“Physiotherapy generally offers a highly science based approach to clinical practice.” This was a recent comment by someone (I presume a physiotherapist) on this blog. It got me thinking – is it true or false? I am in no position to review the entire field of physiotherapy in a blog post. What I will do instead, is list a few alternative therapies often used by physiotherapists.
- Acupuncture: many physiotherapists seem to love acupuncture. In the UK, for example, they have their own organisations. The AACP is the largest professional body for acupuncture in the UK with a membership of around 6000 chartered physiotherapists, practising medical acupuncture. They state that there is an increasing number of research publications in the UK and worldwide proving the treatment effectiveness of acupuncture when compared to (chemical) medication for example.
- Applied kinesiology: some physiotherapists offer applied kinesiology. This clinic, for instance, states that applied Kinesiology combines a system of muscle tests with acupuncture, reflex points emotion and nutrition to find any imbalances present in the whole person.
- Bowen technique: many physiotherapists use the Bowen technique. This practice advertises it as follows. If you’re looking for a way to treat tightness in your upper back, neck or shoulders or are suffering from respiratory pain or headaches, The Bowen Technique could be the answer you’re searching for. Achieving all these things as well as being a great way to treat sports injuries and enhance sporting performance, this therapy also promotes emotional wellbeing. A non-invasive therapy, it is equally suited for the treatment of acute (short-term) and chronic (long-term) conditions.
- Craniosacral therapy: some physios also employ craniosacral therapy. Here is an example. Craniosacral therapy as experienced by thousands of babies and people all around the country, has a proven track record at easing and relieving what makes babies upset. If your baby suffers from:
- Colic
- Wind
- Digestive issues
- Reflux
- Unsettledness
- Sleep problems
- Ongoing crying
- Difficulty with breast feeding/latch/suck
- Other problems
then call…
- Cupping: One physio writes this about cupping. It was good to see the public (Western cultures) exposed more to cupping therapy practice thanks to the recent Olympics in Rio 2016. Last Olympics in London 2012, the Chinese and Japanese Athletes, amongst neighbouring nations, were readily seen to use and advocate the practice, along with the approval no doubt of their large team of Medical and Physiotherapy related support staff. This time however it has bridged to divide to Western World Athletes, such as Michael Phelps (he of 23 Olympic Golds fame). This advocacy of the practice and again the presumed support from his Medical and Sports science entourage with team USA, is a good barometer of the progress and acceptance within Western Medicine, for Cupping Therapy.
- Massage therapy: in many countries, massage and related techniques therapy always have been an integral part of physiotherapy.
- Feldenkrais method: The same applies to The Feldenkrais Method® is based on principles of physics, biomechanics, neuroscience, and the study of human motor development. Feldenkrais recognized the capability of the human brain to learn and relearn at any age – neuroplasticity. The method utilizes slow, gentle movements, and awareness of subtle differences to optimize learning, improve movement, and make changes in the brain.
- Kinesiology tape: If you have suffered an injury or illness that causes a problem with your functional mobility or normal activity, you may benefit from the skilled services of a physical therapist to help you return to your previous level of mobility. Your physical therapist may use various exercises and modalities to help treat your specific problem.
- Reflexology: Here is what the UK Chartered Society of Physiotherapists writes about reflexology: Developed centuries ago in countries such as China, Egypt and India, reflexology is often referred to as a ‘gentle’ and ‘holistic’ therapy that benefits both mind and body. It centres on the feet because these are said by practitioners to be a mirror, or topographical map, for the rest of the body. Manipulation of certain pressure, or reflex, points is claimed to have an effect on corresponding zones in the body. The impact, say reflexologists, extends throughout – to bones, muscles, organs, glands, circulatory and neural pathways. The head and hands can also be massaged in some cases. The treatment is perhaps best known for use in connection with relaxation and relief from stress, anxiety, pain, sleep disorders, headaches, migraine, menstrual and digestive problems. But advocates say it can be used to great effect far more widely, often in conjunction with other treatments…
- Spinal manipulation: Physiotherapists learn spinal manipulation as part of continuing education courses in Canada. The Orthopaedic Division of the Canadian Physiotherapy Association is responsible for the standards of education and supervises exams required to meet the standards of the International Federation of Manipulative Physiotherapists (IFOMPT). In many other countries, the situation is similar.
These 10 therapies have all been discussed on this blog before. They lack
- plausibility or
- proof of efficacy or
- proof of safety or
- all of the above
In other words, they are NOT highly science-based.
QED
116 Responses to “Physiotherapy generally offers a highly science based approach to clinical practice.” WISHFUL THINKING OR TRUTH?
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You published the following about Feldenkrais already may be it needs to be discussed further on? It looks like this method could be integrated into clinical routine? But I think they have a lack of profound medical knowledge because they do not even learn neither anatomy nor pathology in their trainings and their “graduation” is a “yodeling degree” because nearly everybody passes it successfully … may be it’s better done if physical therapists apply it and not free floating practitioners?
https://edzardernst.com/2015/06/an-alternative-treatment-that-could-actually-be-integrated-into-clinical-routine/
I share the concern expressed above that the science base for physiotherapy is thin at best, the profession attracts many practitioners who lack a critical approach to camistry (CAMs), some practitioners actively practice alternative techniques which have no plausible, reproducible evidence base (they are not alone, there are some doctors in this category) and that by deliberately conflating the undoubted benefits of much physical therapy practice with other modalities mentioned, such physiotherapists undermine the integrity of the profession.
And yet…
In my experience, most physiotherapists do appreciate the scientific method, apply it as best they can, do have high ethical standards, are critical and do move on from modalities which are shown to be ineffective.
I only hope the profession of physiotherapy will continue to base itself in evidence and express wider critisicm of those of its members climbing aboard the quackery bandwaggon.
Doctors need professional colleagues they can trust. More to the point, so do patients.
The science base for Physiotherapy is not “thin at best”. If you go to the Physiotherapy Evidence Database (pedro.org.au) you will find over 32,000 RCTs evaluating Physiotherapy treatments.
ok, then name a few (5 or 6) interventions/indications that are solidly based on evidence.
Graded exercise
CBT
Motivational interviewing (MI)
Education (weak evidence and a bit vague I know – and possibly just a part of MI and CBT within PT scope of practice)
OTC NSAIDs
Rapid referral for red flag or otherwise concerning physical or mental health symptom patterns
That’s 6ish.
Re: Gibley Gibley
You assert that my list is not physiotherapy. Sorry dude,you’re wrong.
Well, that is what contemporary physiotherapy looks like. There are few interventions that are specifically medical or physiotherapy. There are simply interventions that work or don’t work and are within the legal scope of practice for a specific discipline within a specific country.
If a practitioner is providing interventions within this scope then they are providing evidence based care. (eg physiotherapy, GP, chiropractic, osteopathy)
If someone is doing much beyond this list then they are playing in the land of woo.
Disciplinary boundaries are more to with historical power plays than any reflection of specific competencies on the part of the practitioners of that discipline. (eg dubious universities assigning the title of Doctor to chiropractors, and PhDs to graduates of online correspondence based on “previous life experience).
If you want rigorous evaluation go to PEDro and search for Cochrane reviews of physiotherapy treatments such as the ones below. Of course not all physiotherapy treatments are effective (just like any area of health care). That is the point of PEDro; to help people choose what to offer to patients.
Supervised exercise therapy versus home-based exercise therapy versus walking advice for intermittent claudication
Yoga for improving health-related quality of life, mental health and cancer-related symptoms in women diagnosed with breast cancer
https://blogs.bmj.com/bmjebmspotlight/2018/09/16/cochrane-a-sinking-ship/
So who do we trust????
Graded exercise NOT EVIDIDNCE BASED
CBT NOT PHYSIOTHERAPY SHAKE BAKE OR FAKE
Motivational interviewing (MI) NOT PHYSIOTHERAPY
Education (weak evidence and a bit vague I know – and possibly just a part of MI and CBT within PT scope of practice) ANYONE CAN DO THIS
OTC NSAIDs REALM OF PHARMACISTS AND SUPERMARKET CHECKOUT S.
Rapid referral for red flag or otherwise concerning physical or mental health symptom patterns YES
And why does the criticism of physiotherapy made by Richard Rawlins, an orthopaedic surgeon, escape unchallenged? The science base for surgery is thin, for orthopaedic surgery it is wafer thin.
It is hard to take you seriously Edzard.
and what has that to do with me?
@Chris Maher
You are parrotting a tired old trope that only proves you know practically nothing about surgery, orthopaedic or otherwise. Scientific approach to surgery is seldom possible using placebo controlled, blinded studies but there are other ways and means of scientific progress. Even in orthopaedics.
I fear you will not understand it but let me give you a small parable that describes how science is widely used in surgery. Think of parachutes. they used to be crude and ineffective, today they are well developed wonders.
No one wants to try parachutes in a blind study against placebo, right? That would be unethical and plain stupid. But you can develop and test variations if you go about it the right way and do the tests properly and with safety first. That is how we make progress in surgery even if it is difficult sometimes.
Björn…. an interesting recent review on the topic.
