MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Some experts concede that chiropractic spinal manipulation is effective for chronic low back pain (cLBP). But what is the right dose? There have been no full-scale trials of the optimal number of treatments with spinal manipulation. This study was aimed at filling this gap by trying to identify a dose-response relationship between the number of visits to a chiropractor for spinal manipulation and cLBP outcomes. A further aim was to determine the efficacy of manipulation by comparison with a light massage control.

The primary cLBP outcomes were the 100-point pain intensity scale and functional disability scales evaluated at the 12- and 24-week primary end points. Secondary outcomes included days with pain and functional disability, pain unpleasantness, global perceived improvement, medication use, and general health status.

One hundred patients with cLBP were randomized to each of 4 dose levels of care: 0, 6, 12, or 18 sessions of spinal manipulation from a chiropractor. Participants were treated three times per week for 6 weeks. At sessions when manipulation was not assigned, the patients received a focused light massage control. Covariate-adjusted linear dose effects and comparisons with the no-manipulation control group were evaluated at 6, 12, 18, 24, 39, and 52 weeks.

For the primary outcomes, mean pain and disability improvement in the manipulation groups were 20 points by 12 weeks, an effect that was sustainable to 52 weeks. Linear dose-response effects were small, reaching about two points per 6 manipulation sessions at 12 and 52 weeks for both variables. At 12 weeks, the greatest differences compared to the no-manipulation controls were found for 12 sessions (8.6 pain and 7.6 disability points); at 24 weeks, differences were negligible; and at 52 weeks, the greatest group differences were seen for 18 visits (5.9 pain and 8.8 disability points).

The authors concluded that the number of spinal manipulation visits had modest effects on cLBP outcomes above those of 18 hands-on visits to a chiropractor. Overall, 12 visits yielded the most favorable results but was not well distinguished from other dose levels.

This study is interesting because it confirms that the effects of chiropractic spinal manipulation as a treatment for cLBP are tiny and probably not clinically relevant. And even these tiny effects might not be due to the treatment per se but could be caused by residual confounding and bias.

As for the optimal dose, the authors suggest that, on average, 18 sessions might be the best. But again, we have to be clear that the dose-response effects were small and of doubtful clinical relevance. Since the therapeutic effects are tiny, it is obviously difficult to establish a dose-response relationship.

In view of the cost of chiropractic spinal manipulation and the uncertainty about its safety, I would probably not rate this approach as the treatment of choice but would consider the current Cochrane review which concludes that “high quality evidence suggests that there is no clinically relevant difference between spinal manipulation and other interventions for reducing pain and improving function in patients with chronic low-back pain” Personally, I think it is more prudent to recommend exercise, back school, massage or perhaps even yoga to cLBP-sufferers.

33 Responses to Chiropractic for back pain? Perhaps we should think again

  • Professor Ernst wrote: “But what is the right dose?”

    IMO, the optimal number of chiropractic treatments *for any condition* has long been an area rife with patient exploitation and the potential for harm, and I’m not convinced that this new study will improve things.

    For example, the UK chiropractor regulator, the General Chiropractic Council (GCC), states the following on its FAQs page regarding the frequency of treatments:

    QUOTE
    “At a recent hearing of our Professional Conduct Committee, the Committee determined that a patient treatment plan involving 3 appointments per week for 12 weeks, followed by a reassessment, was inappropriate, excessive and not in the best interests of the patient. So do ask all the questions you need to before making any payment in advance.”
    http://www.gcc-uk.org/page.cfm?page_id=6#4

    How could patients possibly know what questions to ask? Moreover, even if they did, they could, quite easily, still be open to abuse due to the GCC’s interpretation of evidence-based care:

    QUOTE
    …clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners, including the individual chiropractor her/himself.
    This effectively allows “in my experience” and “the patient likes it” to be considered along with evidence, effectively negating the whole point of evidence-based medicine.
    http://www.sciencebasedmedicine.org/brief-note-the-chiropractic-subluxation-is-dead/

    It would appear that both “in my experience” and “the patient likes it” allow vast numbers of UK chiropractors to evade accountability for their quackery-based practices. See here:
    http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1825-subluxations-still-no-evidence.html

    The GCC has even allowed craniosacral therapy and applied kinesiology to fall within its definition of evidence-based care:
    http://jdc325.wordpress.com/2009/06/09/incompetence-and-the-general-chiropractic-council/

    In essence, until the regulators can produce an evidence-based guideline on ‘dose’, I think we’ll continue to see chiropractic business as usual. (I should add that if such a guideline were to be developed, it would likely sound the death knell for chiropractic, so I’m not holding my breath.)

