Monthly Archives: June 2015
On this blog, we have discussed many different alternative treatments. As it turns out, hardly any of them fulfil the criteria for being used routinely in clinical practice. But here I present one that might be the exception.
The Feldenkrais Method (FM) aims to reduce pain or limitations in movement, to improve physical function, and to promote general wellbeing by increasing the patient’s awareness of herself and by expanding her movement repertoire. The FM is an educational method similar to the Alexander Technique.
The practitioner directs his attention to the patient’s habitual movement patterns which are inefficient or strained, and teaches new patterns using gentle, slow, repeated movements. Slow repetition is believed to be necessary to impart a new habit and allow it to begin to feel normal. These movements may be passive (performed by the practitioner on the recipient’s body) or active (performed by the patient).
At this point, we should ask: but does FM really and demonstrably work?
Ten years ago, we published a systematic review of all RCTs available at the time testing the effectiveness of FM. Six studies met our inclusion criteria. They were all burdened with significant methodological weaknesses. The indications included multiple sclerosis, neck/shoulder problems and chronic back pain. All but one trial reported positive results. We concluded that the evidence for the FM is encouraging but, due to the paucity and low quality of studies, by no means compelling.
Since then, more research has become available, and an update of our research seemed necessary. This new review aimed to update the evidence for the benefits of FM. Included studies were appraised using the Cochrane risk of bias approach and trial findings analysed individually and collectively where possible. Twenty RCTs were included (an additional 14 to our earlier systematic review). The population, outcome, and findings were highly heterogeneous. Meta-analyses were performed with 7 studies, finding in favour of the FM for improving balance in ageing populations. Single studies reported significant positive effects for reduced perceived effort and increased comfort, body image perception, and dexterity. Risk of bias was high in all studies, thus tempering some results. The effects seemed to be generic, supporting the proposal that FM works on a learning paradigm rather than disease-based mechanisms.
The authors concluded that further research is required; however, in the meantime, clinicians and professionals may promote the use of FM in populations interested in efficient physical performance and self-efficacy.
One might discuss whether or not FM is truly an alternative therapy; it has many characteristics of a physiotherapy, and physiotherapists often employ FM. On the other hand, it is considered to be alternative by some practitioners. So, for the purpose of this article, I will call it alternative.
The evidence for FM has become substantially more promising since we last looked at it systematically. The indication for which the evidence is most convincing is the improvement of elderly people’s balance. Considering that FM is virtually risk-free and inexpensive, I feel that it is one of the rare alternative therapy that could be integrated into clinical routine (for this particular indication).
Recently, I was sent an interesting press release; here it is in full:
A new study has shed light on how cancer patients’ attitudes and beliefs drive the use of complementary and alternative medicine. Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the findings may help hospitals develop more effective and accessible integrative oncology services for patients.
Although many cancer patients use complementary and alternative medicine, what drives this usage is unclear. To investigate, a team led by Jun Mao, MD and Joshua Bauml, MD, of the Abramson Cancer Center at the University of Pennsylvania’s Perelman School of Medicine, conducted a survey-based study in their institution’s thoracic, breast, and gastrointestinal medical oncology clinics.
Among 969 participants surveyed between June 2010 and September 2011, patients who were younger, those who were female, and those who had a college education tended to expect greater benefits from complementary and alternative medicine. Nonwhite patients reported more perceived barriers to the use of complementary and alternative medicine compared with white patients, but their expectations concerning the medicine’s benefits were similar. Attitudes and beliefs about complementary and alternative medicine were much more likely to affect patients’ use than clinical and demographic characteristics.
“We found that specific attitudes and beliefs — such as expectation of therapeutic benefits, patient-perceived barriers regarding cost and access, and opinions of patients’ physician and family members — may predict patients’ use of complementary and alternative medicine following cancer diagnoses,” said Dr. Mao. “We also found that these beliefs and attitudes varied by key socio-demographic factors such as sex, race, and education, which highlights the need for a more individualized approach when clinically integrating complementary and alternative medicine into conventional cancer care.”