There is currently insufficient evidence to support the specific efficacy of invasive procedures for the treatment of chronic pain. Very few studies have been done on any one condition, treatments and pain measures differed, and outcomes were inconsistent between studies. Quantitative pooling of outcomes for seven studies on low back pain and three on knee osteoarthritis showed no difference in pain at six months compared with sham procedures. At least for back pain and knee pain, sham surgical procedures explain the majority of the benefit, with confidence in these estimates being strong.
https://academic.oup.com/painmedicine/advance-article/doi/10.1093/pm/pny154/5094687
What are you trying to say DC? This paper is neither interesting nor does it have any useful relevance to the subject.
There are other experts here that are much more familiar with reviews and meta-analyses. But I can see several potentially destructive problems with this. It mixes together trials on extremely differing subjects, mostly small, mean N=80
The problem areas are ridiculously heterogeneous:
The procedures studied were even more vaguely defined:
This included anything from plain old surgery, via partial meniscectomy to percutaneous lumbar facet denervation. And many more as can be seen e.g. in table 2A.
And they look only at sham control if I got that right.
This Potpourri they happily boil down to one (1) general conclusion. One wonders what the authors were thinking and why on earth this was published. Perhaps to stir controversy?
We already know that controlled evidence is scarce in many fields and we already know that some procedures like partial meniscectomy are already considered or proven worthless. Such procedures are generally eliminated from health care in most properly governed countries even if some go more slow than others because, among other reasons, in some countries you can continue to sell whatever that fills your pocket even if it demonstrably does not work.
This paper is not helping this process in any way other than perhaps demonstrate the need for proper audit and analyses.
Let me try to put this way.
This attempt at scientific hand-waving can be compared to taking a handfull of whatever lies on the ground in front of you and cooking soup on it. Even if there were some nice legumes or fruit in the mixture, their taste is spoiled by the weed and dirt, or is spoilt in the mix of unrelated ingredients. You need to pick your legumes, wash, define and sort them. Then you can make soup on each type separately or related species and see if they are worth the effort of soup making.
@Björn Geir
“You are parroting a tired old trope that only proves you know practically nothing about surgery, orthopaedic or otherwise. Scientific approach to surgery is seldom possible using placebo controlled, blinded studies but there are other ways and means of scientific progress. Even in orthopaedics.”
https://twitter.com/insightsbs/status/996284044953423872?lang=en
BTW Ian Harris and Rachelle Buckbinder in this video clip have co-authored articles with Chris Maher.
https://www.georgeinstitute.org/news/professor-chris-maher-named-one-of-worlds-top-two-back-pain-researchers
If you are going to attack one of the top back pain researchers in the world I recommend you do your homework first.
@ Bjorn
Also a tweet by Chris Maher about your reply above:
Chris Maher
Chris Maher
@CGMMaher
·
23h
The blog from @EdzardErnst is the gift that keeps giving. Today an orthopod runs the tired old parachute analogy to explain why placebo controlled surgical trials are not possible. Oblivious to trials that do exist including the CSAW trial in @TheLancet this year.
Interested to hear your reply to this tweet.
I offer no criticism of ethical physiotherapists who do their best to apply scientific methods and avoid camistry/woo/quackery.
I have always worked well with them.
@Richard Rawlins
And ethical chiropractors who do their best to apply scientific methods and avoid camistry/woo/quackery?
Are you prepared to support them as well?
And the researchers and reformers?
@ Bjorn
While you are replying to other posts, it would be nice of you could reply to mine.
What are your thoughts about this tweet from Chris Maher:
Chris Maher
Chris Maher
@CGMMaher
·
23h
The blog from @EdzardErnst is the gift that keeps giving. Today an orthopod runs the tired old parachute analogy to explain why placebo controlled surgical trials are not possible. Oblivious to trials that do exist including the CSAW trial in @TheLancet this year.
All the best,
@AN-other
Why Should I respond?
Neither am I an “orthopod” (lame use of a derogatory term for orthopedic surgeons, if you ask me), nor am I unfamiliar with the referred study of shoulder arthroscopies in Lancet. Nor am I impressed by the tweeter’s argumentation which seems to me to prove my point that he has a narrow perspective of surgery and surgical research and is obviously not referring to my own comment where I wrote “seldom”, a word that does not mean “never”.
Knee and shoulder arthroscopy are not cases upon which you can generalise about the knowlede base of surgery or on surgical research in general.
@CC
You refer to a tweet[sic] referring to a video[sic] about a very narrow and limited case of surgical practice. From that you expect me to admit inferiority to an undoubtedly eminent specialist in back pain who seems to have a rather shallow perspective on surgery and surgical research? You need to sharpen your argumentation 🙂
@ Bjorn
Thanks for the reply 🙂
@Chris Your claim illustrates the intellectual cul-de-sac that physio (and it is certainly in good company with other tribes) reiterates ad nauseum. If you were correct, then why is so hard to find high quality research that demonstrates effectiveness of the interventions that PT (and others) promotes? This is a lame duck claim.
Truth over tribe please.
When will Edzst start to point out the complete lack of evidence in many medical procedures. Moreover what is more important..an intellectual arguement or the very real fact that many of the invasive medical procedures do more harm than good. Look at the lives destroyed and people dying from.medicine. much if it with poor evidence base and corrupted by money. Such hypocrisy.
I dont need evidence to know massage is good for me. Nor massaging my feet..reflexology. nor postural awareness. And I could easily manufacture a trial to show its efficacy.
Love to see a post from.edzdt stating the numbers of people killed annually and historically from.medicine. the procedures and medicines that have been and are recalled or ineffective. The poor training in health issues like nutrition and exercise physiology. Let’s see it. You could write for years. Physio does little harm nor does chiro nir does massage. They all promote health..not reactively treating symptoms.
a truly idiotic argument!
1) learn to spell my name
2) realise that this is a blog about alternative medicine
3) realise that my expertise id in this area
4) realise that you are stating BS
Having lived in Australia, UK, France and the US – I see a lot of overlap between different skillsets and much confusion because the professional nomenclature varies so much.
In Australia, physiotherapists (and allied exercise physiologists) generally have a degree run in conjunction with a reputable medical school. However like pharmacists selling homeopathic treatments and candling services, individuals may choose to incorporate weird complementary practices into their treatments.
Hi Mike,
It’s Accredited Exercise Physiologist and, in the main, we stick to exercise as a treatment modality.
Simon, Exercises have a limited effect in the treatment of Low Back Pain according to the Lancet. Especially in the acute stage.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30489-6/fulltext?code=lancet-site
Why do you use a form of treatment that has been proven to be ineffective, i.e. Exercises?
In fact the shake, bake and fake of physiotherapy is based around unproven and ineffective forms of care. e.g. TENS, Shortwave diathermy, ultrasound.
I am calling out your post as misleading as I was an author on the Lancet paper you cite to support your post.
This blog would be far better if people read research papers closely, cited them accurately and left the politics to the side.
There seems to be some agenda here; but it does not seem to be the advancement of science.
and your comment would be far better if you had abstained from insinuation and extrapolation!
There is BS in physio like chiro.
There are also superb researchers and reformers like Chris Maher, Paul Hodges, Lorimer Moseley, Mark Hancock (All Australian), Jan Hartvigsen, Bruce Walker, Christine Goetz, David Cassidy, Scott Haldeman, Greg Kawchuk, Simon French, Alice Kongstead, Iben Axen etc etc etc.
Carpet bombing the physio’s like you do the chiro’s does not advance science FOR EITHER PROFESSION.
So let me say it yet again:
Step 1: Point out the BS.
Step 2: Support reform, the reformers, research and the researchers.
If you only do step one then you are the CARPET BOMBING critics.
“This blog would be far better if people read research papers closely, cited them accurately and left the politics to the side.
There seems to be some agenda here; but it does not seem to be the advancement of science.”
Didn’t take Chris Maher long to figure things out.
https://edzardernst.com/2017/08/are-critics-of-chiropractic-carpet-bombers/
@EE
In response to your post:
“Edzard on Friday 21 September 2018 at 07:21
https://edzardernst.com/2017/08/are-critics-of-chiropractic-carpet-bombers/”
“I have always thought highly of Charlotte’s work, however, her conclusion made me doubt whether my high opinion of her reasoning was justified.”
https://edzardernst.com/2017/04/we-have-an-ethical-legal-and-moral-duty-to-discourage-chiropractic-neck-manipulations/
And yet you have remained silent all these years until you could take issue with one blog.
So if you “have always thought highly of Charlotte’s work”
Why have you never supported her work?
Are the researchers acceptable collateral damage?
GibleyGibley. Funny name! Why the anonymity? Do you like to pick fights a lot on these sites? My post merely pointed out the correct nomenclature for AEP’s and commented on their scope of practice. I didn’t discuss the tx of lbp, acute or otherwise.
Simon, you wrote……”Hi Mike,
It’s Accredited Exercise Physiologist and, in the main, we stick to exercise as a treatment modality.”
I asked you why do you use a form of care, “exercise”, that has been proven to be ineffective?
I am not picking a fight, I am asking you to justify your rationale for treatment.
Anonymity because I, like many other people on this post prefer it. e.g. D.C., Blue Wode and the “Franks”
OK, GibleyGibley it is. I don’t need to justify exercise as a treatment for lbp because, at no stage, did I state that exercise is an effective treatment for lbp! You left this out of my response to your previous comment: “I didn’t discuss the tx of lbp, acute or otherwise.”