  • Why yoga? There is little to no qualification for teaching it, many versions of it, (which is “prescribed”?), and one might ask if it any better than plain old stretching or physical therapy?

    The link in your post takes me to a PubMed entry, a study done by what appears to be an alt med group–correct me if I am wrong.

    Perhaps you only meant that yoga is as good as anything else with relatively weak evidence.

  • Spinal manipulation has been under criticsizm for awhile, and likely will always be under fire. The truth of the matter is that time and advancements in technology will be able to determine the long term affects of any manipulation of this type. Like so many other treatments, spinal manipulation doesn’t actually address the real issues going on with the body. There is something that is causing misalignments that require manipulation to be placed in proper order. By simply using this technique, it’s often a temporary fix for a long term problem. As a chiropractor myself, I’ve built my practice around actively avoiding spinal manipulation whenever possible. I look at it as little more than a bandaide. Thanks for sharing the indepth research.

    • so we wait [another 100years?] until you show us the convincing evidence – but until then, we have little choice but to characterise as unproven.

  • I love it Blue Wode, an article on chiropractic and you are “in like Flint”. First reply! The discussion about frequency and number of treatments is all wrong. In my practice I reassess the patients response at every treatment and the sooner I can transition the patient onto active care with specific exercises, ergonomic advice, lifestyle changes etc the better. From the outset I will give the patient a indication of treatment goals and a reasonable time frame. This varies depending on the presenting complaint, but I do state that if we have not seen any improvement within three weeks then I will refer and give the patient advice on options. I have a good referal network of masseurs, physio’s, pilates, GP’s, ortho’s, neuro’s etc and communicate with them constantly. This is also part of my informed consent. Sticking to a set formula of treatments regardless of how the patient is or isn’t responding is mindless recipe book care. In setting goals and discussing it with the patient I make the patient aware that it is their back and they are in control and it makes me accountable to the patient. The best goals are functional goals relevant to that patient like a good nights sleep, 18 holes of golf, being able to walk for more that 30 minutes without having to rest every 5 minutes due to the pain or recently, a lady who wanted to dance at her daughters wedding. Interesting article!

    • VERY NICE!
      except informed consent requires telling your patient the options not after three weeks but BEFORE you start.

    • ….and what is wrong with BW making the first comment. think again, thinking chiro: your remark is as daft as me saying: TYPICAL! the thinking chiro thinks so slowly that he comes in last.

  • Informed consent is always done before commencing treatment. Thats mandatory! You must have misunderstood me. I follow Blue Wode and I am not criticising him, just observing that with your posts he does seem to take particular interest in the chiro ones. Your thoughts on the rest of my post would be appreciated.

    • I have not misunderstood you but you expressed yourself very unclearly.
      you are doing a little more than just ‘observing’, I think.
      as to the rest of your comment: this is merely a platitude; every health care professional does/ should proceed in this fashion. this does not in any way preclude that there might be an average number of treatments that is optimal.

  • Agreed, and I give the patient an idea of the average number of treatments at the beginning. But I don’t believe in a blanket approach. Any care should the tailored to the patient and constantly reviewed.

    • …and what average number would that be? and on what evidence is it based? and, in view of this, would you not say that the study I reviewed above was worth while?
      if yes, would you not agree that your initial comment was a bit of hot air?

  • All good questions. When it comes to practice guidelines I have never really critically looked at them or the research behind them. People talk about the WHO guidelines and I am now reading up on them. You have got me thinking! Thanks for that. Who sets them and what are they based on?I don’t know!
    But getting back to number of visits, 3 times a week for three weeks then review and commence active care and reduce chiro care is a good benchmark. If the patient responds sooner then I will review sooner. The study you reviewed seems to say that any more would not be indicated.
    As to hot air, well no as recipe book care plans that are the same for every patient are one of my greatest pet hates.

