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

On this blog, I have repeatedly discussed chiropractic research that, on closer examination, turns out to be some deplorable caricature of science. Today, I have another example of what I would call pseudo-research.

This RCT compared short-term treatment (12 weeks) versus long-term management (36 weeks) of back and neck related disability in older adults using spinal manipulative therapy (SMT) combined with supervised rehabilitative exercises (SRE).

Eligible participants were aged 65 and older with back and neck disability for more than 12 weeks. Co-primary outcomes were changes in Oswestry and Neck Disability Index after 36 weeks. An intention to treat approach used linear mixed-model analysis to detect between group differences. Secondary analyses included other self-reported outcomes, adverse events and objective functional measures.

A total of 182 participants were randomized. The short-term and long-term groups demonstrated significant improvements in back and neck disability after 36 weeks, with no difference between groups. The long-term management group experienced greater improvement in neck pain at week 36, self-efficacy at week 36 and 52, functional ability and balance.

The authors concluded that for older adults with chronic back and neck disability, extending management with SMT and SRE from 12 to 36 weeks did not result in any additional important reduction in disability.

What renders this paper particularly fascinating is the fact that its authors include some of the foremost researchers in (and most prominent proponents of) chiropractic today. I therefore find it interesting to critically consider the hypothesis on which this seemingly rigorous study is based.

As far as I can see, it essentially is this:

36 weeks of chiropractic therapy plus exercise leads to better results than 12 weeks of the same treatment.

I find this a most remarkable hypothesis.

Imagine any other form of treatment that is, like SMT, not solidly based on evidence of efficacy. Let’s use a new drug as an example, more precisely a drug for which there is no solid evidence for efficacy or safety. Now let’s assume that the company marketing this drug publishes a trial based on the hypothesis that:

36 weeks of therapy with the new drug plus exercise leads to better results than 12 weeks of the same treatment.

Now let’s assume the authors affiliated with the drug manufacturer concluded from their findings that for patients with chronic back and neck disability, extending drug therapy plus exercise from 12 to 36 weeks did not result in any additional important reduction in disability.

WHAT DO YOU THINK SUCH A TRIAL CAN TELL US?

My answer is ‘next to nothing’.

I think, it merely tells us that

  1. daft hypotheses lead to daft research,
  2. even ‘top’ chiropractors have problems with critical thinking,
  3. SMT might not be the solution to neck and back related disability.

I REST MY CASE.

 

41 Responses to Chiropractic = the area of (bogus) healthcare where pseudo-research keeps on coming

  • Excellent post and insights as usual. I’d suggest replacing the word “might”…not be a solution to back pain…” with “IS NOT, nor ever was a solution for back or neck pain”.
    Just to put the finest and most accurate “point” on the whole debacle.
    And I wish one of these knucklehead apologists would some day tell the uninitiated HTF they know “what, where, when and how” to deliver this pre-scientific, hocus-pocus SMT ?
    Clearly 65 year old spines are loaded with degenerated-“fixated”, calcified vertebral segments that don’t move…unless you break something. Why wouldn’t their thieving -antics simply be “moving” vertebra already “moving”…(and perhaps moving “more”) to make up for the “degenerated” ones??
    But that might require critical thinking, a skill, unlike “motion-palpation” and “muscle-challenges”, they don’t possess.

  • One wonders if Ernst actually read and understood the paper?

    “Future effectiveness and cost effectiveness studies with long term follow up
    are needed to determine whether these improvements in secondary outcomes are worth the extra time and cost associated with long term management.”

    • so, what does the article tell YOU?

      • It would help if you actually understood the purpose of the study…

        “The primary aim of this randomized, observer-blinded, comparative effectiveness trial was to
        compare the effectiveness of SMT + SRE, delivered via either a short
        -term treatment (12 weeks) or
        long-term management (36 weeks) strategy, on older adults with spine
        -related disability.”

        • I did understand this.
          my question is clearly asked in the post and in my previous reply to you.