A little late but here is my response;
I didn’t make any comment about the use of exercise in the tx of LBP!
I suggest you read my comment again!
Since “treating away pain” is a delusion not a scientific endeavor it is and will continue to be fueled by wishful thinking and throwing shit against the wall to see what sticks.
If, as the authors of Biomechanics of back pain seem to show there are NO valid or reliable tests available to definitively diagnose “sprain/strains”, “trigger points”, “tight muscles”, “subluxation”, “facet syndrome” and only modest diagnostic prevalence in disc and SI joint involvement….all the ruminating, prevaricating and pretending to “really” know something about the internal workings of the body and it’s generation of pain is just a way of stealing money from the gullible and distressed. Resentful demoralization can be avoided and rudimentary “physiotherapy” should ideally be dispensed by MDs and their RNs in a medical setting whose methods are (generally speaking) within the purview of scientific-oversight. “Independent” practitioners whether DC or PT or Lac will always be prone to the greatest degrees of corruption and conniving. For these practitioners it is always about getting new victims and stringing them along indefinitely.
Hi Michael,
Are you still a physiotherapist?
Are you for or against physiotherapy?
Crickets.
@cc: you have iterated the same piffle for what seems years. Why haven’t YOU “reformed” YOUR profession? Could it be it can’t be?? The 8% of the populous that is ensnared seem to embrace the subluxation-dogma and it appears the most successful clinics are those pandering to them. “Reform”, if inclusive of the elimination of subluxation-dogma would spell disaster. The capacious number of PTs, fitness clubs and massage therapists is ample to make DCs doing their “reformed” bullshit superfluous.
So do you want “us” non-believers, those who know Chiropractic began as fraud, was developed as fraud and is now perpetuated as fraud…to “reform “it””?? Is that your charge?
Chiropractic IS entrepreneurial-theatrics masquerading as healthcare for 123 years. The ONLY reform, like having eaten a bad clam…. is elimination.
@MK
Still have not answered the question:
“Are you still a physiotherapist?
Are you for or against physiotherapy?”
Physiotherapy runs the risk of sliding into a conglomerate of unscientific methods. Fortunately, there is some resistance to this from one’s own circle. Recently I have been as well attacked as supported by physiotherapists in a somewhat heated discussion about a osteopathic-critical article. If the profession (I speak primarily for Germany) wants to maintain its good reputation, it must not succumb to the temptation of filling its portfolio with dazzling methods that attract uncritical audiences, but on the contrary strive for a good evidence base.
In Germany, there is the initiative “Physio meets Science” from the circle of physiotherapists, which is highly worthy of support and actively tries to do just that.
http://physiomeetsscience.com
Thanks for highlighting this issue in physiotherapy. There are many within the profession who are disappointed, to say the least, at the slow progress in moving physiotherapy forward.
The biopsychosocial model of health is the direction that evidence from pain science suggests the profession should be moving in.
https://bjsm.bmj.com/content/early/2018/07/17/bjsports-2018-099198
Unfortunately there are still many physios who continue to use the older treatment modalities which you list. Many of these do come from the world of alternative therapy. Old habits die hard in some clinicians…
are you sure it’s ‘old habits’
new physios are just as keen on woo, in my experience
New physios are keen on woo simply because the old woo that they have done has been proven not to work. Their normal “shake, bake and fake” is rubbish. Ultrasound doesn’t work, TENS doesn’t work, Wax baths, shortwave diathermy and exercises don’t work, Pilates exercises don’t work. So what is left? Nothing!!!!! They have to resort to methods of treatment that have evidence base, e.g. Spinal Manual Therapy.
So, how many physios does it take to change a light bulb?
None, because physios cannot change a thing.
GibleyGibley wrote: “they [physiotherapists] have to resort to methods of treatment that have evidence base, e.g. Spinal Manual Therapy”
@GibleyGibley (long-time chiropractic apologist)
In which case it appears that physiotherapists’ use of spinal manual therapy is (along with other providers) far more judicious than that of chiropractors. See Fig. 2 here:
https://academic.oup.com/ptj/article/79/1/50/2857770
This is likely the reason why:
Quote
“Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment.”
Ref: Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines, Edzard Ernst, Int J Clin Pract (18th August 2009).
Reference (11) is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62. Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and gives the reference Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.
I have excellent results from one set of visits to a physiologist. Of course this was a teaching clinic in a medical school where, I believe, the students would be receiving a 4-year degree. No woo there.
Then I walk down a nearby street and see a clinic offering physiotherapy, reflexology, acupuncture and so on and I shudder.
There still seems to be a lot of woo out there.
Good post Edzard. You picked a couple of fringe options that most physios have probably never been exposed to, let alone employed (Feldenkrais & craniosacral therapy spring to mind), and missed a couple of howlers that are still very common (electrophysical agents (sounds siencey, right??) such as ultrasound, laser, interferential & TENS – all don’t work for most if not all conditions studied), but the implication of your post holds true.
It’s good to shine a light on the physio profession. Often their best defence seems to be “at least we’re not chiros” which is a very low bar to clear. The profit motive, the need to compete with other allied health practitioners (such as chiros, osteos, etc) as well as indifference definitely drives a lot of the shonky practices employed.
If the regulatory boards such as the Chartered Society of Physios and Australian Physio Association started calling out clinics and therapists who used fake treatments, and eventually censured those who didn’t change, the profession would be in a vastly better position to cast aspersions at other healthcare professions.
All of the above being said, there have been huge advancements in the way healthcare is provided cheaply and effetively thanks to physiotherapists performing very difficult scientific studies. Pain management (google scholar search Lorimer Moseley), tendon treatment (google scholar search Jill Cook & Ebonie Rio) and orthopaedic procedure decision-making are three areas enormously improved thanks directly to physiotherapist scientists.
We are by no means perfect and have a lot of in-house cleaning to do, but established practice DOES change and we DO attempt to falsify the prevailing claims and practices of the profession. So the answer to your “WISHFUL THINKING OR TRUTH?” should be “It’s complicated.”
In regard to the professions, chiropractic and physiotherapy, this article may be of some interest. Especially the disquiet expressed amongst the physios as to their validity in treatment of a lot of conditions in comparison chiropractors.
https://chiro-trust.org/advanced/chiropractic-physical-therapy/
In terms of individual practitioners offering woo provides profits. Pure and simple.
In terms of the CSP they should be much more forthright in their condemnation of non evidence based treatments.
So since “leg checks”, “motion palpation”, x-ray analysis, AK, energy-imbalances, upper-cervical-misalignment, muscle imbalances AND EVERYTHING else used to determine the “target” for “manual-scamming” are all invalid, unreliable and spurious perhaps there could be agreement they are simply part of the entrepreneurial-trickery to ensnare the gullible into believing that there is “magic in my hands”. IF whackin ‘round on the gullible does offer some temporary quiescence of symptoms rationality would have us understand it as a “shallow” phenomenon not a mechanistically-profound one. A concept anathema to many PTs and virtually ALL DCs.
But somehow “manual therapy” stands as the bastion of respectability for treating-away-pain….since it seems to have one iota of efficacy vs. none. Profound indeed.
You pain-chasers are self-edifying, self aggrandizing entrepreneurs trying to play doctor….or god.
It always sounds like the Christians arguing with the Muslims about how absurd the others’ beliefs are. Idiots all.
@Michael Kenny YOU get the award on this blog piece. Absolutely agree. Ego-driven, sectarian, profit-obsessed thinking has corrupted health care professions, incl PT and DC. The argumentation style, I agree, is no different than religious zealots pointing fingers at those who do not share in the cult.
Edzard,
If you are going to go after Physio minded practitioners, you need to get down to it, the osteopractors.
https://spinalmanipulation.org/
I have done this many times on this blog and elsewhere
“Edzard on Saturday 15 September 2018 at 06:23
I have done this many times on this blog and elsewhere”
~~~~~~~~~~~~~~~
Please/Can you provide a link per your claim?
2 different links were provided; you just need to click on the respective words
@EE
“I have done this many times on this blog and elsewhere”
Click on the Category “Physiotherapists”.
4 pages and this blog is the first with Physiotherapy” in the title.
Zero hits for osteopractor, osteopractic or James Dunning.
Dry Needling gets 4 hits yet none are posted in or tagged physiotherapists.
You have done many SR’s on acupuncture with some having dry needling in the key words going through Pubmed.
Are they are in comments sections where we cite osteopractors? Links?
Dry needling and Myotherapy seem to be popular infestations of physiotherapy here in Australia. My wife left a physio practice because they started offering dry needling.
On the other hand good physiotherapy has taught me how to self-manage cobditions, including one that cost me over a year’s work and threatened my career 30 years ago.
Likewise good physiotherapy diagnosed a very painful condition I had a few weeks ago, taught me how to sooth it so I could cope and sleep, and helped again when I hurt another muscle doing an exercise wrongly.
I think good physiotherapy enables patients to treat themselves and not have to keep coming back.
I don’t know about the evidence base for standard physio or how good most physiotherapists are at handling new research results in a scientific way.
I suggested “academic physiotherapy today is strongly science based” or something similar recently in these forums.
I’d still support this statement.