    • Thinking Chiro wrote: “People talk about the WHO guidelines and I am now reading up on them. You have got me thinking!”

      Here’s something else to get you thinking:

      The WHO’s 2003 Bulletin on Lower Back Pain mentions chiropractic and the reasons people turn to it:

      Quote
      “People with low back pain often turn to medical consultations and drug therapies, but they also use a variety of alternative approaches. Regardless of the treatment, most cases of acute back pain improve. At the time, people in such cases may credit the improvement to the interventions some of which clearly are more popular and even seemingly more effective than others (e.g. chiropractic and other manipulative treatments in which the laying on of hands and the person-to-person interaction during the treatment may account for some of the salutary results).”

      Quote
      “The spread of chiropractic and other manipulative treatments worldwide has won many adherents to this treatment, who perceive that it works better than others. This hypothesis was recently put to the test (25) and, although the respondents still favoured such approaches (chiropractic adjustment, osteopathic manipulation, and physical therapy) perhaps because of the time spent and the laying on of hands meta-analysis cannot confirm the superiority of manipulative treatments (or, for that matter, of acupuncture and massage (26)) over other forms of therapy, or even time as a healer (25), which substantiates the contentions of WHO’s document (1). In most instances, manipulative treatments are more expensive than others (apart from surgery) and not more helpful to outcome (26).”

      Ref: http://whqlibdoc.who.int/bulletin/2003/Vol81-No9/bulletin_2003_81(9)_671-676.pdf

      With regard to your comments directed at me, i.e. “you are “in like Flint” …“just observing that with your posts he does seem to take particular interest in the chiro ones”

      I waited around 24 hours before posting my first comment here. That allowed plenty of time for others to comment before me. Besides, why shouldn’t I take a particular interest in chiropractic posts? It’s evident to me that the harms of chiropractic (both physical and financial) outweigh its perceived benefits and those concerns need to be continuously flagged up until there are serious reforms throughout the chiropractic industry.

  • Thanks for replying Blue Wode. I totally agree with you that there needs to be reform in chiropractic. If you criticise the subluxation true believers they shout you down and launch into personal attack. Edzards article “Five methods for avoiding progress from criticism” sums it up nicely. The rants of Billy De Moss in California are a painful example. Subluxation=Stagnation!
    Looking critically at what I do is important and both you and Edzard have definitely helped me do that. The way I practice must evolve and change and it has. I now use a lot of exercises, rehab, ergonomic advice etc that I was not using previously. I communicate with doctors constantly, which has resulted in increased referrals and ultimately an invitation to join them in practice, I am now practicing in a medical centre. You cannot practice in isolation and chiropractic is not a “subluxation one stop fix all shop”.

  • No physio’s are becoming more like chiro’s! LOL
    Yes I do think the lines between the professions are bluring more and more.

  • I have always enjoyed reading my journals, not just the chiro ones like JMPT but also the physio, ortho, neuro, pain, sports med, biomechanics etc. My favourite right now is Practical Neurology-BMJ journals. Their test yourself and case studies are fun.
    The lines are bluring for some, though I think that the more the subluxationists feel threatened the more extreme, entrenched and vocal they will become.

  • Is chiro redundant? I often get asked what is the difference between you and physio’s and osteo’s and massage and acupuncture etc. I usually reply “We are all approaching the spine with different techniques and no one approach helps everyone. Just as your doctor will vary your dose or change your medication to achieve the best result, you have to find which approach works for you. If I cannot help you I will refer you to a physio or massage to achieve the best outcome for you”.

  • Thinking_Chiro wrote: “…no one approach helps everyone. Just as your doctor will vary your dose or change your medication to achieve the best result, you have to find which approach works for you. If I cannot help you I will refer you to a physio or massage to achieve the best outcome for you”

    That’s all well and good, but you appear to be in a minority with your approach. There are still vast numbers of chiropractors who, unhindered, continue to administer wellness/maintenance ‘adjustments’ to their patients that are designed to do nothing other than boost the chiropractor’s bank balance – aka the business model of interminable therapy.