The researchers noted that as therapies such as acupuncture and yoga continue to demonstrate clinical benefits for reducing pain, fatigue, and psychological distress, the field of integrative oncology is emerging to bring complementary and alternative medicine together with conventional care to improve patient outcomes. “Our findings emphasize the importance of patients’ attitudes and beliefs about complementary and alternative medicine as we seek to develop integrative oncology programs in academic medical centers and community hospitals,” said Dr. Bauml. “By aligning with patients’ expectations, removing unnecessary structural barriers, and engaging patients’ social and support networks, we can develop patient-centered clinical programs that better serve diverse groups of cancer patients regardless of sex, race, and education levels.”
And here is the abstract of the actual article:
Complementary and alternative medicine (CAM) incorporates treatments used by cancer survivors in an attempt to improve their quality of life. Although population studies have identified factors associated with its use, to the best of the authors knowledge, assessment of why patients use CAM or the barriers against its use have not been examined to date.
The authors conducted a cross-sectional survey study in the thoracic, breast, and gastrointestinal medical oncology clinics at an academic cancer center. Clinical and demographic variables were collected by self-report and chart abstraction. Attitudes and beliefs were measured using the validated Attitudes and Beliefs about CAM (ABCAM) instrument. This instrument divides attitudes and beliefs into 3 domains: expected benefits, perceived barriers, and subjective norms.
Among 969 participants (response rate, 82.7%) surveyed between June 2010 and September 2011, patient age ≤65 years, female sex, and college education were associated with a significantly greater expected benefit from CAM (P<.0001 for all). Nonwhite patients reported more perceived barriers to CAM use compared with white patients (P<.0001), but had a similar degree of expected benefit (P = .76). In a multivariate logistic regression analysis, all domains of the ABCAM instrument were found to be significantly associated with CAM use (P<.01 for all) among patients with cancer. Attitudes and beliefs regarding CAM explained much more variance in CAM use than clinical and demographic variables alone.
Attitudes and beliefs varied by key clinical and demographic characteristics, and predicted CAM use. By developing CAM programs based upon attitudes and beliefs, barriers among underserved patient populations may be removed and more patient centered care may be provided.
Why do I find this remarkable?
The article was published in the Journal CANCER, one of the very best publications in oncology. One would therefore expect that it contributes meaningfully to our knowledge. Remarkably, it doesn’t! Virtually every finding from this survey had been known or is so obvious that it does not require research, in my view. The article is an orgy of platitudes, and the press release is even worse.
But this is not what irritates me most with this paper. The aspect that I find seriously bad about it is its general attitude: it seems to accept that alternative therapies are a good thing for cancer patients which we should all welcome with open arms. The press release even states that, as therapies such as acupuncture and yoga continue to demonstrate clinical benefits for reducing pain, fatigue, and psychological distress, the field of integrative oncology is emerging to bring complementary and alternative medicine together with conventional care to improve patient outcomes.
I might be a bit old-fashioned, but I would have thought that, before we accept treatments into clinical routine, we ought to demonstrate that they generate more good than harm. Should we not actually show beyond reasonable doubt that patients’ outcomes are improved before we waffle about the notion? Is it not our ethical duty to analyse and think critically? If we fail to do that, we are, I think, nothing other than charlatans!
This article might be a mere triviality – if it were not symptomatic of what we are currently witnessing on a truly grand scale in this area. Integrative oncology seems fast to deteriorate into a paradise for pseudoscience and quacks.
It is now about three years that I retired from my Exeter post. Sadly, my unit was closed down under circumstances that were not all that happy. But my university is doing its very best to keep up the good work, I am proud to report.
The university’s website informs us, for instance, that, during the ‘staff festival, alternative medicine is very much alive and kicking: Our complementary therapists will be offering 15-20 minute taster sessions in our complementary therapies yurt. The therapy taster sessions on offer will include: shaitsu bodywork, reflexology, indian head Massage, seated back massage and much more. To take advantage of these free taster sessions just pop along to the yurt on the day of the festival.