I would also support Edzard’s statement that much of what many PTs actually do in the field is crap. This includes pilates, needling, spinal manipulation and all other assocated hussles. PT crap is as bad as chiropractic and osteopathic crap.
At this point, I think science based PT is basically a behavioual discipline. That is, the interventions that demostrably work are focused on explaining the mainstream science of musculoskeletal probems, CBT and motivational interviewing, exercise prescription and adherence. Equally, if others such as chiropractors are moving beyond this list, they too are selling 100% pure bulshit.
Personally, I spend much of my time explaing how individuals can navigate the health system at lowest cost, how health systems work, how health economics works, hierarchies of evidence, information asymmetry and plain old financial conflicts of inteterest in the health industry within the broad scope of PT practice. I routinely sit and explain peer reviewed evidence to patients.. It seems to be what many people actually want in a clinical setting. It comes under the rubric of PT patient education.
Health economics and science provide a rationale for ditching the bullshit. And Im personally much more comfortable with economics and evidence hierarchies as placebo talk.
In summary, teaching exercises is simple, and generally lots of different exercises are just fine. Encouraging self efficacy and adherence through 2-3 longish sessions over as many weeks seems to be about as much input as most people need.
My 2c.
In recent years, more and more physical therapists have started to embrace pain science and the biopsychosocial model.
In the process of adopting this mindset, rather than hold themselves accountable for all that they haven’t been able to offer patients, the biopsychosocial model has provided them with information that places more of an emphasis on the patient’s history and overall makeup. So for all of the good stuff that’s within the biopsychosocial model, physical therapists are still working within the confines of a certain business model that doesn’t allow for the highest tier of service (or the best possible results).
Needless to say, physical therapists are using the biopsychosocial model as a smokescreen. By placing more importance on the biopsychosocial model, physical therapists have found a workaround that doesn’t allow for the bigger problems to be addressed. This allows for comfort, and of course, business as usual.
As important as physical therapists pretend to be, in most clinics, the treatments are addressing symptoms and chasing pain. So of course, treatment takes much longer than it should.
As broken as a physical therapist’s methodologies are, and have been for decades, longer treatment aligns with a business model that they’ve chosen to work within.
Even if physical therapists had the knowledge, skill, and experience to get to the root cause in the shortest amount of time, it’s not humanly possible to provide the best possible service to multiple patients in the same space of time.
When physical therapists throw a bunch of ridiculous stuff at something, given enough time, some of it is bound to stick.
Dragging the treatment out just gives the brain more time to figure out how to find stability in positions that are less than optimal (i.e., protection).
While physical therapists are busy pretending to do work that’s allowing for the best possible outcome, the part of the story that’s being left out is that patients aren’t capable of performing better than they were prior to the pain or injury.
Since most patients don’t know what they don’t know, this practice isn’t likely to change any time in the near future.
So what would you suggest in place of a course of care with a PT?
Chiropractic is a business model built on repeat visits if I have ever seen one AND they tend to offer many of the same modalities as well as supplements that are not necessarily science-based.
Add to that, they often offer VERY expensive diet/nutrition programs that are also not well-founded…
the only reasonable option is to use reason… in other words EBM!!!
AGREED!
The problem is quite simple, “Physiotherapy, especially the overuse of exercises is not evidence based”.
But at least your ‘innate intellegence’ will have been ‘adjusted’.
Beth, if one looks at the research one finds that the average number of chiropractic treatments per episode is around 4-6 treatments…depending on the study and condition being addressed.
So if you mean that when people have a “repeat” spine issue they go back to their chiropractor, yah, that holds true for other health professions and disciplines as well.
Yep. Agree 100%.
It’s primarily a business model problem. I came back to PT on a very part time basis about 2 years ago after many years of project management, consulting and executive roles mainly for large health ngos.
I now mainly work as an academic teaching at medical schools after doing a non PT PhD..
I like having some patient contact to “keep it real” from an academic perspective.
I dont rely on PT for income. Which is very liberating business model wise.
As i mentioned in my earlier post – i think at its best, contemporary PT is a no bullshit talking cure that can facilitate self efficacy. Further, PT has the distinct benefit of framing problems as physical, thereby removing much of the stigma of approaching pain and disability as emotional or mental health problems. PT opens the door to these discussions and appropriate mainstream referral.
Another advantage of PTs is generally longer appointment times than GPs. It really is possible to cram a lot of useful advice and motivation in 45 minutes or an hour. But 2-3 sessions in total of this, with more often than not some OTC NSAIDs over as many weeks is usually all the face to face PT that most people need.
Richard, with all due respect, I think you have no idea what Physiotherapy is.
This is exposed by the therapies that you tried to link to Physiotherapy.
For Christ Sake, you said Applied Kinesiology is Physiotherapy. Are you crazy? The same goes to Reflexology… Christ.
The Physiotherapists are the main critiques of Kinesiotape. Have you read the systematic reviews, made by (brazilian) Physiotherapists? Have you seen the results?
Please, it might suit your personal marketing, but you shouldnt bash Physiotherapy for what it is not.
Physiotherapy is an applied science.
Go check PEDro database and find some useful MA , SR and RCTs.
Cheers,
Claudio
For back pain this is an accessible place to start – it largely replicates the themes in this blog IMHO.
Cathryn Jakobson Ramin, “Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery”. Here is a brief review.
https://nypost.com/2017/06/28/the-back-pain-industry-is-full-of-crooked-methods-book-claims/
Ramin doesn’t much like chiropractors. Nor most PTs. Nor surgeons. Nor oxycontin prescribing physicians.
Edzard – any thoughts on Ramin’s book? I assume you’ re aware of it.
Critical_Chiro wrote on Friday 21 September 2018 at 01:47 : “There are also superb researchers and reformers like Chris Maher, Paul Hodges, Lorimer Moseley, Mark Hancock (All Australian), Jan Hartvigsen, Bruce Walker, Christine Goetz, David Cassidy…
@ Critical_Chiro
Not everyone would agree with you there. For example, Jan Hartvigsen, in a recent slide presentation, appeared to make no mention of the chiropractic bait and switch (the majority of chiropractors are not evidence-based) or risks:
https://rcc-uk.org/wp-content/uploads/2018/06/Jan-Hartvigsen_Royal-College-of-Chiropractors.pdf
Christine Goetz was lead author of this recent appalling paper
https://edzardernst.com/2018/05/new-back-pain-study-support-for-the-inclusion-of-chiropractic-care-as-a-component-of-multidisciplinary-health-care-for-low-back-pain/
and David Cassidy, as you should know by now, is not to be trusted…
https://edzardernst.com/2018/08/until-the-precise-risks-from-chiropractic-manipulation-are-known-patients-are-better-served-by-other-treatments/#comment-105139
As explained before re the JAMA military study, the design of the study was set by the government based upon how chiropractic is currently being used within the armed forces.
@DC
I haven’t seen your previous explanation (please provide a link). From the paper itself (Supplement 1, trial protocol): “Responsibility for the conduct of the clinical trial described in this protocol is placed on the Palmer College of Chiropractic, in collaboration with RAND Corporation, the parent institution, and the Samueli Institute (SIIB). Please see the organizational chart in Figure 4.”
Figure 4 (this blog doesn’t permit insertion of graphics) shows the ‘External Advisory Committee’ is the topmost-ranking overseer of the trial. The supplement provides the following details: “The EAC is comprised of six individuals who have all agreed to sit on the Board. These individuals represent leaders in either the research community in LBP, the chiropractic research community or in the military. They include the following individuals: Anthony J Lisi, DC, National Director Chiropractic Services, Department of Veteran Affairs; Valerie Johnson, DC, Staff Chiropractor, VAGLA, Department of Veteran Affairs; Dan Cherkin, PhD, Senior Scientific Investigator, Group Health Research Institute; Marion McGregor, DC, FCCS(C), PhD, Canadian Memorial Chiropractic College; Scott Haldeman, DC, MD, PhD, Clinical Professor Neurology, UC Irvine; Reed Phillips, DC, PhD, NCMIC Foundation.”
Will you kindly explain which of these individuals represents ‘the government’? Does he or she come from the legislative, executive, or judicial branch? You see, it seems to me to be a most unusual circumstance where — even when the military is involved — a national government ever takes a direct interest in the detailed conduct of a clinical trial, particularly when they’re not even funding it, directly or indirectly. The paper explicitly states the funding came from the RAND Corporation, which certainly receives money from the US government, but also from many other sources.
At the moment your comment seems to be based on extremely economical use of the truth.
This trial was funded by Department of Defense Office of Congressionally Directed Medical Research Programs, Defense Health Program Chiropractic Clinical Trial Award (W81XWH-11-2-0107).
Yes, but that doesn’t mean the design of the study was in any way set by the government!! Do you chiropractors have no idea how research grants work? The (pragmatic) design of the study will have been set by the investigators and contained in their grant application. They’ll have submitted a proposal which was accepted for funding, but once granted, it was all in their hands. Which government official do you imagine oversaw the research?!
The publication tells us precisely who handled the trial. I’m making no comment about the quality of the research — others have already done that. Just that when you say “the design of the study was set by the government” you’re talking horse manure. It’s very sad if you can’t see that, and that you’re trying — absurdly — to invoke the highest possible supporting authority for this trial, in an attempt to elevate its status.