  • I see. It is kind of disappointing to know that spinal manipulation is not that effective when there are lots of claims about it being a good therapy for chronic back pains. I somehow think that it also depends on each person whether they respond to treatment well or not.

  • I agree that some of the aggressive marketing promoted by “Practice Management Experts” from the US are an endless source of facepalms. (Also mostly illegal here in Australia). But to throw a net over the entire profession is not accurate or helpful.
    I was at a meeting last week and we discussed how we practice and there was not one chiro there that does not work closely with their local doctors and has a referral network of physio’s, Dr’s, ortho’s etc. Low back pain, for example, does have a nasty habbit of reoccuring, so I do offer a regular checkup to my patients, be it 1/m, 1/3m, 1/6m or call me if there is a flare-up, but it is up to the patient and I respect their decision. So are chiro’s becoming like physio’s? In regards to communication and marketing themselves to doctors, absolutely. I am just another tool available to the doctors in their care of back pain. (No puns please in regards to “Tool”). Are physio’s becoming more like chiro’s? They do seem to be manipulating more and they are aquiring some of our bad habbits like aggressive marketing and seeing patients more frequently!
    So I do not think that I am in the minority, I think that I am more a vocal member of the silent majority.
    I recently tweeted to you a great quote by Sam Homola DC “A significant percentage of chiropractors have difficulty thinking critically about their own profession”. This is so true and it allows the vocal subluxation true believers free reign and a larger representation. It is this shortage of self criticism that is at the heart of the problems within chiropractic.
    As to adjusting patients in a way that is good to my bank balance, If I practiced like that my patients would smell it in seconds and I would be out of business. If what I did was not totally patient focused, they would know. Whether that is just the Australian consumer who is famously cynical and picky, I am not sure. Americans do seem to be gullible and accept behavior from thier chiro’s that would not happen here.

    • Thinking_Chiro wrote: “I agree that some of the aggressive marketing promoted by “Practice Management Experts” from the US are an endless source of facepalms. (Also mostly illegal here in Australia).”

      FYI, there is plenty aggressive marketing promoted by “Practice Management Experts” here in the UK. As for chiropractic in Australia, I would refer you to Reasonable Hank’s blog. It’s quite an eye-opener:
      http://reasonablehank.com/category/chiropractic/

      Thinking_Chiro wrote: “But to throw a net over the entire profession is not accurate or helpful.”

      Until there is over-arching, science-based standardisation in place, throwing a net over the entire chiropractic industry would appear to be the only solution to the problem. IOW, at the moment, how would members of the public locate an evidence-based chiropractor, and more to the point, how would they *know* to look for one in the first place?

      Thinking_Chiro wrote: “I do not think that I am in the minority, I think that I am more a vocal member of the silent majority.

      Then why is your alleged majority remaining silent when the problems with chiropractic are myriad?

      Thinking_Chiro wrote: “I recently tweeted to you a great quote by Sam Homola DC “A significant percentage of chiropractors have difficulty thinking critically about their own profession”. This is so true and it allows the vocal subluxation true believers free reign and a larger representation. It is this shortage of self criticism that is at the heart of the problems within chiropractic.”

      Then shouldn’t your “silent majority”, as a matter of urgency, be educating themselves in critical assessment? Why the apathy? Or could it be that your silent majority secretly tolerates the ‘true believers’ in order to prevent the chiropractic industry going into decline now that the scientific data that are emerging are far from favourable?

      Thinking_Chiro wrote: “As to adjusting patients in a way that is good to my bank balance, if I practiced like that my patients would smell it in seconds and I would be out of business. If what I did was not totally patient focused, they would know.”