What about outside the festival? Fear not, the Exeter student guild offers homeopathy for those who need a quick, cheap, safe and effective cure of their ailments.
And what about research? Yes, even on the academic level, there still is lots going on. Only notoriously negative sceptics like David Colquhoun would dare to criticise its quality. He has analysed the scientific rigor of one specific paper here and concluded that:
(1) This paper, though designed to be susceptible to almost every form of bias, shows staggeringly small effects. It is the best evidence I’ve ever seen that not only are needles ineffective, but that placebo effects, if they are there at all, are trivial in size and have no useful benefit to the patient in this case..
(2) The fact that this paper was published with conclusions that appear to contradict directly what the data show, is as good an illustration as any I’ve seen that peer review is utterly ineffective as a method of guaranteeing quality. Of course the editor should have spotted this. It appears that quality control failed on all fronts.
David also made interesting and important comments about Simon Mills. Those of you who have read my memoir know that Simon, a top class critical thinker and fierce defender of traditional herbalism, has long been associated with Exeter; the website of the College of Medicine tells us that, at Peninsula Medical School (Exeter), he developed the first taught MSc programme in Integrated Health care at a UK medical school and co-founded the world’s first University centre dedicated to studying complementary health care. More about this particular story can be found here.
So, altogether a very satisfactory picture, I’d say: Exeter university is doing all that is necessary to train its staff and students in the all-important task of critical thinking. It is good to know that at least some British universities take their moral and ethical duties seriously.
I wish my university well and am proud that they carry on the good work that I have started.
You may feel that homeopaths are bizarre, irrational, perhaps even stupid – but you cannot deny their tenacity. Since 200 years, they are trying to convince us that their treatments are effective beyond placebo. And they seem to get more and more bold with their claims: while they used to suggest that homeopathy was effective for trivial conditions like a common cold, they now have their eyes on much more ambitious things. Two recent studies, for instance, claim that homeopathic remedies can help cancer patients.
The aim of the first study was to evaluate whether homeopathy influenced global health status and subjective wellbeing when used as an adjunct to conventional cancer therapy.
In this pragmatic randomized controlled trial, 410 patients, who were treated by standard anti-neoplastic therapy, were randomized to receive or not receive classical homeopathic adjunctive therapy in addition to standard therapy. The main outcome measures were global health status and subjective wellbeing as assessed by the patients. At each of three visits (one baseline, two follow-up visits), patients filled in two questionnaires for quantification of these endpoints.
The results show that 373 patients yielded at least one of three measurements. The improvement of global health status between visits 1 and 3 was significantly stronger in the homeopathy group by 7.7 (95% CI 2.3-13.0, p=0.005) when compared with the control group. A significant group difference was also observed with respect to subjective wellbeing by 14.7 (95% CI 8.5-21.0, p<0.001) in favor of the homeopathic as compared with the control group. Control patients showed a significant improvement only in subjective wellbeing between their first and third visits.
Our homeopaths concluded that the results suggest that the global health status and subjective wellbeing of cancer patients improve significantly when adjunct classical homeopathic treatment is administered in addition to conventional therapy.
The second study is a little more modest; it had the aim to explore the benefits of a three-month course of individualised homeopathy (IH) for survivors of cancer.
Fifteen survivors of any type of cancer were recruited by a walk-in cancer support centre. Conventional treatment had to have taken place within the last three years. Patients scored their total, physical and emotional wellbeing using the Functional Assessment of Chronic Illness Therapy for Cancer (FACIT-G) before and after receiving four IH sessions.
The results showed that 11 women had statistically positive results for emotional, physical and total wellbeing based on FACIT-G scores.
And the conclusion: Findings support previous research, suggesting CAM or individualised homeopathy could be beneficial for survivors of cancer.
