation and the only differences so far established are to do with length of levers, force, direction and speed. Can you say?
So chiro and osteo are simply competitors in the marketplace of ‘spinal health’?
Can you explain what nature of statutory regulation meant that there are separate regulatory bodies?
The regulations are in many ways similar, but not entirely. But none of this explains why there are separate bodies nor the need for them.
Can you explain where you are going with this? Have you not learnt how to use Wikipedia? So far you’ve asked me what the bronfort study was about and now you’re asking me the parametric differences between chiropractic and osteopathy and why they have separate statutory regulators. If you can explain how this responds to the bronfort report ill answer your questions.
Jesgol said:
Wikipedia says little about the differences between chiropractic and osteopathy (other than how they were invented) and certainly nothing about the parametric differences I am asking you about.
I thought it was rather obvious why I was asking this. You cited the Bronfort report in support of ‘spinal manipulative therapy’ and chiropractic. Since many of the studies included in Bronfort didn’t mention chiropractic manipulation, I was hoping you could explain how a trial done on one form of undefined SMT or osteopathic manipulation could be extrapolated to cover chiropractic manipulation. You have since explained how chiro and osteo are similar but yet different in many ways; an understanding of those differences is essential to understanding to what types of manipulation the conclusions of Bronfort can reasonably be applied.
Can you now explain what the differences actually are and why those differences don’t prevent results from one therapy being applied to another?
Any progress on the parametric differences between chiro and osteo yet?
SORRY! what i posted here about the bronford report was incorrect; i have thus deleted it with the comments it prompted.
here is a brief critique of this report and a correction of my previous statement:
1) quatity of the primary studies was only assessed for the ones published after systematic reviews of each specific subject; i estimate that this was only ~10% of the total.
2) any type of manual therapy was included, e.g. massage.
3) it was commissioned by the GCC and writien by chiropractors; there was no input of critical experts.
in my view, the report is seriously flawed and would not have passed peer-review of a non-chiro journal of high standing. its acceptance by the world of chiropractic shows, i think, a worrying degree research-naivety.
Hi Edzard,
thanks for correcting the comments, although I must admit I still don’t understand why you felt it necessary to delete the comments, particularly considering you based some very damning conclusions about the naivety of chiropractors and their attitude towards research on it. I would suggest that you at least make statement that you were wrong to say chiropractors are naive in research because they took on board a piece of research which you (until I – a former chiropractor – pointed this error out to you) wrongly believed to “not even contain a critical analysis”.
You correct and explain certain aspects of this strange behaviour (the erasing of comments) but in my opinion certainly not all.
Lastly I would point out to you that your correction implies that chiropractors still remain research naive because they took on board the conclusions of this piece of research (the Brondford report). This made me wonder what you base yourself on to make that statement? What evidence have you got to state that they (the chiropractic world) accepted it?
This is quite crucial because this point in turn validates/invalidates your conclusion in the same manner as the previous comment was invalidated.
Stefaan
i corrected my slight [~10% instead of o% studies not evaluated for quality] error and appologised but did not retract the NAIVITY allegation. on the contrary, i re-stated it as there is ample evidence for it above or on the >11000 chiro sites which quote the bronfort report. this, in turn also shows how widely the report is accepted.
SO, WHAT ARE YOU ON ABOUT???
Ok Prof ernst. A few suggestions. Here is one.
Many chiropractors, especially in the UK, don’t use rotational neck adjustments. So, one of your arguments ie. chiro adj causes strokes does not apply. You can critically analyse that all you want, but for some reason you fail to grasp the concept. So as your biggest problem with chiropractic seems to be that the risks out weigh the possible benefits please enlighten me as to the risks involved with a non rotational neck adjustment. Try, because I know you can’t, and supply me with any evidence that this is not the case. Then please let me know how a chiropractor who does not use rotational chiropractic adjustments ,in your opinion, can be classed as too much of a risk. Now if there are possible benefits from chiropractic and you have removed a possible risk, please let me know what conclusions you draw.
1) i do not necessarily write about UK chiro here, but about chiro in general.
2) i am working on a post about non-vascular risks which will include also non-rotational ones, i guess.
3) a bit easy to say “you dn’t grasp the concept”
4) where are the suggestions that we might agree with?
Heres another one for you prof Ernst.
Yo say you were trained in SMT, you have mentioned that you have worked with chiropractors in the past. You constantly mention how bad chiropractic research is, yet you have put together a research study that may finally answer the question as to “does chiropractic work” and you have DONE NOTHING WITH IT????????
I know you couldn’t get funds 12 years ago but have you tried any of the chiropractic associations or colleges?
can you name a single chiro organisation which, 12 years ago, funded clinical research by non-members?
Prof Ernst, nice side step. You talk about chiropractic full stop.
Are you able to answer this?
“Now if there are possible benefits from chiropractic and you have removed a possible risk, please let me know what conclusions you draw.”