      There are many patients and CAM practitioners who make wrong assumptions about healthcare outcomes. CAM practitioners, nearly all of whom rely on ‘patient satisfaction’ in order to earn a living, will be particularly averse to questioning if it really was their intervention that produced a positive result. For a more comprehensive understanding of this mindset, I suggest that you have a slow read through the late Barry Beyerstein’s classic essay, Social and Judgmental Biases That Seem to Make Inert Treatments Work. It’s a thorough analysis of alternative medicine and common errors of reasoning:
      http://web.archive.org/web/20050329093720/http://www.sram.org/0302/bias.html

  • In Reply to Blue Wode:
    “As for chiropractic in Australia, I would refer you to Reasonable Hank’s blog. It’s quite an eye-opener:”
    I am a big fan of Reasonable_Hank and the references you linked to are in regards to the deceptive AVN (Australian Vaccination Network), which is actually antivax. AHPRA/Chiro registration Board has taken action and it was a good result. There are 120 chiro’s in the AVN out of 4700 in Australia. I am a member of COCA which has had a position statement in support of vaccination for years.

    “FYI, there is plenty aggressive marketing promoted by “Practice Management Experts” here in the UK.”
    Much of the aggressive US style practice management practices have been banned here, which is great. I remember going to a conference years ago where C.J Mertz was one of the presenters. I was horrified at some of his expert tips. Two friends did sign up to his practice coaching. One soon quit and the other had a nervous breakdown. You registration board should clamp down those practices. Ours did!

    “Then shouldn’t your “silent majority”, as a matter of urgency, be educating themselves in critical assessment?”
    We are critically assessing what we do. Again look at COCA. The other association, CAA, has coped a lot of deserving flack recently and are changing slowly, though under duress. As for silent, that is one of the reasons I am here, to make our position clear. Critically evaluating reasearch etc is a full subject at Macquarie Uni.

    “CAM practitioners, nearly all of whom rely on ‘patient satisfaction’ in order to earn a living”
    I was talking above about why I practice. If my motivation was money, then patients would realise this immediately and walk. As for patient satisfaction, it is important as it does influence the outcome. A good example of this is an orthopod who I regularly recommend. I warn my patients that he is rude, abrupt and has the bedside manner of Atilla the Hun. His secretary, who is his wife, is a female version of Basil Fawlty, but in the operating theatre he is DaVinci. So put up with all the rest because he is the best where it counts. My patients come back laughing and say OMG you were right. If hadn’t warned them would the outcome have been different? Possibly, Possibly not! But I am still going to warn the next patient just in case.
    Thankyou for that final link. I agree with much of what is says.
    The section Symptomatic relief or Cure is interesting: “Short of an outright cure, alleviating pain and discomfort is what sick people value most.” Only 1% of my new patients come in for a check up. 99% are in pain. This is the starting point leading to relief, rehab and prevention. Initially it is “I’m in pain, get me out of pain”.
    Will being and thinking critically put me out of business? No, it has actually generated more medical referrals and more new patients!

  • Thinking_Chiro wrote: “I am a big fan of Reasonable_Hank and the references you linked to are in regards to the deceptive AVN (Australian Vaccination Network).”

    No, they’re not all about AVN. Here are three Reasonable Hank blog posts on chiropractic (just for starters)….
    http://www.ebm-first.com/component/search/?searchword=reasonable%20hank&searchphrase=all&Itemid=101

    Thinking_Chiro wrote: “Much of the aggressive US style practice management practices have been banned here, which is great.”

    That doesn’t seem to have made much of a difference. For example, the largest annual chiropractic event in Australia will, in February 2014, be featuring sessions on practice growth, marketing strategies, communicating chiropractic, philosophy, paediatrics, and families. Have browse round the event’s website and see if you can spot any indications of ‘reform’:
    http://www.spinalresearch.com.au/Events/DynamicGrowthCongress2014/tabid/404/language/en-AU/Default.aspx

    It seems to me that despite the practice management ban, chiropractic pseudoscience is thriving in Australia. See these links:

    http://www.ebm-first.com/chiropractic/treating-children/2180-friends-of-science-in-medicines-open-letter-to-australian-healthcare-organisations-regarding-chiropractic-treatments-especially-those-for-children.html

    http://www.ebm-first.com/chiropractic/treating-children/2217-chiropractic-funding-called-into-question.html

    http://www.ebm-first.com/chiropractic/various-concerns/2093-credibility-of-chiropractic-tribunals-questioned.html

    Thinking_Chiro wrote: “We are critically assessing what we do…As for silent, that is one of the reasons I am here, to make our position clear. Critically evaluating reasearch etc is a full subject at Macquarie Uni.”