As I said: one has to admire their tenacity, perhaps also their chutzpa – but not their understanding of science or their intelligence. If they were able to think critically, they could only arrive at one conclusion: STUDY DESIGNS THAT ARE WIDE OPEN TO BIAS ARE LIKELY TO DELIVER BIASED RESULTS.
The second study is a mere observation without a control group. The reported outcomes could be due to placebo, expectation, extra attention or social desirability. We obviously need an RCT! But the first study was an RCT!!! Its results are therefore more convincing, aren’t they?
No, not at all. I can repeat my sentence from above: The reported outcomes could be due to placebo, expectation, extra attention or social desirability. And if you don’t believe it, please read what I have posted about the infamous ‘A+B versus B’ trial design (here and here and here and here and here for instance).
My point is that such a study, while looking rigorous to the naïve reader (after all, it’s an RCT!!!), is just as inconclusive when it comes to establishing cause and effect as a simple case series which (almost) everyone knows by now to be utterly useless for that purpose. The fact that the A+B versus B design is nevertheless being used over and over again in alternative medicine for drawing causal conclusions amounts to deceit – and deceit is unethical, as we all know.
My overall conclusion about all this:
QUACKS LOVE THIS STUDY DESIGN BECAUSE IT NEVER FAILS TO PRODUCE FALSE POSITIVE RESULTS.
Nonspecific neck pain is extremely common, often disabling, and very costly for us all. If we believe those who earn their money with them, effective treatments for the condition abound. One of these therapies is osteopathy. But does osteopathic manipulation/mobilisation really work?
The objective of a recent review (the link I originally put in here does not work, I will supply a new one as soon as the article becomes available on Medline) was to find out. Specifically, the authors wanted to assess the effectiveness of osteopathic manipulative treatment (OMT) in the management of chronic nonspecific neck pain regarding pain, functional status, and adverse events.
Electronic literature searches unrestricted by language were performed in March 2014. A manual search of reference lists and personal communication with experts identified additional studies. Only randomized clinical trials (RCTs) were included, and studies of specific neck pain or single treatment techniques were excluded. Primary outcomes were pain and functional status, and secondary outcome was adverse events.
Studies were independently reviewed using a standardized data extraction form. Mean difference (MD) or standard mean difference (SMD) with 95% confidence intervals (CIs) and overall effect size were calculated for primary outcomes. GRADE was used to assess quality of the evidence.
Of 299 identified articles, 18 were evaluated and 15 excluded. The three included RCTs had low risk of bias. The results show that moderate-quality evidence suggested OMT had a significant and clinically relevant effect on pain relief (MD: -13.04, 95% CI: -20.64 to -5.44) in chronic nonspecific neck pain, and moderate-quality evidence suggested a non-significant difference in favour of OMT for functional status (SMD: -0.38, 95% CI: -0.88 to -0.11). No serious adverse events were reported.
The authors concluded that, based on the three included studies, the review suggested clinically relevant effects of OMT for reducing pain in patients with chronic nonspecific neck pain. Given the small sample sizes, different comparison groups, and lack of long-term measurements in the few available studies, larger, high-quality randomized controlled trials with robust comparison groups are recommended.
Yet again I am taken aback by several things simultaneously:
- the extreme paucity of RCTs, particularly considering that neck pain is one of the main indication for osteopaths,
- the rather uncritical text by the authors,
- the nonsensical conclusions.
Let me offer my own conclusions which are, I hope, a little more realistic:
GIVEN THE PAUCITY OF THE RCTs AND THEIR SMALL SAMPLE SIZES, IT IS NOT POSSIBLE TO CLAIM THAT OMT FOR NONSPECIFIC NECK PAIN IS AN EVIDENCE-BASED APPROACH
Dear Professor Robinson,
please forgive me for writing to you in a matter that, you might think, is really none of my business. I have been following the news and discussions about the BLACKMORE CHAIR at your university. Having been a professor of complementary medicine at Exeter for ~20 years and having published more papers on this subject than anyone else on the planet, I am naturally interested and would like to express some concerns, if you allow me to.