        • Only frauds and a bounders would be looking at stringing along +65 yos with pointless “treatments”. And that’s precisely the schtick of the DC (and PT)…wildly extended treatment-plans which are of no value and hugely detrimental to society-at-large. The only way to make the kind of money a DC thinks they deserve is by seeing every gullible-mark innumerable times, is it no wonder their “researchers” are always concocting “evidence” to try to validate further patient “retention”?

  • “Chiropractic is founded on different principles than those of medicine.”
    David Palmer, founder.

    In which case, why use the principles which underpin modern medicine (science and critical thinking) to offer substantiation of chiropractic’s principles?

    • The so called ‘heroic therapy’ was practiced well into the 19th century by orthodox doctors. The principle behind the heroic therapy was that severe illnesses could only be treated with harsh therapies, which led doctors to use frequent bleedings and strong medication on already weak patients.

      Several popular movements began to arise in opposition to the harsh therapies, strong drugs, and orthodox medical authorities in the 19th century.

      Most of them promoted a more natural way of healing through changes in lifestyle or non-toxic treatments. And even though they challenged medical authorities, they also set out to present their own theories as scientifically viable and to establish medical schools and journals.

      http://sciencenordic.com/printpdf/6927

      Of course, as within other professions, evolution of thinking has occurred within most of the chiropractic profession away from DD views.

  • Those papers have posted here before. Most surveys show that around 20% of chiropractors hold to Palmers vitalistic views.

    • @ DC

      Re “most surveys show that around 20% of chiropractors hold to Palmers vitalistic views”, for the benefit of new readers, please post links to those surveys.

      • Just look at the McDonald you like to refer to…

        “10.9% believe the subluxation contributes to 100%
        of all visceral ailments,…”

        Then look at Table 1.

        Scope of Practice Scale (Self-reported)*

        6 6.6%
        7 9.3%
        8 4.8%
        9—Focused Scope (straight) 5.3%

        By collapsing the data in Table 1, we see that the respon-
        dents make up three broad philosophical groupings: middle
        scope (46.4%), broad scope (34.3%), and focused scope
        (19.3%).

        “The fact that 93.4% endorse the differential diagnosis at
        new patient examinations is a clean break with the old prop-
        osition that chiropractors should eschew all diagnosis in fa-
        vor of analyzing the spine for subluxations only.”

        Etc.

        • DC wrote: “Just look at the McDonald you like to refer to…10.9% believe the subluxation contributes to 100% of all visceral ailments…”

          @DC

          The rest of that sentence states “…and 1.5% believe the subluxation never contributes to visceral ailments.”

          Ref. https://tinyurl.com/y9yvfhms

          DC wrote: “By collapsing the data in Table 1, we see that the respondents make up three broad philosophical groupings: middle scope (46.4%), broad scope (34.3%), and focused scope (19.3%).”

          Yes, and a closer inspection of the survey tells us that:

          QUOTE
          “…76.5% of chiropractors teach that there is a relationship between spinal subluxations and internal health and that subluxation is a significant contributing factor in 62.1% of visceral ailments. The overwhelming majority of respondents (88.1%) said they want to retain the term “vertebral subluxation complex” and 89.8% opposed limiting use of chiropractic adjustments to treatment of musculoskeletal problems.”

          Ref .https://www.chirobase.org/17QA/basis.html

          DC wrote: “The fact that 93.4% endorse the differential diagnosis at new patient examinations is a clean break with the old proposition that chiropractors should eschew all diagnosis in favor of analyzing the spine for subluxations only.”

          That’s only one aspect of practice and hardly lets chiropractors off the hook. For example, the survey’s look at services, procedures, and privileges thought by respondenets to be ‘Appropriate for the Chiropractic Profession’s Scope of Practice’ included vitamins (96.7%), acupressure (94%), herbs (91.1%), homeopathic meds (82.1%), and acupuncture (76.8%).

          Suffice to say that in July this year it wasn’t surprising to read the following declaration from the President of the World Federation of Chiropractic (WFC):

          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…Arguably, the profession is now more diverse than it has ever been. Diversity is no longer confined to a straight/mixer or vitalist/mechanist dichotomy. 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)

          • Go back and read Richards comment.