Several meetings took place with the involved parties before the application was even submitted. No, i dont have access to those notes, I’ve only had conversations with several of the lead investigators.
But sure, the researchers elected not to include shams in this part of the study even though they did in ACT 3 (asymptomatics) because they just didn’t know better.
Or, could it be that we are in the midst of a freaking war and the DoD didnt want us doing a sham procedure on symptomatic active military personnel? Nah.
All this shows is how low some people will go to try and discredit a profession which is trying to help with the some of the highest disability burdens we face.
Sad.
“Because chiropractic care for LBP in the military is delivered within a multidisciplinary framework of care, rather than as a single system of care, the study is focused on the comparative effectiveness of chiropractic care plus usual medical care with usual medical care alone, in a pragmatic design.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4746780/#!po=9.05797
Sorry, DC, your attempts to add authority to what has already been described as a lousy study by claiming the study design was “set by the government” is simply not working.
The trial was funded by the RAND Corporation, to whom the principal investigator(s) will have submitted a grant application. Even the W81XWH-11-2-0107 document states “The views, opinions and/or findings contained in this report are those of the author(s) and
should not be construed as an official Department of the Army position, policy or decision
unless so designated by other documentation.” Please try to get a feel for how research gets funded.
So it wasn’t funded by the DoD even though they say it was funded by the DoD?
“This trial was funded by the Department of Defense Office of Congressionally Directed Medical Research Programs, Defense Health Program Chiropractic Clinical Trial Award (W81XWH-11-2-0107).”
https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-016-1580-1
@BW
Citing blogs again Blue?
Time to cite research.
R.E. David Cassidy. Have you read up on that case in 1999 or are you citing blogs on that as well?
Have you bothered to read up on all his research, where he currently works, where he has worked, world leading researchers from many professions he has and is collaborating with etc etc etc???
https://www.researchgate.net/profile/J_David_Cassidy
R.E. Jan Hartvigsen. Have you bothered to read his research?
https://www.researchgate.net/profile/Jan_Hartvigsen
You are aware that he was recently ranked one of the top musculoskeletal pain researchers in the world?
http://nikkb.com/research/jan-hartvigsen-is-the-world-s-leading-expert-in-musculoskeletal-pain
R.E Christine Goertz. Have you bothered to read her research? Who she has collaborated with? What may have recently happened to her professionally for supporting the Choosing Wisely campaign?
https://www.researchgate.net/profile/Christine_Goertz
Chris Maher was right. When you post “it does not seem to be the advancement of science.”
You attack the character of the scientists and cite blogs instead of discussing their research.
Critical_Chiro wrote: “@BW R.E. David Cassidy. Have you read up on that case in 1999…Have you bothered to read up on all his research, where he currently works, where he has worked, world leading researchers from many professions he has and is collaborating with…???”
@ Critical_Chiro
Yes.
David Cassidy was sued for asking an employee to manipulate the stats in a paper to produce the results he wanted http://www.chirosmart.net/nfaures.txt
QUOTE
“in or about September 1998, and contrary to all normal and appropriate practices and procedures in regards to independent medical research, she was instructed by Cassidy to produce certain statistical results that would support the end conclusion desired. Specifically . . . Cassidy instructed her to produce results and graphs that would support the conclusion that an injured person’s time (date) of settlement is a good proxy for the person’s time (date) of recovery” (Statement of Claim, In the Court of Queen’s Bench for Saskatchewan, Judicial Centre of Saskatoon, between Dr. Emma Bartfay, plaintiff, and The University of Saskatchewan and Dr. J. David Cassidy, Defendants. Filed May 21, 1999, Q.B. #1679 of 1999).”
The insurance company that paid for the study to be performed allegedly attempted to influence the study as well. “Yong-Hing alleged that SGI‚ the province’s only motor vehicle injury insurer, which funded the study‚ wanted its contributions to pay for certain study expenses in a way that “could well be interpreted as an attempt by SGI to disguise the destination of Saskatchewan residents’ money” (Letter from Dr. Ken Yong-Hing, Professor and Head of Orthopedic Surgery, University of Saskatchewan, to Colin Clackson, President, Saskatchewan Trial Lawyers Association (Nov. 3, 1996) (on file with author).”
Ref: http://scienceblogs.com/insolence/2009/02/04/the-most-ridiculous-kerfuffle-ever/#comment-55817
And here’s an analysis of some of Cassidy’s flawed reasoning regarding his research (credit – Björn Geir Leifsson, MD):
QUOTE:
“In a hearing before the Connecticut State Board of Chiropractic Examiners Cassidy admitted upon a direct question, that a patient of his suffered stroke after spinal manipulation. He was asked whether he considered the manipulation to have caused the stroke. His reply was to the effect that he did think so at first but after researching the matter he no longer did.
This fact does cast a different light on the whole matter and should be kept in mind when considering his choice of study subjects, designs and conclusions and when evaluating his results against other researcher’s findings. I certainly find it easier to understand some rather peculiar aspects of his study designs and deductive reasoning.
I would not blame any therapist or clinician who has faced such a terrible adverse outcome in someone who placed their trust in his hands, if they looked for and tried to find support for the notion that they or their vocation were not to blame.
David Cassidy has certainly pursued the question with ardour and an admirable academic arsenal, but has the incident, which must have been tormenting, affected his work and his deductive reasoning? I am inclined to suspect it did.”
Ref: https://edzardernst.com/2017/02/upper-neck-manipulations-by-chiropractors-regularly-cause-serious-harm-why-is-it-still-used/#comment-86862
and
QUOTE
“Cassidy 2008 and other similar attempts at estimating away the risk of CAD after SMT has been reevaluated in later work and the mistakes analysed. Here is an excerpt from “Case Misclassification in Studies of Spinal Manipulation and Arterial Dissection” Xuemei Cai, MD, Ali Razmara, MD, PhD, Jessica K. Paulus, ScD, Karen Switkowski, MS, MPH, Pari J. Fariborz, Sergey D. Goryachev, MS, Leonard D’Avolio, MS, PhD, Edward Feldmann, MD, David E. Thaler, MD, PhD DOI: http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.03.007
The earlier studies omitted the dissection-specific codes (443.xx) in their case definition because they were not in use in Ontario at the time (personal communication, Navin Goocool, April 30, 2013). The population in our study did have these codes available, and therefore, to avoid an overestimation of case misclassification, we included the 3 additional dissection codes in our initial EMR query (‘‘modified Rothwell/Cassidy strategy’’).
Cassidy et al [2008] suggested that the association between cases and PCP/SMT exposure was because of patients with pre-existing dissections seeking care for neck pain (reverse causation). However, if the ICD-9 code positive predictive value measured in the VA database is generalizable to the Ontario health system data, then the Cassidy study actually found an association between PCP visits and patients with conventional strokes due to atherosclerotic and cardioembolic mechanisms. This association is well known and has been described before. It is because of the frequent clinical
visits needed to manage established vascular risk factors.10 Our sensitivity analysis suggests that the ORs for the association between SMT and CAD would be very large with accurately identified cases. Lastly, the misclassification may disproportionately affect ORs for those less than 45 years of age—a group of patients with a lower prevalence of atherosclerosis-related infarcts and a higher prevalence of strokes due to dissections.16 Given the small numbers of true cases, ORs within age strata could not be calculated, but our sensitivity analysis suggests the association between SMT and CAD in younger patients is markedly stronger after adjusting for case misclassification
And what do they mean by “large” ? Among the subgroup of the population less than 45 years of age and applying the above assumptions, those with a chiropractor visit within 30 days of their stroke would have nearly 7 times the odds of CAD (OR 5 6.91, 95% CI 2.59-13.74).
That means that the risk is most likely about seven fold and there is 95% chance that the true odds ratio is about between 2,6 to 13.7. That is nothing less than horrendous if correct.”
Ref: https://edzardernst.com/2017/02/upper-neck-manipulations-by-chiropractors-regularly-cause-serious-harm-why-is-it-still-used/#comment-86782
Also note that Cassidy has reported financial links with the Canadian Chiropractic Protection Association, the Ontario Chiropractic Association, the National Chiropractic Malpractice Insurance Company, and the (subluxation-based) International Chiropractic Association:
https://www.medpagetoday.com/PainManagement/BackPain/33142
Critical_Chiro wrote: “R.E. Jan Hartvigsen. Have you bothered to read his research?”
Yes.
Critical_Chiro wrote: “You are aware that he was recently ranked one of the top musculoskeletal pain researchers in the world?”
Yes, but that still doesn’t exonerate him from failing to factor in proper risk/benefit assessments in his promotion of the recent Lancet low back pain papers, one of which he co-authored:
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/
FYI, he blocked me on Twitter when I pointed out to him that he’d been remiss in that area.
Critical_Chiro wrote: “R.E Christine Goertz. Have you bothered to read her research? Who she has collaborated with? What may have recently happened to her professionally for supporting the Choosing Wisely campaign?”