    If you *are* critically assessing what you do, and you’re here “to make our position clear”, then why the extremely slow change if you are representing the majority? Also, with regard to Macquarie University, isn’t it dropping its chiropractic degree? See: http://www.ebm-first.com/chiropractic/latest-news/2255-macquarie-university-proposes-to-ditch-its-chiropractic-degree.html

    Thinking_Chiro wrote: “As for patient satisfaction, it is important as it does influence the outcome. A good example of this is an orthopod who I regularly recommend. I warn my patients that he is rude, abrupt and has the bedside manner of Atilla the Hun. His secretary, who is his wife, is a female version of Basil Fawlty, but in the operating theatre he is DaVinci.”

    Your orthopod is in the business of highly-skilled, evidence-based surgery in which a good bedside manner is not an essential prerequisite, whereas most CAM proponents, including chiropractors, are in the business of patient-engaging touchy-feely psychobabble.

  • In reply to Blue Wode:
    Reasonable_Hank has done quite a lengthy series on chiro’s who are part of the AVN and it has brought about change. Some of the other posts especially the chiro’s sneeking into hospitals is profoundly wrong and I have heard that complaints have been submitted to the Health Complaints Commission. I hope they take legal action. Havn’t heard anything more yet.

    The Dynamic Growth Congress was all about fundraising for research, with all speakers and staff volunteering. The recent blog by The Rogue Chiropractor where he tore them apart in regards to their low level of funding of research will make the 2014 congress very interesting. Since Rogue Chiropractors blog I have talked to collegues and we are all pretty disgusted. Hopefully Martin Harvey and Co will be replaced. I have a feeling there will be a bloodbath next year.

    As for Macquarie Uni it is a case of large institution politics centred around the previous vice chancellor who replaced the previous dean of the faculty of science who supported chiropractic etc etc etc. The Uni statement about their investment in and focus on the new hospital and research is BS. Dalcross Private Hospital and their orthopods who were to move in have instead amalgamated with The Adventist Private hospital. Macquarie Private is seriously overcapitalised and has been haemorrhaging money since before they opened. I have heard through the grapevine that Ramsay Health is in negotiations to buy/bail them out and make them part of Royal North Shore Private. As for chiropractic research at Macquarie, they got very little support from the uni in the first place. I hear that some their PhD students are currently at the George institute(Sydney Uni).

    A good bedside manner is very important for any professional. The neuro I use the most is a superb communicator with a great bedside manner. The orthopod doesn’t need it as it is a case of supply and demand. If there were more orthopods he would be out of business. There was a recent discussion at the Royal Australian College of Surgeons about the low number of surgical procedures supported by research. They put it optimistically at around 40%. They put it down to three factors, Insufficient funding, difficulty recruiting surgeons and difficulty recruiting patients. So even they are concerned about their evidence base. As for touchy feely, the psychosicial model of back pain is well documented by other professions. A positive patient outlook does influence the outcome and prognosis.

    • Thinking_Chiro wrote: “There was a recent discussion at the Royal Australian College of Surgeons about the low number of surgical procedures supported by research. They put it optimistically at around 40%. They put it down to three factors, Insufficient funding, difficulty recruiting surgeons and difficulty recruiting patients. So even they are concerned about their evidence base. As for touchy feely, the psychosicial model of back pain is well documented by other professions. A positive patient outlook does influence the outcome and prognosis.”

      I think this brings us back to the conclusions of Professor Ernst’s original post. Chiropractic is a far narrower field than orthopaedic surgery, and the robust data that are now in are telling us that chiropractors really have no excuses left for their widespread, injudicious use of spinal manipulation (chiropractic ‘adjustments’):

      QUOTE
      “In view of the cost of chiropractic spinal manipulation and the uncertainty about its safety, I would probably not rate this approach as the treatment of choice but would consider the current Cochrane review which concludes that “high quality evidence suggests that there is no clinically relevant difference between spinal manipulation and other interventions for reducing pain and improving function in patients with chronic low-back pain“. Personally, I think it is more prudent to recommend exercise, back school, massage or perhaps even yoga to cLBP-sufferers.”

      Thinking_Chiro wrote: “I have a feeling there will be a bloodbath next year.”

      I suspect that chiropractic’s vicious in-fighting will become more public, but as chiropractic doesn’t bring anything scientifically unique to the neuro-musculoskeletal table, I think it unlikely that “a bloodbath” will lead to universal reform. If anything, it will probably marginalise chiropractors even more. If I was an evidence-based chiropractor, I’d be doing all I could to retrain as physiotherapist.

  • In reply to Blue Wode:
    The subluxation chiropractors are used to practicing in their own little bubble without any outside scrutiny. The last few years have definitely burst that bubble. The infighting is becoming more public, just look at the rants of Billy De Moss on Youtube. Facepalm! I agree that a bloodbath at ASRF’s Dynamic Growth Congress next year will not lead to universal reform, but it will lead to greater accountability. I never looked at their research levels until Rogue Chiropractor pointed it out. The discussion at the RACS is totally applicable to chiropractic and hopefully one change will be more research funding from them and a change at the helm.

    One interesting question you could ask is “Why am I here?”
    I have to thank you and Edzard amongst others for this. I initially responded to the attacks on chiropractic as a case of more of the usual knee jerk responses from from the high priests of the medical temple who should clean up the mess in their own house before attaching us chiropractors. I thought I could ignore you and that it would blow over and you would go away. (I bet you are laughing right now). I was practicing in my own bubble separate from the subluxationists and ignored them too. Then I started to read what you guys were writing and I thought Hmmmmm well written , well referenced and well thought out. You have a point and I agree with you. Then I looked at the vocal subluxationists and thought Holy F*@#, have these guys read a journal recently or do they just read DD and BJ Palmers manifesto’s (Oops I mean books) going to bed every night to give then a warm fuzzy feeling? Then I thought I cannot allow them to be the voice of my profession and I need to make people aware of what I think and how I practice. Any negative press and I am on the horn to my doctors straight away, they hear from me before they read the papers, but now I need to go beyond my referral network. I have been way too quiet.
    Your reference to Prof Ernst’s original post is relevant. The subluxationists feel that any reform will limit their scope of practice and be bad for business. (The doctors feel threatened so they are trying to control us. It’s a conspiracy!) But in the eyes of the public do chiropractors own health, natural health, wellbeing etc. No! We already own one word “Spine” if we focus on that, promote that, research that and ditch the “one stop fix all shop” we have a future.
    As for retraining as a Physio, there is an oversupply here in Australia with 4 colleges in Sydney now, when there used to be only one. Friends have kids graduating this year and one next year as physio’s and I have talked to them and they are very pessimistic about their job prospects and future. Instead I will continue to retrain my doctors and you and Prof Ernst and convert you to my cause. I love a good challenge.

    • Thinking_Chiro wrote: “I agree that a bloodbath at ASRF’s Dynamic Growth Congress next year will not lead to universal reform, but it will lead to greater accountability.”

      Will it? You’d have thought the same would have happened in the aftermath of the British Chiropractic Association’s very public and unsuccessful libel suit against Simon Singh, but nothing’s really changed except for some limitations on advertising. Certainly, most of the time the UK regulator, the General Chiropractic Council, seems to turn a blind eye to widespread blatant chiropractic quackery and patients being misled.

      Thinking_Chiro wrote: “I initially responded to the attacks on chiropractic as a case of more of the usual knee jerk responses from the high priests of the medical temple who should clean up the mess in their own house before attacking us chiropractors. I thought I could ignore you and that it would blow over and you would go away. (I bet you are laughing right now).”

      No, I’m not laughing. I admire your honesty.