The fact you mention UK chiro and not techniques, again shows your lack of knowledge. Is an activator chiropractor UK or not?
can you phrase questions which make sense, please?
Stefaan Vossen wrote: “…healthcare, in all its forms is about one thing and one thing only and that is the patient. Whether a clinician helps his or her patient by offering sympathy, a listening ear, placebo medication or “effective” (whatever that means) medication is irrelevant (to a point) but whether it helps the patient get better IS.”
Get better or feel better? Is telling a (fee paying) patient that their (mythical) subluxations need regular adjustments in order for them to achieve optimal health acceptable to you in this scenario? Or would you agree that it is patient exploitation even if a patient, through erroneous reasoning, is convinced that following such a course is, in some way, helping him/her?
compassion is essential, of course, [see my previous post on VISION FOR GOOD MEDICINE] but it is no excuse or justification for using bogus treatments
Stefaan: i am so glad that you explained to me what an ad hominem is!
and i am even more delighted that, thanks to you, i finally have a moral compass to re-direct my vision
@Skepticat:
“Stefann wrote
…of course safety, and cost-effectiveness are valid and highly necessary pursuits, but NEVER (if you are a clinician held to account by your Hippocratic oath) to the detriment of the patient. This, I feel with equal fervour and passion as you feel that a patient should shun treatment which has not yet been shown to be efficacious and which has not yet been shown to be safe. I understand your point of view but fundamentally disagree with it because it does not put the potential for benefit to the patient first.
Did you perchance mean that it doesn’t put the potential for benefit to the practitioner first?
I’m not sure how pursuing safety could be to the detriment of the patient but never mind. More confusing is that you seem familiar with the Hippocratic oath and then argue that it is worth putting a patient at risk of (1) harm and/or (2) wasting their time and money by subjecting them to an unproven therapy because it might be safe and of benefit. Doesn’t sound very Hippocratic to me.”
Btw, I think Edzard knows what an ad hominem is, while you still seem a bit muddled about it.”
Please don’t reinterpret/paraphrase what I state with comments that have nothing to do with it. If you have a question just ask the question.
Blindly pursuing safety to the detriment of positive outcomes is to the detriment of the patient who wants positive outcomes. Patients can make these decisions just fine and understand that procedures carry risks. In fact I don’t think any procedure which carries the potential for benefit does not carry risk. Your statement makes me think you doubt that there is benefit to be had. Coud you please clarify if this is indeed your position?
If Edzard knows all too well what an ad hominem is then he uses the term incorrectly with astonishing regularity. I am just trying to do the man a favour.
@Blue Wode:
“Get better or feel better? Is telling a (fee paying) patient that their (mythical) subluxations need regular adjustments in order for them to achieve optimal health acceptable to you in this scenario? Or would you agree that it is patient exploitation even if a patient, through erroneous reasoning, is convinced that following such a course is, in some way, helping him/her?”
I think the line between the two is a very fine one which can be hard to identify. Your other (second) point is not one which I am able to engage in as I have relatively little experience in that field and no research to base a comment on.
Stefaan
STEFAAN: you are excellent in lecturing us about the painfully obvious!
“positive outcomes” of chiro? can you please list them so that some critical thinkers can analyse them?
@Stefann
I didn’t “reinterpret/paraphrase what (you) state with comments that have nothing to do with it”. I paraphrased you very acurately and the second paragraph of your response would seem to confirm this.
As you have not specified which treatment you have in mind, I am unable to answer this. I thought we were talking in general terms about the ethics surrounding treating people. When I seek treatment, I don’t expect to be offered treatment that “has not yet been shown to be efficacious and which has not yet been shown to be safe”, unless I’m taking part in a trial.
That when you
Stefann, I don’t understand your first sentence; therefore I can’t work out what you are asking me. Please clarify.
Now here’s the question you seem to want so much:
What you see as the difference between your statements that:
and my reading of these as:
Please explain exactly where I’ve gone wrong with my paraphrasing?
Sorry, on re-reading I realise that in your first sentence you are referring to what I said about what I expect when I seek treatment. (1) Yes, I believe that my opinion is the best one to adopt as a general principle. (2) What are “all the other variables”?
@septic cat
the paraphrasing you present here on 14/02 15.34, is NOT the same as the one you presented prior. It now contains the addendum “because it might be safe and of benefit”. Now (after this addendum) I agree with your paraphrasing but that was NOT the spirit of what you first wrote. I therefore stand by my comment that you incorrectly paraphrased me. The fact that you later added this gives the readers of this blog the impression that you wrote this in the first place, and thus seems to me to support the notion that you too have realised that you incorrectly paraphrased me and are trying to influence said readers of this blog to condemn me. I would appreciate an apology for this quasi-forging behaviour.