Yes, I have bothered to read her research. For example, she was lead author of a recent appalling paper which was critically analysed here: https://edzardernst.com/2018/05/new-back-pain-study-support-for-the-inclusion-of-chiropractic-care-as-a-component-of-multidisciplinary-health-care-for-low-back-pain/
As for the Choosing Wisely campaign, this is Goertz writing about it…
https://www.acatoday.org/News-Publications/ACA-Blogs/ArtMID/6925/ArticleID/384/Choosing-Wisely-Separating-Facts-from-Fears
…and here’s why numerous chiropractic groups have rejected it:
http://chiropractic.prosepoint.net/158379
but Science Based Medicine’s summation of it is probably best:
“All that the ACA has done is provide a list of redundant or unnecessary recommendations”
Ref: https://sciencebasedmedicine.org/the-american-chiropractic-association-answers-crislips-call-joins-the-choosing-wisely-campaign/
For those interested in the Cassidy case above, it proceeded thus:
http://desantis.hypermart.net/EnsignStories_201-300/Ensign_story204/story204.htm
And ultimately…
“…on June 30, 2000, Dr. Barry McLennan, assistant dean of research in the college of medicine at the University of Saskatchewan, was writing in the StarPhoenix that a university committee “concluded there was absolutely no evidence of research misconduct.” Dr. McLennan also absolutely defended Dr. Cassidy’s study when employee Dr. Emma Bartfay, in filing a lawsuit against Dr. Cassidy and the University of Saskatchewan, was stating that she was told to produce statistical results that would prove that whiplash victims recovered faster under the province’s new no-fault system. Some weeks ago we learned that Dr. Bartfay agreed to drop her case against Dr. Cassidy and the University of Saskatchewan and that in return she was going to receive an undisclosed amount of money. This is the way public justice is brokered by the confidentiality of the private contract.
Ref: http://desantis.hypermart.net/EnsignStories_801-913/Ensign_story805/story805.htm
But it remains that:
“The study does not prove what it claims to prove. The exhibited bias and flawed methodology show that under a rigid no-fault scheme that mandates a single treatment regime within an artificial time frame, the duration of open insurance claims is shorter than under a traditional tort system.”
Ref: https://www.casd.org/index.cfm?pg=No%20Fault%20NEJM
BW wrote…”and here’s why numerous chiropractic groups have rejected it:
http://chiropractic.prosepoint.net/158379”
Using McCoy ramblings? The fact that that group rejects it is an indication that it’s good for the profession.
have you heard this sentence before: “THEY WOULD SAY THAT WOULDN’T THEY?”
https://edzardernst.com/2013/02/they-would-say-that-wouldnt-they/
Yes, they would say that.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024283/
@BW
R.E. David Cassidy.
Keep digging Blue and you will find that the large insurance company that funded that research threatened and coerced not only the researcher(s) involved but also the subjects participating in that study.
Finally you cite a paper here:
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.03.007
Bravo. Now you are aware that the authors wrote a letter to the editor in reply?
See here:
http://sci-hub.tw/10.1016/j.jstrokecerebrovasdis.2014.11.034
“David Cassidy, as you should know by now, is not to be trusted…”
Instead of attacking the character of the researcher have you tried writing a letter to the editor?
R.E. Jan Hartvigsen
“Yes, but that still doesn’t exonerate him from failing to factor in proper risk/benefit assessments in his promotion of the recent Lancet low back pain papers, one of which he co-authored”.
The Lancet series is a CALL TO ARMS FOR ALL PROFESSIONS written by leading researchers from ALL THE PROFESSIONS. Would you care to attack the character of those other researchers?
Are you aware of just how big a deal the Lancet Back Pain Series is and its future impact on all professions who treat back pain?
“FYI, he blocked me on Twitter when I pointed out to him that he’d been remiss in that area.”
Try writing a letter to the editor. Just make sure that is is well referenced with research papers and not links to blogs otherwise it will probably not be published.
If your letter is published then I am sure he will reply and science will move forward.
R.E. Christine Goertz.
You cite Matthew McCoy and McCoy Press. Face Palm.
That is like citing Burzinski in the USA and calling it recommended cancer treatment. Facepalm.
Choosing Wisely is very important and the key points are reklevant to ALL professions participating:
1. In the absence of red flags, do not obtain spinal imaging (X-rays) for patients with acute low-back pain during the six weeks after the onset of pain.
2. Do not perform repeat spinal imaging to monitor patients’ progress.
3. Avoid prolonged or ongoing use of passive or palliative physical therapy treatments for low-back pain unless they support the goal(s) of an active treatment plan.
4. Do not provide long-term pain management without psychosocial screening or assessment for possible related psychological disorders, most notably depression and anxiety.
5. Do not prescribe lumbar supports or braces for the long-term treatment or prevention of low-back pain.
I recommend you become current with recent research. This paper is a good start:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097773/?tool=pmcentrez
“redundant or unnecessary recommendations”
Time to read and cite the research accurately Blue and not blogs with agenda’s.
Its about time you supported the researchers and reformers.
They are NOT acceptable collateral damage.
@CC &DC
No one is attacking Mr. Cassidy’s character. He is undoubtedly an honest and hard working man. By conducting research and publishing his results and his interpretation of them, he is obliged to accept and defend the possible sources of bias and motivated reasoning involved in the design, conduct and analysis of his work. He has chosen to conduct research on a very serious type of adverse event and his inference from it has been heavily criticised. Therefore itis absolutely indicated and expected that factors which may be serious confounders behind this are explored and discussed. That is not attacking the man’s character and does not constitute an ad-hominem fallacy.
As to BW’s references to blog posts, I have not read all his comments but those that I have seen are fully adequate. He refers to posts that contain supportive references AND a relevant analysis in each case.
Please keep to the point and stop nitpicking and building strawmen
Björn…”He has chosen to conduct research on a very serious type of adverse event…”
I don’t think it’s been established that this is an actual adverse event…at least in all the cases were it’s been reported to be.
The term adverse event does not imply causation. Your reply describes exactly the apparently desperate avoidance of liability typical for most chiropractors.
VAD is a very serious event with extreme consequences if it leads to stroke. No one knows how many VAD’s heal without anyone becoming aware of it.
When a VAD-stroke occurs after any kind of intervention, it is by definition an adverse event connected to that intervention, causality notwithstanding. If I do a surgery and the patient gets, say a DVT shortly after, then it is an adverse event if it can in any way be suspected to have a causal relationship to the surgery (the intervention). The patient might have gotten a DVT anyway, but it is a consequence of the intervention if a causal relationship is possible.
This is the case with neck manipulation and VAD/stroke. The causal mechanism is there for all to see and the cases are there for anyone to see, even if they are RELATIVELY few in relation to the common intervention of neck manipulation.
One death or one locked in syndrome is enough, if it can be prevented and especially if the risk/benefit ratio is high as it is in this matter. In cases where neck manipulation precedes a stroke, there is a clear possibility that the manipulation may have caused the stroke by affecting the cervical vessels, in particular the vertebral arteries that are stretched by a rotating movement. The event (stroke) may be delayed by days so many cases may go unnoticed.
The problem here is that chiro’s are head over heals trying to cast doubt on the very possible causality. Cassidy may be conducting his research using the null hypothesis backwards, trying to find support for it rather than trying to falsify it.
Instead of considering the rare but extremely severe adverse event and advising against neck manipulations they constantly try to find excuses for denying it. They should at least realize that the common argument that is often brought fort, that a preexisting VAD explains (most?) cases of stroke after manipulation for neck pain is seriously wrong and counterproductive. It should instead be a rule NOT to touch the neck of someone with the remotest possibility of a preexisting/latent VAD because it might disrupt a plaque and cause stroke, which can as I have said, be delayed in relation to the intervention. A plaque can start to dislodge and the stroke happen later. Then the victim might be at home and not be in a position to tell about the recent manipulation, or even not live to tell.
And talking of chiropractors and liability…
https://www.seekingjustice.com/dc-injury-lawyer/chiropractic-malpractice/chiropractic-strokes/
Björn….I injected the word actual for that purpose….clarification.
If I was so inclined I could share dozens if not more posts I’ve made over the years asking for more research on this topic. Don’t assume I have a “desperate avoidance of liability”.
As far as the “in particular the vertebral arteries that are stretched by a rotating movement.“
“When the atlanto-axial joint is fully rotated the additional length is less than 0.4 units or about 8 millimeters in an artery that is about 10 to 12 centimeters from the C6 transverse process to the basilar artery.“. http://www.geometricalanatomy.com/CervicalSpine/Vertebral%20Artery%20Strain.doc
From my involvement in clinical trials, I can tell you that if a subject catches a cold, or stubs their toe on a rock, or walks into a door and bangs their nose, then this is recorded as an adverse event.
@Björn Geir
“No one is attacking Mr. Cassidy’s character.”
Blue Wode wrote:
“and David Cassidy, as you should know by now, is not to be trusted…”
Classic Ad Hom.
Blogs by their very nature are echo chambers. They are far from being peer reviewed and reflect the bias of the blogger.
The Charlotte Leboeuf-Yde blog is a good example. I have been citing her work on this blog for years to zero comments. Then Edzard takes issue with one line published in a blog and he does a hatchet blog. If he is aware of her research in the past:
“I have always thought highly of Charlotte’s work” (Edzard Ernst).
Then why has he never supported it especially as a lot of her early research has been on adverse events?
I have said this in the past here that much of what the regulars here criticize in within chiropractic mirrors OUR criticism.
Reform needs critics both within and without the profession. They are a precious resource.