With my background, I would probably be the last person to argue that a research chair in alternative medicine is not a good and much-needed thing. However, accepting an endowment from a commercially interested source is, as you are well aware, a highly problematic matter.
I am confident that you intend to keep the sponsor at arm’s length and plan to appoint a true scientist to this post who will not engage in the promotional activities which the alternative medicine scene might be expecting. And I am equally sure that the money will be put to good use resulting in good and fully independent science.
But, even if all of this is the case, there are important problems to consider. By accepting Blackmore’s money, you have, perhaps inadvertently, given credit to a commercially driven business empire. As you probably know, Blackmores have a reputation of being ‘a bit on the cavalier side’ when it comes to rules and regulations. This is evidenced, for instance, by the number of complaints that have been upheld against them by the Australian authorities.
For these reasons, the creation of the new chair is not just a step towards generating research, it could (and almost inevitably will) be seen as a boost for quackery. It is foremost this aspect which might endanger the reputation of your university, I am afraid.
My own experience over the last two decades has taught me to be cautious and sceptical regarding the motives of many involved in the multi-billion alternative medicine business. I have recently published my memoir entitled ‘A SCIENTIST IN WONDERLAND. SEARCHING FOR TRUTH AND FINDING TROUBLE’; it might be a helpful read for you and the new professor.
I hope you take my remarks as they were meant: constructive advice from someone who had to learn it all the hard way. If I can be of further assistance, please do not hesitate to ask me.
All this recent attention to Charles’ amazing letters and unconstitutional meddling made me think quite a lot about STUPIDITY. Thus I came across the writings of Carlo Maria Cipolla who seemed to have thought deeply about human stupidity. He described “The Basic Laws of Human Stupidity” and viewed stupid people as a group of individuals who are more powerful by far than even major organizations. I liked his approach; it made me think of Prince Charles, strangely enough.
It might be interesting, I concluded, to analyse Charles’ actions against Cipolla’s 5 laws.
Here are Cipolla’s 5 basic laws of stupidity:
- Always and inevitably each of us underestimates the number of stupid individuals in circulation.
- The probability that a given person is stupid is independent of any other characteristic possessed by that person.
- A person is stupid if they cause damage to another person or group of people without experiencing personal gain, or even worse causing damage to themselves in the process.
- Non-stupid people always underestimate the harmful potential of stupid people; they constantly forget that at any time anywhere, and in any circumstance, dealing with or associating themselves with stupid individuals invariably constitutes a costly error.
- A stupid person is the most dangerous type of person there is.
How does Charles measure up against these criteria, I ask myself? Let’s go through the 5 ‘laws’ one by one.
Charles is just a ‘study of one’, so this point is irrelevant as far as he is concerned. However, he surrounds himself with yes-men of the Dixon-type (I have blogged about him here and here and here), and this evidence seems to confirm this point at least to a certain degree.
Charles had a good education, he is rich, he has influence (just read my previous post on how he made his influence felt in Exeter), and he has many other characteristics which make him unlikely to appear stupid. So, this point seems to be spot on.
Read my previous post and you will agree that this ‘law’ applies to Charles quite perfectly.
Yes, I did underestimate Charles influence. In particular, I did not appreciate the importance and impact of the KNIGHTHOOD STARVATION SYNDROME.
I think that this is a valid point. His ‘black spider memos’ reveal that he is obsessed with integrating bogus treatments into the NHS to the inevitable detriment of public health. And what could be more dangerous than that?