Stefaan
Before spitting the dummy, Stefann, you should have read my original comment properly. Look again at my post of Tuesday 12 February 2013 at 17:17. Look at the second and third lines of the second paragraph. There you will see the exact words that I copied and pasted into my post of Thursday 14 February 2013 at 15:34. The words in both posts are:
I did not add anything later and the “spirit of what I wrote” remains the same. Obviously you didn’t read my original post properly before accusing me of wrongly paraphrasing you and you didn’t bother checking it before accusing me of backtracking on what I said and demanding an apology for “quasi-forging behaviour”, whatever that is.
If you ever find business is slack, Stefann, you might consider moonlighting with some Commedia dell’Arte company. You’d make a convincing prima donna.
Ciao.
Stefaan Vossen said in reply to Skepticat_UK:
Was that a typo?
Edzard, I agree it is obvious and take it for assumed that we agree on the principle. In order for me to answer your question: can you define what you understand “chiro” to be? As discussed previously and reiterated here its effectiveness is really the key point so we need to agree on what “it”is?
for the purpose of my question, can i suggest it to mean ANY TYPE OF SPINAL MANIPULATION PERFORMED BY A CHIROPRACTOR?
In that case I would state that in my experience and that of my patients those patients who have chronic biomechanical back pain and: 1) are not flat footed 2) have no significant leg length discrepancy, 3) have no occlusion problems and 4) haven’t had spinal fusion surgery or congenital or post-traumatic anomalies the positive outcomes associated to spinal manipulation as delivered by chiropractors with a frequency of 1 to 2 visits per week for a period of 2 to 4 weeks is a significant reduction of back pain.
Stefaan
Compared to what?
@Mojo
Compared to itself
@septic cat
lol your original comment was not the one you reference here but the one the one you made at 15.38. That is the comment that elicited my response you try to slate above. As I said, you corrected your position which is very good of you. I did indeed not catch onto your later addition which was a nuance you added AFTER the original paraphrasing I was commented on. The point still stands nevertheless. I might be a diva, as I can be all sorts of things, but at least I am not reconstructing my statements.
Huh?
My original comment, which was the first one I made on this page and was in response to you, was posted on Tuesday 12 February 2013 at 15:38. The evidence that it includes the exact same complete phrase that I repeat in my post Thursday 14 February 2013 at 15:34 and that I did not add any ‘addendum’ and that I have not changed my position in any way, is clear for all to see on this page. The fact that, in spite of this evidence, you persist in making a false assertion about what I have written, coupled with the fact that you have not provided any evidence in support of your assertion, is a very revealing illustration of how you think. I’m sure we all better understand now how you became a quack in the first place.
If you wish to persist in making this false accusation against me, then prove it. Copy and paste the relevant sections and point to the alleged difference.
@septic cat, I have reviewed the evidence you bring before me, and you are right, I mis-read your paraphrasing of me. It is more or less accurate or accurate enough for the purpose of discussion. I hereby retract that you reconstructed that statement. I still however maintain that it is not in the spirit of its original and that indeed in the face of the common position faced by patients who present to me in practice of having had “no improvement” with classic existing care as experienced by many patients, “the possibility of benefit and safety” is well worth the time and the risk (the money is not at risk as I provide a money-back guarantee) and and in the light of informed consent we are actually only talking about time. So most patients, in my experience do indeed find it worthwhile risking a little time (usually no more than two weeks) to find out whether my approach to their problem is worthwhile. You may personally feel different about that but your reference to the Hippocratic oath (which I am very familiar with) does place a very different “spirit” into the discussion and reveals the presence of an issue on morality and ethics. You may not mean it like that? Please let me know what you do mean with it in case I mis-read that too.
Stefaan
In reply to Skepticat_UK, Stephaan Vossen said:
As you’ve now used this three times, I think we can assume it is not a typo but deliberate, which somewhat undermines your belated apology. Time to grow up?
Stefaan Vossen said in reply to Skepticat_UK:
Still got finger trouble? You might find copy and paste more accurate.
I don’t think Stefann understands ‘copy and paste’.
I have been reading all these comments trying to make head or tail of it all. Cant say i am any further in my understanding but reading it does remind me of my 4 years kindergarden play group. Prof E, Blue Wode, Henness et al….is this what you are doing with your lives?? There is a whole world out there, go and do something with your lives that will give you and this world meaning. You are not who you would like to believe you are. You are not savours of the world, you are not the light to guide the misguided or easily led. If the public see a chiro/ osteo/homeopath/GP/Physio/dog walker/back scratcher, pay for it out of their own money and get better or feel better or whatever…the point being receive value according to their own beliefs, then who are you to interfere…
i am pleased to see that you are so much better, important, world-changing etc.
I’m glad you managed to find time in your busy schedule saving the world to read our comments. Pity you’ve understood so little of what’s been said, though.
So, Drifter, do you think it’s OK for practitioners to lie to consumers about what their therapy can do for them?
quacks do; responsible health care professionals don’t.
Came across this from a chiro organisation and thought it was interesting: