Do musculoskeletal conditions contribute to chronic non-musculoskeletal conditions? The authors of a new paper – inspired by chiropractic thinking, it seems – think so. Their meta-analysis was aimed to investigate whether the most common musculoskeletal conditions, namely neck or back pain or osteoarthritis of the knee or hip, contribute to the development of chronic disease.
The authors searched several electronic databases for cohort studies reporting adjusted estimates of the association between baseline neck or back pain or osteoarthritis of the knee or hip and subsequent diagnosis of a chronic disease (cardiovascular disease , cancer, diabetes, chronic respiratory disease or obesity).
There were 13 cohort studies following 3,086,612 people. In the primary meta-analysis of adjusted estimates, osteoarthritis (n= 8 studies) and back pain (n= 2) were the exposures and cardiovascular disease (n=8), cancer (n= 1) and diabetes (n= 1) were the outcomes. Pooled adjusted estimates from these 10 studies showed that people with a musculoskeletal condition have a 17% increase in the rate of developing a chronic disease compared to people without a musculoskeletal condition.
The authors concluded that musculoskeletal conditions may increase the risk of chronic disease. In particular, osteoarthritis appears to increase the risk of developing cardiovascular disease. Prevention and early
treatment of musculoskeletal conditions and targeting associated chronic disease risk factors in people with long
standing musculoskeletal conditions may play a role in preventing other chronic diseases. However, a greater
understanding about why musculoskeletal conditions may increase the risk of chronic disease is needed.
For the most part, this paper reads as if the authors are trying to establish a causal relationship between musculoskeletal problems and systemic diseases at all costs. Even their aim (to investigate whether the most common musculoskeletal conditions, namely neck or back pain or osteoarthritis of the knee or hip, contribute to the development of chronic disease) clearly points in that direction. And certainly, their conclusion that musculoskeletal conditions may increase the risk of chronic disease confirms this suspicion.
In their discussion, they do concede that causality is not proven: While our review question ultimately sought to assess a causal connection between common musculoskeletal conditions and chronic disease, we cannot draw strong conclusions due to poor adjustment, the analysis methods employed by the included studies, and a lack of studies investigating conditions other than OA and cardiovascular disease…We did not find studies that satisfied all of Bradford Hill’s suggested criteria for casual inference (e.g. none estimated dose–response effects) nor did we find studies that used contemporary causal inference methods for observational data (e.g. a structured identification approach for selection of confounding variables or assessment of the effects of unmeasured or residual confounders. As such, we are unable to infer a strong causal connection between musculoskeletal conditions and chronic diseases.
In all honesty, I would see this a little differently: If their review question ultimately sought to assess a causal connection between common musculoskeletal conditions and chronic disease, it was quite simply daft and unscientific. All they could ever hope is to establish associations. Whether these are causal or not is an entirely different issue which is not answerable on the basis of the data they searched for.
An example might make this clearer: people who have yellow stains on their 2nd and 3rd finger often get lung cancer. The yellow fingers are associated with cancer, yet the link is not causal. The association is due to the fact that smoking stains the fingers and causes cancer. What the authors of this new article seem to suggest is that, if we cut off the stained fingers of smokers, we might reduce the cancer risk. This is clearly silly to the extreme.
So, how might the association between musculoskeletal problems and systemic diseases come about? Of course, the authors might be correct and it might be causal. This would delight chiropractors because DD Palmer, their founding father, said that 95% of all diseases are caused by subluxation of the spine, the rest by subluxations of other joints. But there are several other and more likely explanations for this association. For instance, many people with a systemic disease might have had subclinical problems for years. These problems would prevent them from pursuing a healthy life-style which, in turn, resulted is musculoskeletal problems. If this is so, musculoskeletal conditions would not increase the risk of chronic disease, but chronic diseases would lead to musculoskeletal problems.
Don’t get me wrong, I am not claiming that this reverse causality is the truth; I am simply saying that it is one of several possibilities that need to be considered. The fact that the authors failed to do so, is remarkable and suggests that they were bent on demonstrating what they put in their conclusion. And that, to me, is an unfailing sign of poor science.
35 Responses to Do musculoskeletal conditions contribute to chronic non-musculoskeletal conditions? A lesson in critical thinking
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Dear Edzard,
I don’t think this study is necessarily so daft as you make out. From what you say, it doesn’t seem that the authors are drawing any unwarranted conclusions, and they are being open about the limitations of their methods.
I can think of several mechanisms whereby musculoskeletal problems could contribute to the chronic diseases that they mention. For a start, they are all likely to result in weight gain and a reduction in exercise (though of course a healthy diet and an active lifestyle can reduce the risk of musculoskeletal problems in the first place).