But when external critics look on ALL chiropractors as being vitalists and card carrying members of the high church of DD and BJ and fail to make the distinction then they are tearing down Jan Hartvigsen, David Cassidy, Charlotte Lebouuf-Yde, Kim Humphries, Bruce Walker, Scott Haldeman etc etc. These are the internal critics, the researchers, educators, leaders and reformers.
This is why I am so polite and patient on this blog and often have to pause and take a deep breath before replying. The sweeping statements, generalizations and carpet bombing has to stop.
Should you stop criticizing chiropractic? NO. But you need to be more TARGETED and BALANCE it with support for the researchers and reformers within the profession.
The regulars reading this will then rightly reply that it is “not our job to reform chiropractic”.
To which I reply that taking out the researchers and reformers is counterpraductive.
If critics have an issue with a research paper then write a letter to the editor and start a conversation. That advances science.
“The problem here is that chiro’s are head over heals trying to cast doubt on the very possible causality. Cassidy may be conducting his research using the null hypothesis backwards, trying to find support for it rather than trying to falsify it.”
Actually chiropractors are having identical arguments/debates on association v causation, regression to the mean, informed consent and precautionary principle as those on this blog and other sites.
We taer into chiropractors who
Correct me if I am wrong Edzard, but did you not write a paper years ago discussing rare serious chiropractic adverse events and the type of study that would need to be done which David Cassidy, Peirre Cote and Scott Haldeman subsequently did doing a retrospective case controlled study mining big data from Canada.
This is whats is so frustrating.
Carpet bombing the chiro’s and physio’s for that matter needs to stop.
“And talking of chiropractors and liability…”
A surgeon who I discussed these topics with once said to me:
“In medicine we bury our mistakes”.
He meant both meanings.
Your rather erratic response is confirming my point, I think. To carry your own analogy further, carpet bombing is an extreme measure that I believe is used in warfare when other measures fail. If you feel that the barage of criticism we are trying to lay down can be likened to “carpet bombing”, then so be it. Chiropractors need to stop wringing the necks of unsuspecting customers to the extremes, particularly those with symptoms from the area that might signify a preexisting dissection. They need to warn others (neck wringing is very common showmanship by gym instructor’s and the like) not to apply such manipulations and they need to realise that neck manipulation is essentially a useless theatrical act with very doubtful benefit against a terrible albeit rare risk of death or destruction to the victims.
As to your politeness I value it as far as it extends. Carrying on a discussion with someone who hides behind a pseudonym and throws silly joke innuendos and lame accusations of ad hominem behaviour at me, places an untoward strain on my respect.
‘carpet bombing’ as a term to describe any type of criticism is intensely stupid, if you ask me.
@DC
Your reference to an unpublished wordy manuscript that seems to be trying to calculate away the risk of stretching the vertebral arteries by rotation, rather proves my point, don’t you think?
If I am not mistaken, in the citation you have chosen for your argument, “fully rotated” applies to rotation within and not extending beyond the range of normal unforced rotation.
That is not the same as the obvious risk of “HVLA” manipulation being (inadvertently) carried beyond the normal rotational range, a forced movement that is thought to be the causative factor behind cases of chiropractic stroke.
Björn…the last paper I read on the topic stated that, at least in the mid to lower cervical spine, the facet gap during manipulation is 0.9 ± 0.40mm. Increase in the Range of motion post manipulation is between 1.1° and 3.9° dependent on the direction of motion and level measured.
Several studies have looked at the forces required to cause damage to the VA, particularly in reference to MVA. The forces required far exceed those calculated to occur from a properly performed HVLA manipulation.
The area that is typically targeted has a decrease in range of motion thus, although I haven’t seen a study on it, it would be logically to think that the vertebral artery is not stretched to its average of 8 mm in such cases…nor would it significantly exceed the 8 mm, with a properly applied cervical manipulation, to the point of inducing a VAD.
It would be good to study the vertebral artery during HVLA, although there are already several that looking at the VA during maximimal rotation, etc. It would be good to do more studies on possible HVLA induced rebleeds (although rebleeds appear to be a common risk even without HVLA).
Are there subpopulations that are at greater risk? Of course.
Is there a need for more research on AE? Of course.
Is there a need for more research on potential benefits? Of course.
Is it feasible to get three professions to halt all cervical manipulation with the current evidence? Of course not.
But we have been thru this before. Have a good day.
@DC
“Rebleeds”? What on earth are you on about? Are you thinking about something entirely different?
I also thought I just pointed out that it is silly to try to calculate or measure away the obvious risk of stretching the VAD. A you write yourself , there is a good probability that there may be predisposing individual factors that annulate any guesswork of this sort.
Let me repeat myself: The consequences of VAD-stroke are so severe that even an extremely rare risk factor is important. When there is little to no benefit associated then it is impossible to defend the practice. Chiropractors hide behind their wallets and see the benefit of stuffing them greater than the security of their customers. That is the problem.
This exchange is getting silly.
Originally, DC wrote
.
Which struck me as strange, because I never yet heard of any clinical study design being set by a government. And when I looked into the detail, sure enough the design was NOT set by any government (or government department). I named the members of the External Advisory Committee who were responsible for oversight of the trial and therefore, by implication, of the trial design.
But now DC has changed horses in mid-stream. Instead of the ‘JAMA military study’ (Goertz et al. (2018), JAMA Network Open. 2018;1(1):e180105. doi:10.1001/jamanetworkopen.2018.0105), which was the one cited by Blue Wode and critiqued by Edzard in a post on this blog, and — like I already said — funded by the RAND Corporation, he’s switched to an entirely different study: De Vocht et al. (2016), Trials201617:457, https://doi.org/10.1186/s13063-016-1580-1. This was indeed funded directly by the Department of Defense but it has nothing to do with chiropractic relief of back pain. It doesn’t even have Ian Coulter, the senior author of the JAMA paper, among its authors!!
There are paragraphs within the 2016 study that are relevant to the current discussion, including “Grants administration is managed by the RAND Corporation including the financial aspects and Institutional Review Board (IRB) issues of the grant award. It also ensures that the program officer at the DoD receives the required deliverables. The Samueli Institute ensures that the study complies with those entities that regulate the conduct of human subjects’ clinical research within the DoD, which include the U.S. Army Medical Research and Material Command Human Research Protection Office and the Army’s Clinical Investigation Regulatory Office. The Samueli Institute also provides advice concerning the general processes associated with the conduct of research within the military community.” So not even by a long stretch of the imagination did ‘the government’ set the study design.
Sorry DC, I give up. There’s no point in my continuing to debate anything with someone who freely refers to two completely different studies, published two years apart in different journals, as if they were one. Today’s piece of your flim-flam (above) takes the biscuit: “could it be that we are in the midst of a freaking war and the DoD didnt want us doing a sham procedure on symptomatic active military personnel? Nah.” In the midst of a ‘freaking war’ does the DoD toss properly conducted science out of the window in its desire to produce inevitably sham results supporting a ‘profession’ that practises metaphysical witchcraft?
I was struck by one of the the reviewer’s comments on De Vocht et al. (the Trials journal has an open review policy. Asked to comment on the level of interest of the manucript, the reviewer responded: “An article whose findings are important to those with closely related research interests.” Says it all, really, doesn’t it?
Yah…we are done here. Do your homework
REPORT DATE: March 2014
CONTRACTING ORGANIZATION: RAND Corporation
This annual report provides updates for the reporting period February 15, 2013 through February
14, 2014 on the study “Assessment of Chiropractic Treatment for Low Back Pain, Military Readiness
and Smoking Cessation” (Grant Number W81XWH-11-2-0107)
Clinical Trial A (ACT 1) ……………………………………………….…..2
Clinical Trial B (ACT 2)……………………………………………………13
Clinical Trial C (ACT 3)……………………………………………………15
The Assessment of Chiropractic Treatment 2 (ACT2) assesses changes in reaction/response times following Chiropractic Manipulative Therapy (CMT) using a randomized controlled trial in members of SFQ or SOAR.
This trial was funded by Department of Defense Office of Congressionally Directed Medical Research Programs, Defense Health Program Chiropractic Clinical Trial Award (W81XWH-11-2-0107).
Trials. 2016 Feb 9;17:70. doi: 10.1186/s13063-016-1193-8.
Assessment of chiropractic treatment for active duty, U.S. military personnel with low back pain: study protocol for a randomized controlled trial
So when delivering “chiropractic” manipulation (as opposed to “other” lesser forms of the virtually pointless endeavor) does it entail “diagnosing” the manipulative-lesion via Chiropractic “science” procedures(?): AK, leg checks, Derefield assessment, Gonstead x-ray and thermography, Tofness energy-changes, Network-neurology, CBP, Pettibon, PST…..perhaps all of these or some other I missed? Perhaps whackin’ on the sore spot, or just rackin’ & crackin’ anywhere the mood strikes. Since, to be fair it matters not one jot where or how “it” is delivered, just that it’s delivered, and by a DC AND any coincidental relief be reported as proof of Chiropractics’ effectiveness.
Ah the sweet smell of screwing our veterans. You DCs should be rightly proud.
Mr Kenney, This was the approach these researchers utilized…
spinal manipulation to the regions of palpable tenderness and restricted movement in the cervical spine [41–44].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5831387/#!po=92.2131
Perhaps Mr Kenney would like to comment on this?