      Thinking_Chiro wrote: “I was practicing in my own bubble separate from the subluxationists and ignored them too. Then I started to read what you guys were writing and I thought Hmmmmm well written, well referenced and well thought out. You have a point and I agree with you. Then I looked at the vocal subluxationists and thought Holy F*@#, have these guys read a journal recently or do they just read DD and BJ Palmers manifesto’s (Oops I mean books) going to bed every night to give then a warm fuzzy feeling? Then I thought I cannot allow them to be the voice of my profession and I need to make people aware of what I think and how I practice. Any negative press and I am on the horn to my doctors straight away, they hear from me before they read the papers, but now I need to go beyond my referral network. I have been way too quiet.”

      I just hope there are enough of you good guys to make the (huge) amount of noise required to bring about the necessary changes – and not just in Australia, but also internationally. And remember, you’ll need lots of good publicity regarding any successful reforms as most of the public seems to be in the dark regarding the problems with chiropractic.

      Thinking_Chiro wrote: “Your reference to Prof Ernst’s original post is relevant. The subluxationists feel that any reform will limit their scope of practice and be bad for business. (The doctors feel threatened so they are trying to control us. It’s a conspiracy!) But in the eyes of the public do chiropractors own health, natural health, wellbeing etc. No! We already own one word “Spine” if we focus on that, promote that, research that and ditch the “one stop fix all shop” we have a future.”

      But do you “own” the spine? And would many thousands of EBP chiropractors (which, I understand is what you are hoping for) be able to generate enough business in order to earn a reasonable living?

      Thinking_Chiro wrote: “As for retraining as a Physio, there is an oversupply here in Australia with 4 colleges in Sydney now, when there used to be only one. Friends have kids graduating this year and one next year as physio’s and I have talked to them and they are very pessimistic about their job prospects and future. Instead I will continue to retrain my doctors and you and Prof Ernst and convert you to my cause. I love a good challenge.”

      I don’t think you’ll convert many in the science camp when chiropractic can only claim slim evidence for spinal manpulation for back pain. Further (and bearing in mind Professor Ernst’s conclusion above, i.e. “…the current Cochrane review concludes that “high quality evidence suggests that there is no clinically relevant difference between spinal manipulation and other interventions for reducing pain and improving function in patients with chronic low-back pain”. Personally, I think it is more prudent to recommend exercise, back school, massage or perhaps even yoga to cLBP-sufferers”), if there’s already a glut of other MSK professionals, then the prospects for EBP chiropractors are likely to be less than rosy.

  • Thanks for the reply Blue:
    “I think it is more prudent to recommend exercise, back school, massage or perhaps even yoga to cLBP-sufferers”), if there’s already a glut of other MSK professionals, then the prospects for EBP chiropractors are likely to be less than rosy.”
    I am currently using all these in conjunction with spinal adjustments. Combined treatments get better outcomes.
    The health industry as a whole is undergoing sizemic shifts. New South Wales used to have 3 medical faculties, now we have 7. It has reached the point in the last few years where there is insufficient Intern positions in hospitals for the uni graduates. This is on top of 200 foriegn doctors per year passing the boards as well. I work in a medical centre and even though they are busy and well established like myself, they are pessimistic about the tsunami of doctors coming through the system. This year there were 400 applicants for 90 accredited specialist training positions. The highest ever.
    I think chiropractic needs to put out a focused message. There is a lot of back pain out there. 1 in 7 patient visits to a GP is for back pain. I remember reading a survey many years ago where 50,000 US doctors responded to a detailed survey. (I will have to dig it up). Two questions were very interesting;
    “What condition do you dislike seeing in your practice the most?” – Majority replied “Back Pain”.
    “What area do you feel you lack sufficient knowledge to diagnose?” – Most common response “the spine”.
    Doctors are frustrated by back pain. If we market our profession as part of the solution we have a great future.
    Funnily enough chiro’s are moving into interesting areas. Recently one of the drug company reps (3-4/week drop into the centre) was a chiropractor. Imagine a chiro working for a Pharmaciutical Company, the subluxationists are having a coronary reading this!

    • Thinking_Chiro wrote “Doctors are frustrated by back pain. If we market our profession as part of the solution we have a great future.”

      I’m not convinced. Chiropractors have been marketing themselves as back pain specialists for some time and don’t seem to have got very far.

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