CONCLUSION: FROM THIS BRIEF ANALYSIS, IT SEEMS AS THOUGH THE ‘FIVE BASIC LAWS OF STUPIDITY’ ARE CONFIRMED BY THE ACTIONS OF PRINCE CHARLES
Prince Charles’ meddling beyond his constitutional role is yet again in the press today. I was sent the 2nd batch of ‘spider memos’ yesterday, studied them and commented as follows:
The letters demonstrate yet again that Prince Charles relentlessly meddles in UK health politics and thus disrespects his constitutional role. His arguments in favour of CAM, and in particular homeopathy, show a devastating lack of knowledge and understanding; they are ill-informed, invalid and embarrassingly naïve – but at the same time they are remarkably persistent. Charles tries to give the impression that he is motivated by passion and compassion, but in health care such drivers need solid evidence and expertise. Charles has neither which is not just regrettable, it is arrogant on his part and potentially harmful for public health.
If you get the feeling that I have little patience with Charles’ meddling, you may be right. I have little doubt that it was his interfering that led to the closure of my research unit at Exeter. In my book, A SCIENTIST IN WONDERLAND, I provide the full details of what happened. Here I would just like to reproduce the incredible ‘spider memo’ in question.
It was not actually authored by Charles but by Sir Michael Peat, his 1st private secretary. On 22 September 2005, Peat wrote on Clarence House note-paper to the Vice Chancellor of Exeter University wrongly accusing me of a serious breach of confidentiality:
I am writing both as The Prince of Wales’ Private Secretary and as Acting Chairman of His Royal Highness’ Foundation for Integrated Health.
There has been a breach of confidence by Professor Edzard Ernst in respect of a draft report on the efficacy of certain complementary therapies sent to him by Mr. Christopher Smallwood. The report was commissioned by The Prince of Wales.
Mr. Smallwood sent Professor Ernst an early and, at that stage, incomplete draft of the report for comment. The accompanying e-mail requested and stressed the need for confidentiality. Professor Ernst implicitly agreed to comment on the report on this basis but then, as you probably saw, gave his views about the report to the national press. I attach a copy of a letter from the Editor of the Lancet published by The Times which summarises the issues well. I also attach a copy of the e-mail sent to Professor Ernst by Mr. Smallwood.
I apologise for troubling you, but I felt that you should have this matter drawn to your attention.
What followed was embarrassing and shameful: my uni started a 13 month investigation, eventually I was pronounced innocent but my unit was closed down. Unbelievably, Clarence house denied that Charles even knew about this amazing attempt to meddle in academic affairs. As I say, you need to read my memoir to understand this story fully.
The purpose of this study was to evaluate the impact of early and guideline adherent physical therapy for low back pain on utilization and costs within the Military Health System (MHS).
Patients presenting to a primary care setting with a new complaint of LBP from January 1, 2007 to December 31, 2009 were identified from the MHS Management Analysis and Reporting Tool. Descriptive statistics, utilization, and costs were examined on the basis of timing of referral to physical therapy and adherence to practice guidelines over a 2-year period. Utilization outcomes (advanced imaging, lumbar injections or surgery, and opioid use) were compared using adjusted odds ratios with 99% confidence intervals. Total LBP-related health care costs over the 2-year follow-up were compared using linear regression models.
753,450 eligible patients with a primary care visit for LBP between 18-60 years of age were considered. Physical therapy was utilized by 16.3% (n = 122,723) of patients, with 24.0% (n = 17,175) of those receiving early physical therapy that was adherent to recommendations for active treatment. Early referral to guideline adherent physical therapy was associated with significantly lower utilization for all outcomes and 60% lower total LBP-related costs.
The authors concluded that the potential for cost savings in the MHS from early guideline adherent physical therapy may be substantial. These results also extend the findings from similar studies in civilian settings by demonstrating an association between early guideline adherent care and utilization and costs in a single payer health system. Future research is necessary to examine which patients with LBP benefit early physical therapy and determine strategies for providing early guideline adherent care.
These are certainly interesting data. Because LBP is such a common condition, it costs us all dearly. Measures to reduce this burden in suffering and expense are urgently needed. The question is whether early referral to a physiotherapist is such a measure. The present data show that this is possible but they do not prove it.