Also, they are very commonly treated with NSAID’s. A number of drugs from this group have been shown to be associated with an increased risk of cardiovascular disease, and their prescribing has been significantly reduced as a result (diclofenac, for instance), and it would not surprise me if others such as ibuprofen are found to carry a similar risk. Ditto COX-2 inhibitors, which have now more-or-less been withdrawn, but may have been used over the course of the above cohort studies.
There has been a lot of interest recently in the role of chronic, low-grade inflammation as a mechanism in the development of malignancy, diabetes and cardiovascular disease, again associated with poor diet and a sedentary lifestyle, but not necessarily only those.
Indeed, it is well established that there is a genetic component in the development of osteoarthritis, though I have no idea what research there has been into the molecular pathways involved, or indeed whether they may have any bearing on other chronic diseases.
From the list of authors, while one comes from a chiropractic organisation, the rest do not and three of them seem to be in the business of public health.
Finally, I don’t think that there is anything to take issue with in their conclusions, and inasmuch as they are advocating intervention at all it is via public health strategies.
@Julian
The points you make are all good ones, but they don’t (on my reading of Edzard’s post and your comment) solve the basic problem. As ever, we’re dealing with associations rather than causality.
The heart of the issue comes from the authors’ discussion: “We did not find studies that satisfied all of Bradford Hill’s suggested criteria for casual inference (e.g. none estimated dose–response effects) nor did we find studies that used contemporary causal inference methods for observational data (e.g. a structured identification approach for selection of confounding variables or assessment of the effects of unmeasured or residual confounders. As such, we are unable to infer a strong causal connection between musculoskeletal conditions and chronic diseases.”
That makes the meta-analysis a bit of a non-starter. The points you make about NSAIDs and COX-2 inhibitors, also “a lot of interest recently” in the role of chronic inflammation as a contributory mechanism are interesting, but have any of the studies in these areas (well out of my field of expertise) gone beyond demonstration of associations and satisfied current criteria for proving causality?
We seem to be dealing with a chicken-and-egg problem in conditions with build-ups to outcomes so very long-term that isolating any single factor as causal requires — at the very least — massive number crunching of decades-long cohort studies based on birth dates. The fact that a genetic component has been identified in development of osteoarthritis is supportive evidence as what I see as the basic problem. Gene sequencing at least provides a single, objective measure of something, while examining such factors as obesity and sedentary lifestyle does not, because they can have other ultimate causes.
Even a gene sequence may not provide an absolute explanation; epigenetics may qualify associations between the genome and diseases. Fact is, proving causality is way more complicated than proving associations, but the latter often turn out to be wrong (as astute readers of the Daily Mail and the Daily Express should already realize). Edzard’s example of the nicotine-stained fingers is an excellent one; I shall use it henceforth in clear preference to the old chestnut about frog’s legs being hearing organs because if you amputate them then clap your hands the frog no longer jumps.
I came across this paper today which may relate to the general topic.
https://www.mdpi.com/2077-0383/7/9/236
@DC
In what way do you find this paper relevant to the topic, perhaps because of the absence of critical thinking?
I have neither the interest, desire nor time to have discussions with someone who resorts to insults…Toodles.
If you feel insulted by a comment, take a deep breath, go get another cup of coffee and then read the comment again to see if you perhaps misunderstood it, before writing an unnecessarily indignant reply.
When your heart stops racing and your palms stop sweating, why don’t you sit down and try to find five faults in this paper It would be a good exercise in critical thinking for you.
As Julian points out (below), the authors have missed out on critical thinking in their urge to publish something.
DC,
I think Bjorn was referring to the absence of critical thinking in the paper. It doesn’t seem to me that he was insulting you.
It certainly doesn’t seem to be a very good paper, as you can find all kinds of odd associations if you look hard enough, entirely due to chance. Having said that, I’m not sure that I can understand what point you are making by referring to it.
@Edzard
Do you think some honesty on how you tag the post would be in order?
I suggest you have a closer look at the authors and their professions.
Here is a list of the authors:
Amanda Williams, Steven J. Kamper, John H. Wiggers, KateM.O’ Brien, HopinLee, Luke Wolfenden, Sze Lin Yoong, Emma Robson, JamesH.McAuley, Jan Hartvigsen and Christopher M. Williams.
FROM:
1. School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia. [email protected].
2. Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia. [email protected].