“CONCLUSIONS: Based on the data obtained, classical physiotherapy proposals show ineffectiveness in the treatment of chronic non-specific low back pain.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055602/
“classic” physiotherapy includes manipulation. I’m not surprised it was ineffective.
Actually, what the review suggests is that spinal manipulation as a sole modality is ineffective in the medium and long term for chronic nonspecific back pain.
Critical_Chiro wrote on 26 September 2018, 06:11:55 “@ BW R.E. David Cassidy. Keep digging Blue and you will find that the large insurance company that funded that research threatened and coerced not only the researcher(s) involved but also the subjects participating in that study.”
So why did David Cassidy indulge the insurers by undertaking the study? And why did Dr Bartfray receive money for dropping her case against him?
Critical_Chiro wrote: “you cite a paper here: http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.03.007
Bravo. Now you are aware that the authors [Cassidy and Côté] wrote a letter to the editor in reply?
See here: http://sci-hub.tw/10.1016/j.jstrokecerebrovasdis.2014.11.034 ”
I see that there was a response to that Cassidy and Côté reply. Please provide the full response.
Critical_Chiro wrote: “R.E. Jan Hartvigsen… The Lancet series is a CALL TO ARMS FOR ALL PROFESSIONS written by leading researchers from ALL THE PROFESSIONS. Would you care to attack the character of those other researchers?”
My criticism of Jan Hartvigsen and his ignoring of risk still stands, and didn’t I link to valid critiques of the Lancet papers?
Critical_Chiro wrote in response to my comment ‘FYI, he blocked me on Twitter when I pointed out to him that he’d been remiss in that area [risks]’: “Try writing a letter to the editor. Just make sure that is is well referenced with research papers and not links to blogs otherwise it will probably not be published. If your letter is published then I am sure he will reply and science will move forward.”
Jan Hartvigsen stated in a slide presentation to chiropractors that ‘it is not who you are, it is what you bring to the table’:
http://rcc-uk.org/wp-content/uploads/2018/06/Jan-Hartvigsen_Royal-College-of-Chiropractors.pdf
Evidently he is very picky about his tables given that he appears to be unable to respond on Twitter to simple questions (i.e. he prefers to click on the ‘block’ button instead).
Critical_Chiro wrote: “R.E. Christine Goertz. You cite Matthew McCoy and McCoy Press. Face Palm. That is like citing Burzinski in the USA and calling it recommended cancer treatment. Facepalm.”
I was merely highlighting some of the more recent infighting that is widespread in the chiropractic industry.
Critical_Chiro wrote: “Choosing Wisely is very important and the key points are reklevant to ALL professions participating…”
Yes, and chiropractors’ involvement is subjected to valid criticism here:
https://sciencebasedmedicine.org/the-american-chiropractic-association-answers-crislips-call-joins-the-choosing-wisely-campaign/
DC wrote on Monday 24 September 2018 at 16:56 “Yes, they would say that. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024283/ ”
@ DC
Is the third author in that paper the same Deed Harrison who is a hard-core anti-vaccine chiropractor? See http://reasonablehank.com/2014/09/25/anti-vaccine-chiropractors-redux-8-the-deed-is-done/
I don’t know Deeds view on vaccinations. He has blocked me out on social media.
+1 DC. He does not like to be criticized. He has blocked me as well. 😉
Critical_Chiro wrote on Thursday 27 September 2018 at 00:56 “Classic Ad Hom” (re my comment that David Cassidy “is not to be trusted”)
@ Critical_Chiro
It is not an ad hom. IMO, it is very shady for a researcher to admit that he caused a woman to have a stroke following neck manipulation and then go on to lead-author a paper that he subsequently claimed exonerated him from being responsible for it even although the paper acknowledged that “the results should be interpreted cautiously…we have not ruled out neck manipulation as a potential cause of some vertebrobasilar stroke”.
Listening to PTs argue this with DCs is like watching Kanye West’s meeting with Donald Trump in the Oval Office yesterday.
https://m.youtube.com/watch?v=Jkv-9ifmY5w
It is important to distinguish ‘spinal manipulation’ from ‘spinal mobilisation’- the latter also performed by physiotherapists but not one of the dodgy 10 treatments listed, which does have its efficacy rooted in scientific principles?
I am a physiotherapist.
The way you build your argument doesn’t make sense. Basically, you stated at the beginning that many physiotherapists use an alternative medicine “toolbox”, you listed it and gave your conclusion. As a physio, I did not recognize myself in these techniques and I do not use any of them. Also, it seems that you are aware of some ancient techniques that I have never heard of in my entire career and have graduated for 16 years. Speaking of massage, most physiotherapists avoid this technique because it is technically boring and it makes no sense intellectually when you have a high level of education in anatomy.
I agree that a lot of things don’t make sense in physiotherapy (US, electrotherapy, etc.). But it’s frustrating for a physiotherapist like me to see the lack of consideration of our university education by a doctor of medicine.
What is needed is a survey of what PTs do for certain conditions.
From that one can determine how much is “science-based”.
Otherwise one may just be pointing out what’s on the bottom of the barrel (as EE likes to do).
I am a patient and I can confidently say that I could NOW ring a private physio in UK and be offered all those modalities that EE mentioned. The profession is trying to ‘clean up’ and there are various initiatives such as MSKR ( MusculoSkeletal Reform) who are trying but until professions actually ‘call out’ their colleagues when they are seen to be offering nonsense like cupping then we will always have this. In UK the problem is exacerbated by the NHS offering minimal physiotherapy treatment- a once size exercise based option complete untargeted to the patient, that is couched in inappropriate language like ‘back being out’ rather than embracing pain science reasoning ( Lorimer Mosely). Patients drift when they can afford it into the private sector generally because they need help with pain. There is woeful harm reporting mechanism in the private sector. I am actually a big fan of what physiotherapy could be because it is taught in Universities and the content is regulated. However once out in the ‘world’ therapists seem free to offer whatever nonsense they like. The affection and support by the public for the NHS should encourage private physiotherapists to offer science based treatment and thus strengthen, improve and enhance in general what the HNS could offer. That way we could get rid of the charlatans because there would be no need for them!.
That a technique is “boring” to you is irrelevant. Likewise, that you refer to your apparent frustration with not being afforded the respect you believe you deserve because of your “university” education is not relevant, but a feature of the frustrated inferiority complex of PT. I am not sure if you have missed the entire gist of this discussion otherwise.
I have definitely an inferiority complex as a physical therapist. This feeling can be more pronounced, when you evaluate as a physio in Europe. I am supervised by the GP or consultant for any kind of treatments, so yes It’s not comparable to what’s happene abroad. I have learned trough the years that the university tag as no real value in the medical field when your are not a physician. I understand that stating that a technique is boring is not very relevant. But on an every-day basis, you must make you job confortable. If I think that global massage technique is frustrating for some physios, it’s not just my reality… most of modern physio relate to EBM and massage didn’t show up nice evidence. Personally, I just don’t want a feel at Pattaya… (and its my right).
I am a physio for 17 years and an osteo for te last 5 years. Since 2004, I saw the evidences against physiotherapy one after one. Recently, a new RCT demonstrated that manipulation is not more effective than placebo for chronic LBP… So at the end of the day, what we will I do a Physio/Osteo??? I am completely against the “toolbox” of some physio (pilate, dry needling, etc…). Ok the profession is shifting to new trends based on the bio-psychosocial model. So my patient comes to see me, I decreased the nocibo and increase the placebo effect. No worries I am aware about all the neuroscience aspect of pain et management of patients. But technically, what will we be my life as a physio in the future. Reassuring people, explaining that they are in pain because of catastrophization and fatigue/stress…
People don’t realise the impact of this lack of evidence on physio daily-life. For me, it’s just let me despressed and feeling useless. Maybe the end of this career.
I would largely agree about the lack of ability of a lot physiotherapists to apply critical thinking to their treatments. This is because the education requirements for a physiotherapy course used to be quite
low. The physios who qualified some years ago are still practicing with low-grade understanding of science. They have a business need to do what they do!
There is however an ongoing reform with UK Physiotherapy “MSKR” which is championed by a group of highly motivated physiotherapists who are anxious to rid the profession of it non-EBM elements. They need to ‘call out’ their colleagues and other professions who champion SCAM ( often unwittingly )
However physios are always going to be seen as those who get the patients that medicine has ‘failed’ – however much physios strive to be seen as the first ‘point of call’ for clinical treatment. This is because patients want to be relieved of their pain/problem quickly – they will nearly always turn to a surgery seeing it as the quickest method for relief; so Physios end up with those for whom surgery is not an option or for whom it has failed.(excepting the briefest of attendance of an NHS physio after NHS surgery). This need has fostered all sorts of rubbish treatment and of course the less intelligent physio being reliant on the anecdotal response from their patient will believe that their treatment is working!
The problem for Physios is that even if they begin to weed out the non EBM element in their profession, until patients themselves are empowered and educated enough to recognize good quality treatments the patients themselves will vote with their feet and seek out the Scam treatment – believing the ‘clinician’. Patients are generally not that interested in ‘natural progression’, ‘regression to the mean’ etc. It is a dilemma!.