I applaud the authors for realising this point and discussing it at length: The results of this study should be examined in light of the following limitations. Given the favorable natural history of LBP, many patients improve regardless of treatment. Those referred to physical therapy early are also more likely to have a shorter duration of pain, thus the potential for selection bias to have influenced these results. We accounted for a number of co-morbidities available in the data set and excluded patients with prior visits for LBP to mitigate against this possibility. However, the retrospective observational design of this study imposes limitations on extending the associations we observed to causation. Although we attempted to exclude patients with a specific spinal pathology, it is possible that a few patients may have been inadvertently included in the data set, in which case advanced imaging may be indicated. Additionally, although our results support that early physical therapy which adheres to practice guidelines may be less resource intense, we cannot conclude without patient-centered clinical outcomes (i.e., pain, function, disability, satisfaction, etc.) that the care was more cost effective. Further, it may be that the standard we used to judge adherence to practice guidelines (CPT codes) was not sufficiently sensitive to determine whether care is consistent with clinical practice guidelines. We also did not account for indirect or out-of-pocket costs for treatments such as complementary care, which is common for LBP. However, it is likely that the observed effects on total costs would have been even larger had these costs been considered.
I was originally alerted to this paper through a tweet claiming that these results demonstrate that chiropractic has an important role in LBP. However, the study does not even imply such a conclusion. It is, of course, true that many chiropractors use physical therapies. But they do not have the same training as physiotherapists and they tend to use spinal manipulations far more frequently. Virtually every LBP-patient consulting a chiropractor would be treated with spinal manipulations. As this approach is neither based on sound evidence nor free of risks, the conclusion, in my view, cannot be to see chiropractors for LBP; it must be to consult a physiotherapist.
Not much is known about the interactions of real doctors (by this I mean people who have been to medical school) and chiropractors who like to call themselves ‘doctors’ or ‘DCs’ but have never been to medical school. Therefore this recent article is of particular interest, in my view.
The purpose of this paper was to identify characteristics of Canadian chiropractors (DCs) associated with the number of patients referred by medical doctors (MDs). For this purpose, secondary data analyses were performed on the 2011 cross-sectional survey of the Canadian Chiropractic Resources Databank survey which included 81 questions about the practice of DCs. Of the 6533 mailed questionnaires, 2529 (38.7%) were returned and 489 did not meet our inclusion criteria. In total, the analysed sample included 2040 respondents.
The results show that, on average, DCs reported receiving 15.6 (SD 31.3) patient referrals from MDs per year. Nearly one-third of the respondents did not receive any. The type of clinic (multidisciplinary with MD), the province of practice (Atlantic provinces), the number of treatments provided per week, the number of practicing hours, rehabilitation and sports injuries as the main sector of activity, prescription of exercises, use of heat packs and ultrasound, and the percentage of patients referred to other health care providers were associated with a higher number of MD referrals to DCs. The percentage of patients with somatovisceral conditions, using a particular chiropractic technique (hole in one and Thompson), taking own radiographs, being the client of a chiropractic management service, and considering maintenance/wellness care as a main sector of activity were associated with fewer MD referrals.
The authors concluded that Canadian DCs who interacted with other health care workers and who focus their practice on musculoskeletal conditions reported more referrals from MDs.
One could criticise this survey for a number of reasons, for instance:
- the response rate was low,
- the sample was small,
- the data are now 4 years old and might be obsolete.
Despite these flaws, the paper does seem to reveal some relevant things. What I find especially interesting is that:
- the level of referrals from doctors to chiropractors seems exceedingly low,
- dubious chiropractic activities such as maintenance therapy or treatment of non-spinal conditions led to even less referrals.
To me, that implies that Canadian doctors are, on the one hand, willing to co-operate with chiropractors. On the other hand, they remain cautious about the high level of quackery in this profession.
All this means really is that Canadian doctors are responsible and aim to adhere to evidence-based practice…in contrast to many chiropractors, I hasten to add.