3. Centre for Pain, Health and Lifestyle, Ourimbah, NSW, Australia. [email protected].
4. Centre for Pain, Health and Lifestyle, Ourimbah, NSW, Australia.
5. School of Public Health, University of Sydney, Lvl 10, King George V Building, Camperdown, NSW, 2050, Australia.
6. School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.
7. Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia.
8. Neuroscience Research Australia (NeuRA), PO Box 1170, Randwick, NSW, 2031, Australia.
9. Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, UK.
10. Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.
11. Nordic Institute of Chiropractic and Clinical Biomechanics, Campusvej 55, 5230, Odense M, Denmark.
“And that, to me, is an unfailing sign of poor science.”
Your accusing the likes of James McAuley from NeuRA, Steve Kamper from Sydney University Public Health and Jan Hartvigsen from University of Odense of POOR SCIENCE.
I recommend you write a letter to the editor.
@EE
So you take a multidisciplinary paper and make it all about chiropractic.
Steve Kamper on Twitter in regards to this blog:
“I’m happy to let informed readers assess the quality of the science, and whether they think our interpretation is reasonable. Also happy to chat about specific issues if people have them. Not really sure what to make of the cheap dig on chiros though”.
Nailed it.
Chris Maher’s reply:
“I wouldn’t worry about a spray from Ernst. I copped similar stuff a week or two back. Its what he does. He is the shock jock of science commentary.”
I notice that you do not try to counter my arguments. Is this because you have no counter-arguments?
Why don’t you ask the authors with a letter to the editor instead of turning the paper into a “cheap dig on chiros”.
Some honesty here would be refreshing:
“Posted in bias, Cancer, causation, chiropractic, coronary heart disease, critical thinking, musculoskeletal problems, neck-pain, osteoarthritis, pseudo-science”
pointing out that Palmer stated ‘95% of disease is caused by subluxation…’ and mentioning that this paper has some bearing on this dogma, is a ‘cheap dig’?
Critical_Chiro wrote at Prof Ernst: “Your accusing the likes of James McAuley from NeuRA, Steve Kamper from Sydney University Public Health and Jan Hartvigsen from University of Odense of POOR SCIENCE.”
@ Critical_Chiro
Taking Jan Hartvigsen DC as an example, the accusation that he produces poor science seems to fit the bill.
FYI, in 2019, Jan Hartvigsen is giving an address on “Lessons from The Lancet: Our Great Global Opportunity” (see https://twitter.com/WFCchiropractic/status/1045270977964396544 p. 5 of the link given).
A better title might be ‘Our Great Global Hoodwinking Opportunity’, if you consider the following:
https://edzardernst.com/2018/03/suffering-from-back-pain-walk-to-your-therapist-dont-accept-or-pay-for-treatment-but-walk-straight-back-home-again/
https://edzardernst.com/2018/03/low-back-pain-alternative-practitioners-feel-encouraged-by-the-recent-lancet-articles-wrongly-so-i-hasten-to-add/
https://complementaryandalternative.wordpress.com/2018/03/23/chiropractors-and-osteopaths-continue-to-mislead-about-their-role-in-the-treatment-of-back-pain/
@EE
FYI
The researchgate profile researcher who described your article as a “cheap dig on chiros”:
https://www.researchgate.net/profile/Steven_Kamper
http://sydney.edu.au/medicine/people/academics/profiles/steven.kamper.php
A highly published and highly regarded PHYSIOTHERAPY researcher.
Now that is what I call an unbiased assessment.
The Twitter post was liked by another one of the authors James McAuley:
https://www.neura.edu.au/staff/dr-james-mcauley/
https://www.researchgate.net/profile/James_Mcauley2
A very highly regarded psychology researcher.
“pointing out that Palmer stated ‘95% of disease is caused by subluxation”
Support these researchers and reform and stop clinging to an outdated dogma like the vitalistic chiropractors.
@BW
A world leading and highly regarded researcher in the field of Musculoskeletal pain and you write:
“the accusation that he produces poor science seems to fit the bill.”
And then you cite nothing but blogs.
Enough is enough.
Start reading the research for a change instead of echo chambers.
http://nikkb.com/research/jan-hartvigsen-is-the-world-s-leading-expert-in-musculoskeletal-pain
https://www.researchgate.net/profile/Jan_Hartvigsen
I have been patient and polite on this blog but I have to finally say your as much a part of the problem as the worst subluxation based chiropractor and just as resistant to change.
stop wining!
you have been neither patient nor polite.
most importantly, you have been mostly wrong!
@ Critical_Chiro wrote on Friday 05 October 2018 at 08:21: “…you cite nothing but blogs. Enough is enough.”
@ Critical_Chiro
Don’t you ever read the content of the blog links I post? They almost invariably contain valuable links and valid scientific argument which you have repeatedly appeared to be unable to counter in a convincing manner.
@ Critical_Chiro wrote: “I have been patient and polite on this blog but I have to finally say your as much a part of the problem as the worst subluxation based chiropractor and just as resistant to change.”
How do you reconcile that with what the President of the World Federation of Chiropractic (WFC) wrote in his July 2018 President’s Message regarding ‘change’:
QUOTE
“For thirty years the WFC has attempted to facilitate unity in the global chiropractic community. When it was realized that unity was unattainable the WFC sought unity with diversity. Neither objective has yet been achieved. At its recent meeting in Lima, WFC Council made the bold decision to shift away from endeavoring to promote unity…the profession is now more diverse than it has ever been…Chiropractors now practice in a range of different settings, using a wide range of interventions, and practicing from varying philosophical standpoints.”
Ref. https://www.wfc.org/website/images/wfc/qwr/2018/QWR_2018JUL.pdf (p.3)
@EE
When you get smacked down by three highly ranked and respected international researchers (two of them physiotherapists) on Twitter and a 4th high powered researcher and many rising researchers from multiple professions likes their comments.
Do you think its time to take the next step and support researchers and reform?
@BW
The WFC has had enough with the “unity with diversity as has the American Chiropractic Association.
Blogs by their very nature are echo chambers that reinforce you bias.
Are they peer reviewed?
They cherry pick research and extrapolate the findings to fit their agenda like the most religiously fundamental subluxation chiropractor. They also use the same arguments. How ironic.
I am perfectly aware of how much time you have devoted on social media over the decades to one side of the argument and this makes you incapable of accepting research and reform.
The vitalists are being left behind and so are the entrenched critics.
The only reason I come on this blog is to put both sides of the argument into the public record and to engage with the lurkers who are reading this.
Critical_Chiro wrote: “The WFC has had enough with the ‘unity with diversity’ as has the American Chiropractic Association.”
@ Critical_Chiro
Have they really? They still seem to be prepared to accept double standards – e.g. see the WFC President’s message here
https://www.wfc.org/website/images/wfc/qwr/2018/QWR_2018JUL.pdf (p.3)
and the British Chiropractic Association’s message here:
http://www.mccoypress.net/i/bca_bennett_letter_december_2016.jpg
Critical_Chiro wrote: “Blogs…cherry pick research and extrapolate the findings to fit their agenda like the most religiously fundamental subluxation chiropractor. They also use the same arguments. How ironic.”
I disagree. It’s the chiropractors and their apologists who are the cherry-pickers. Published systematic reviews are the antithesis of cherry-picking and are often examined on this blog. However, as you are dismissive of blogs, here’s one of Professor Ernst ’s responses to criticism of one of his systematic reviews: http://journals.sagepub.com/doi/pdf/10.1177/014107680710001011
and here’s a pertinent Cochrane systematic review:
http://www.ebm-first.com/chiropractic/research-and-efficacy/2163-spinal-manipulative-therapy-for-acute-low-back-pain-update-of-the-earlier-cochrane-review-first-published-in-january-2004.html
Critical_Chiro wrote: “I am perfectly aware of how much time you have devoted on social media over the decades to one side of the argument and this makes you incapable of accepting research and reform.”
It’s an important argument when the scientific data are demonstrating that chiropractic is, at best, unnecessary.
Critical_Chiro wrote: “The vitalists are being left behind and so are the entrenched critics.”
Evidence please.
Critical_Chiro wrote: “The only reason I come on this blog is to put both sides of the argument into the public record and to engage with the lurkers who are reading this.”
And, as I already mentioned above, you have repeatedly been unable to counter your side of the argument in a convincing manner.
@BW. Rather than picking just one review, I tend to look at multiple reviews to get a broader picture. Here is the list I have compiled (due to the size of my file, I am limiting the list here to only the past two years).
Skelly 2018
Chronic low back pain: At short term, massage, yoga, and psychological therapies(primarily CBT) (strength of evidence [SOE]: moderate) and exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation (SOE: low) were associated with slight improvements in function compared with usual care or inactive controls. Except for spinal manipulation, these interventions also improved pain.
Minkalis 2017
No clinical trials of thrust manipulation for non-surgical shoulder conditions other than subacromial impingement syndrome were found. There is limited evidence to support or refute thrust manipulation as a solitary treatment for this condition. Studies consistently reported pain reduction, but active treatments were comparable to shams. High-quality studies of thrust manipulation with safety data, longer treatment periods and follow-up outcomes are needed. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5215137/
Kranenburg 2017
Most patients were treated by chiropractors (66%). Manipulation was reported in 95% of the cases, and neck pain was the most frequent indication. Cervical arterial dissection (CAD) was reported in 57% (P = 0.21) of the cases and 45.8% had immediate onset symptoms. The overall distribution of gender for CAD is 55% (n = 71) for female and therefore opposite of the total AE. Patient characteristics were described poorly. No clear patient profile, related to the risk of AE after CSM, could be extracted. However, women seem more at risk for CAD. There seems to be under-reporting of cases. Further research should focus on a more uniform and complete registration of AE using standardized terminology. http://www.sciencedirect.com/science/article/pii/S246878121730019X?via%3Dihub
Nielsen 2017
It is currently not possible to provide an overall conclusion about the safety of SMT; however, the types of SAEs reported can indeed be significant, sustaining that some risk is present. High quality research and consistent reporting of AEs and SAEs are needed. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5366149/
Chou 2017
Evidence continues to support the effectiveness of exercise, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture for chronic low back pain (SOE, low to moderate). http://annals.org/aim/article/2603230/nonpharmacologic-therapies-low-back-pain-systematic-review-american-college-physicians
Kovanur-Sampath 2017
The current review found that spinal manipulation can increase substance-p, neurotensin, oxytocin and interleukin levels and may influence cortisol levels post-intervention. However, future trials targeting symptomatic populations are required to understand the clinical importance of such changes. http://www.sciencedirect.com/science/article/pii/S246878121730067X?via%3Dihub
Paige 2017
Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large. http://jamanetwork.com/journals/jama/article-abstract/2616395
Thoomes 2016
There is low level evidence that cervical manipulation and mobilisation as unimodal interventions are effective on pain and range of motion at the immediate follow up, but no evidence on the effectiveness of thoracic manipulation or mobilisation as unimodal interventions. There is low level evidence that a combination of spinal mobilisation and motor control exercises is more effective on pain and activity limitations than separate interventions or a wait-and-see policy. There is low level evidence of the effectiveness of cervical mobilisation with a neurodynamical intent as unimodal intervention, on the effectiveness of a multimodal intervention with neurodynamic intent on pain activity limitations and global perceived effect compared to a wait-and-see policy. There is also low level evidence that a multimodal intervention consisting of spinal and neurodynamic mobilisations and specific exercises is effective on pain in patients with CR. There is low level evidence that traction is no more effective than placebo traction. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5146882/
Rothberg 2016
In conclusion, for patients with nonchronic, nonradicular LBP, available evidence does not support the use of spinal manipulation or exercise therapy in addition to standard medical therapy. https://www.ncbi.nlm.nih.gov/pubmed/27751598
Wong 2016
Most high-quality guidelines recommend education, staying active/exercise, manual therapy and paracetamol/NSAIDs as first-line treatments for LBP. Recommendation of paracetamol for acute LBP is challenged by recent evidence and needs updating. http://onlinelibrary.wiley.com/doi/10.1002/ejp.931/abstract;jsessionid=F01708A428FECC4297DB9F026C61D07C.f04t03
Hall 2016
11 articles reporting on 10 studies on a total of 1198 pregnant women were included in this meta-analysis. The therapeutic interventions predominantly involved massage and osteopathic manipulative therapy. Meta-analyses found positive effects for manual therapy on pain intensity when compared to usual care and relaxation but not when compared to sham interventions. Acceptability did not differ between manual therapy and usual care or sham interventions. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5044890/
Ruddock 2016
There is some evidence that SM has specific treatment effects and is more effective at reducing nonspecific low back pain when compared with an effective sham intervention. However, given the small number of studies included in this analysis, we should be cautious of making strong inferences based on these results. http://www.journalchiromed.com/article/S1556-3707(16)30026-8/abstract
Garcia 2016
Seven of the 10 studies had statistically significant findings that subjects who received mobilization or manipulation interventions experienced improved outcomes or reported fewer symptoms than control subjects. These results suggest that mobilization or manipulation of the cervical spine may be beneficial for individuals who suffer from CEH, although heterogeneity of the studies makes it difficult to generalize the findings. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800981/
Varatharajan 2016
For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful. https://www.ncbi.nlm.nih.gov/pubmed/26851953
Zhou 2016
Three trials with 502 participants were included. Meta-analysis suggested that cervical spine manipulation (mean difference 1.28, 95% confidence interval 0.80 to 1.75; P < 0.00001; heterogeneity: Chi(2) = 8.57, P = 0.01, I(2) = 77%) improving visual analogue scale for pain showed superior immediate effects compared with cervical computer traction. The overall strength of evidence was judged to be moderate quality. https://www.ncbi.nlm.nih.gov/pubmed/25681406
@ DC
I’m not sure what your point is. Basically, those reviews reveal small effects, ‘more evidence needed’, and under-reporting of adverse events. Therefore a responsible risk/benefit assessment would contraindicate the use of manipulation as an intervention in nearly all cases, yet it remains the hallmark intervention of most chiropractors with many continuing to use it for quasi-religious reasons:
https://sciencebasedmedicine.org/the-bait-and-switch-of-unscientific-medicine/
Was that what you were ultimately trying to point out?
I mentioned my point in my response…it had to do with the comment, “It’s the chiropractors and their apologists who are the cherry-pickers.“
However, if one looks at the review you linked to, from the original 2013 version we find this…
“The experimental interventions examined in this review included both spinal manipulation and mobilization of the spine. Unless otherwise indicated, SMT refers to both modes of “hands-on” treatments of the spine.”
and that PTs performed almost double the studies compared to chiropractors…
“Most treatments were administered either by physiotherapists32–36,39,40,45,47 or chiropractors,37,41,42,46,51”
DCs 5/20 and PTs 9/20.
Safety…
“Six studies, with a total of 1195 participants, reported on adverse events.34,36,38,41,46,49 One study reported 4 serious adverse events occurring equally in both the experimental and control groups; however, “neither of the events seemed to be related to the allocated treatment strategies.”38 In another study, 25% of the participants reported at least 1 side effect of treatment; however, there were no differences between the groups and all symptoms resolved within 48 hours of onset.34 None of the other studies reported serious adverse events.”
Seems like a strange review to use if ones purpose is to look at chiropractors doing spinal manipulation.
Regardless, the authors conclusion…
“The decision to refer for SMT should be based upon costs, preferences of the patient and providers, and relative safety of the various treatment options.”
So, maybe you cherry picked the wrong review? Strange.
@ DC
No, I didn’t cherry pick the wrong review, so it’s not strange.
A total of 1195 participants is not high-powered enough to show the true frequency of serious adverse events (and remember, we’re talking about an intervention that is no better than sham, that is the hallmark intervention of chiropractors, and one which is used often by them for quasi-religious reasons – e.g. low back pain sufferers will have their necks manipulated as a matter of course to release ‘Innate Intelligence’). In view of that, the authors’ conclusion that “The decision to refer for SMT should be based upon costs, preferences of the patient and providers, and relative safety of the various treatment options” means that a responsible risk/benefit assessment cannot favour SMT. The list you compiled above arrives at the same result.
Again, from the review you linked to…
“However, 2 large cohort studies of SMT failed to identify any serious adverse events following more than 6500 SMT treatments to the neck or low back, or both.83,84.”
As well as…
Effect of SMT Versus Sham SMT
One study was identified.37 For the outcomes of pain and functional status, there was very low-quality evidence (high RoB, inconsistency, imprecision) from 1 study37 that SMT was not significantly better than sham SMT at 1-month follow-up
(Statistically, the chiropractic group responded significantly better than the control group with respect to a decrease in pain scores. Hoiriis, et al)
But the primary questions are….does the research represent how conditions are typically addressed in a clinical setting? How is spinal manipulation typically utilized in the overall care of those patients? What percentage of chiropractors only do spinal manipulation? Does spinal manipulation have an additive effect with an multimodal approach or perhaps even a synergistic effect in some cases? How does the overall safety of the chiropractic model compare to the medical model? What are valid outcome measures when comparing two completely different approaches….manual vs pharmaceutical? Etc, etc, etc.
So, in summary, yes, I agree that the current research (as studied with the inclusion/exclusion criteria) indicates that spinal manipulation as a unimodality isn’t very impressive…I’ve been telling my peers that for years. Fortunately, very few chiropractors use spinal manipulation as a unimodality approach to patient care.
Good day and good night. I’m out.
“…the current research (as studied with the inclusion/exclusion criteria) indicates that spinal manipulation as a unimodality isn’t very impressive… Fortunately, very few chiropractors use spinal manipulation as a unimodality approach to patient care…”
you know that this is a daft argument, don’t you?
@EE
“you know that this is a daft argument, don’t you?”
Chiropractors just adjust subluxations.
If it’s not subluxation then it’s not chiropractic.
These are identical daft arguments used by vitalistic chiropractors and the carpet bombing critics.
Oh the irony.
@cc: having followed your “input” here closely I am suspecting you suffer from a mental-disorder.
As you clearly see yourself as the uncola-of-Chiropractic and obviate all reasonable discussions to the contrary. You point out ALL those lesser-examples of DC can’t hold a candle to YOUR lofty standards. Problem is those 80%ers are all pretending to be doctors, just like you, and using the title DC, just like you….so how are we poor, misguided science-minded folk to avoid occasionally carpet-bombing the whole lot of you….like hitting the occasional flower with Roundup? “DC” points out “unimodality” manipulation don’t cut the butter (though he won’t tell us what DOES)….
Since your fellow activist GibletsGiblets points out PT doesn’t work, it’s just “shake, bake and fake”, since structuralism has lost robust scientific and epidemiological footing, palpation is not now (or was ever) valid, neither are short-legs or muscle-challenges…..I keep comin’ round to the same old question: WTF IS CHIROPRACTIC? And HTF do YOU do it differently that makes it so F%@*§ing scientific and efficacious? How do ANY of you know-what “target” you are after while in your “clinics”??
If you want to give people in pain some temporary “shake and bake” relief then have at it….charge accordingly and quit the bait and switch. Otherwise become an MD.
@cc
The history of chiropractic is too recent for you to say “These are identical daft arguments used by vitalistic chiropractors and the carpet bombing critics.” The concept of a non-vitalistic chiro is analogous to that of an astrologer who doesn’t believe that movement of celestial objects influence human behaviour or a palm-reader who doesn’t believe the furrows in a person’s hand don’t predict the person’s future. Or, for that matter, a christian who doesn’t believe Jesus died nailed to a cross and was divinely resurrected 3 days later.
You repeatedly complain about “carpet-bombing”, when all your critics are doing is trying to get you to see simple common sense. If you want to rebirth chiropractic as a new, rational sub-discipline within medicine, you need to establish — on the basis of some sound evidence — what area of medicine chiropractors are supposed to work in and what they do that is novel and of clinical value. And if you want to create this wonderful new medical sub-discipline, I’d suggest that a new name might avoid undoing all your good work by associating it with a crock of metaphysical horse manure.
I used to bother asking you what chiropractors do if not address subluxations, though I’ve given up hope of a rational response. I’ve suggested the answer is physiotherapy, but that suggestion provokes scornful derision of physiotherapists (whose work is certainly not the best example of evidence-based medicine) from the likes of GibleyGibley. The latter once asked me to “give an indication of my education in science, especially neurophysiology”. That suggests that chiropractors consider themselves expert neurophysiologists. Do you go along with that, c_c? If so, why not change your profession to ‘neurophysiologist’ and seek the appropriate qualifications?
To an outsider, all your hot air closely resembles arguments about the different ‘teachings’ of Roman Catholics vs. Anglicans vs Greek Orthodox. All based on intellectual vapourings about belief systems. The question “why aren’t you a physiotherapist or an osteopath?” can be answered only with “because I am a chiropractor.” You claim to be a reformer, so that puts you in the position of the Protestants. But all you’re doing is creating another belief system that differs from the others in small points of detail. But it’s still only a belief system and therefore commands no respect from those of us who value science and evidence.
Cue Edzards sock puppets:
@MK
“Problem is those 80%ers are all pretending to be doctors, just like you”
“and using the title DC, just like you”
“charge accordingly and quit the bait and switch”
I have made it abundantly clear on this site for years how I practice and yet you still adhere to this BS.
“I keep comin’ round to the same old question: WTF IS CHIROPRACTIC? And HTF do YOU do it differently that makes it so F%@*§ing scientific and efficacious? How do ANY of you know-what “target” you are after while in your “clinics”??”
“you suffer from a mental-disorder”
Swearing and Ad Homs.
Try keeping up with the latest research and where things are heading instead of adhering to an outdated dogma like the vitalists.
@FO
If its not vitalistic then it’s not chiropractic??
“I’d suggest that a new name might avoid undoing all your good work by associating it with a crock of metaphysical horse manure.”
I agree with you on these points and have had extensive debates with vitalists. I tell them that the profession has moved on and they should have the integrity of Reggie Gold and rename themselves Spinologists. I also agree that their “chiropractic foolosophy” (to quote Keith Charlton) is a “metaphysical horse manure”.
“I used to bother asking you what chiropractors do if not address subluxations, though I’ve given up hope of a rational response. I’ve suggested the answer is physiotherapy”
You call me a pseudo-physio whole the vitaists use the term medipractor. Do you not see the irony? Employing similar arguments.
“But all you’re doing is creating another belief system that differs from the others in small points of detail. But it’s still only a belief system and therefore commands no respect from those of us who value science and evidence.”
The only thing I believe in is change and going where the science and evidence leads.
You are desperately clinging to an outdated belief system just like the vitalists. Acknowledging reform, reformers and researchers would be just too painful for the carpet bombing critics who have invested a great deal of time and effort running around in circles with the vitalist fringe.
“But it’s still only a belief system and therefore commands no respect from those of us who value science and evidence.”
I have for years on this blog said repeatedly that I am fine with much of the criticism as it reflects similar criticism within the profession. But if you do not take the next step and support reform, reformers and researchers then you are Carpet Bombing critics where reform, reformers and researchers are acceptable collateral damage.
It is a very apt description.
Edzard recently got flamed by three highly ranked and respected researchers on Twitter. The tweets were also liked by quite a few heavy hitting researchers from multiple professions.
Perhaps it’s time for the critics to “value science and evidence”.
I have cited a researcher Charlotte Lebouf-Yde many times on this blog to be met with silence. The Edzard takes offense at one sentence from Charlotte and decides to do a hatchet blog:
“I have always thought highly of Charlotte’s work, however, her conclusion made me doubt whether my high opinion of her reasoning was justified” (Edzard Ernst).
Well if you “have always thought highly of Charlotte’s work” why have you never SUPPORTED it?
“value science and evidence”?
Evidence would suggest otherwise.
Time for you to change.
@C_C
“I tell them that the profession has moved on and they should have the integrity of Reggie Gold and rename themselves Spinologists.” OK, but what NEW discovery about the spine is going to form the basis of this novel ‘profession’? Don’t neurosurgeons and orthopedic surgeons already have the evidence base for ‘spinology’? You’re surely not suggesting putting the cart before the horse and assembling the various shreds and tatters of subluxation-free chiropractic into your new (evidence-free) medical discipline? Pulling treatment rationales from their own rectum is the hallmark of the pseudo-scientist. We (should) have moved on from the era in which individual pronouncements without supporting evidence are regarded as the province of the seriously stupid.
Can you never, even in your deepest moments of troubled sleep, recognize the utter folly of ‘reformed chiropractic’? If you agree the original is a crock of metaphysical horse manure, then its current range of practices, reformed or otherwise, is surely just a more extensive crock of metaphysical horse manure!
a spinologist = a physio only doing spinal issues?
twist and turn it as you like, chiros do have an existential problem
From what I’ve read and the discussion I’ve had with the evidence based part of the profession they are moving more into this model. http://www.psp.pitt.edu.
@un-chiropractor: “Try keeping up with the latest research…” is that now my responsibility? THAT “chiropractic” doesn’t work for me or anyone I know, and innumerable persons commenting on this blog or in systematic reviews, BUT I’m suppose to keep up with the spurious-research done by the religiously-imbued snipe hunters that supposedly validate your life’s calling? Why?
Unlike you I’m expert in uncovering obfuscatory meanderings and pointing out mental-disordered thinking…which is NOT ad hom. I took some pepto and then reviewed several of your former blog-entries and am still positing the query WTF IS CHIROPRACTIC and HTF do you do it that makes it anything other than a pseudo-religion somehow different (and better?) than the lowly “vitalist subluxation DCs”….You continue to promulgating the notions: “you can treat away another persons pain”, “you have specialized training and tactile attributes which give you this magic prestidigitation”, “it requires a 4 year $200,000 education at a “special-college” and, though it never really works better than anything-else it is deserving of the utmost respect and latitude AND my time and effort to “keep up on the “research”. Big demands from a pretend doctor-of-misalignment.
And why do you keep reiterating the inane and arcane mantra: “you are just like the vitalists living in the past”…that sounds stupid and it is stupid. I am not a “vitalist” whatever that’s suppose to mean and I only “live in the past” when I’m recounting my sexual prowess.
@MK , but when someone cite a positive outcome the only reply I get from you folks: well that’s an anecdote.
Anyways it was a good read with good arguments on both sides. The only down side when the skeptics start personal attacks.
“The only down side when the skeptics start personal attacks.”
and when the charlatans do it, it’s ok, is it?
Generally a positive-outcome IS an anecdote…the “outcome” typically being well within the purview of ANY manual-theatric administrated by any number of “magicians”. Positive-effects never seem to happen to skeptics or those committed to critical rationalism since those folks tend to recognize “shallow effects” vs “deep effects”….and when the magician tries the bait-and-switch they simply walk away. The gullible recite their anecdotes with ever-increasing verisimilitude….the magician fervently reiterates them to ensnare other like-minded believers.