            How many chiropractor practice/belief based upon DD original principles?

            DD stated 95% of all ailments are due to spinal subluxations. The other 5% are due to extraspinal joint issues.

            Based upon the McDonald study a very small percentage still hold to that original principle.

  • Reforming chiropractic is like taking a nail, putting it in a pot with water and bring it to a boil. Then adding meat, salt, vegetables, condiments and cream, let it boil for a while and serve it as a “nail-soup”

    Here’s a good, albeit lengthy article on chiropractic.
    https://www.theglobeandmail.com/canada/article-chiropractors-at-a-crossroads-the-fight-for-evidence-based-treatment/?fbclid=IwAR2unBV-OKExtPCjY4q67ofj695RyvTLyfesS1XqIX5IsgfjWIEzCjOrXgg

  • And of course there is NO “Chiropractic-science” since it’s a made up portmanteau…without substance…contrived entrepreneurial-theatrics that can apparently masquerade as “healthcare” to the ill informed. It’s a “job”…a field-of-fraud for those without the aptitude, stomach or general constitution capable of becoming a real “doctor”. A job where they can steal money from the worried-well and wander through their pitiful life pretending to be “important”…. but the decent ones seething inside with regret and embarrassment….and laughing all the way to the bank.

    • @Michael Kenny
      Watch this video at 1 min 20 sec.
      https://www.youtube.com/watch?v=IzueFu1cq5U
      Prof. Ian Harris. Orthopedic Surgeon, researcher and author of the book “Surgery. The Ultimate Placebo”.
      “There is a very important difference to being cynical and being skeptical.
      To be a skeptic is to be scientific. To be cynical is to judge the motives of the people and not rely on the science”.
      Maybe I should start using the term “Carpet Bombing Cynics”.

      • @uncritical: I’m sure other skeptics and cynics here appreciate your patronizing comments…we’re all under-educated compared to a clown-college graduate….how could we possibly know the difference between skepticism and cynicism without your help?
        And our lack of critical-thinking skills just won’t allow us to fully understand and appreciate the immutable “big idea” y’all live by. If only you could feel the utter embarrassment and distain I have towards myself.
        I’m sure if we switched the topic from your (pecuniary) lunacy (Chiroquackery) and asked your opinion of Scientology, Iridology, Reiki, reflexology, non-touch-energy balancing, Auras, AK, Islam, the 1000 variants of Hinduism, Catholicism, Homeopathy, Bach flowers, Christian Science….and the myriad other “stuff” discussed at length on this blog and elsewhere…often by skeptics or cynics…you would tell us you believe in it all? Otherwise you’d be a carpet-bombing-skeptic, bordering on becoming a cynic yourself? Funny how frauds always ask us to “suspend-our-disbelief” in the BS that makes them money.

        • @Michael Kenny
          Don’t subscribe to the “big Idea” or any of the other BS.
          I have made that abundantly clear for years on this blog.
          “To be cynical is to judge the motives of the people and not rely on the science” – Prof Ian Harris.
          So how do you respond:
          “@uncritical”, “appreciate your patronizing comments”, “your (pecuniary) lunacy (Chiroquackery)”, “frauds always ask”, “BS that makes them money”.
          Do you see the pattern yet?
          Lets scroll up the comments for a further sample:
          “contrived entrepreneurial-theatrics that can apparently masquerade as “healthcare” to the ill informed”, “fraud”, “steal money”, “nail-soup”, “frauds and a bounders”, “schtick of the DC (and PT)” ( nice to see some honesty for once from you as your past posts would indicate that you are a physio), “always concocting “evidence”, “knucklehead apologists”, “thieving -antics”.
          Now do you see the pattern?
          @Blue Wode
          I recommend you cite research and not blogs when replyng to DC.
          Blogs are echo chambers that feed your bias.

          • @uncritical: oh, ok now I see the “pattern”. You refer to your profession and it’s “big idea” (without which there would be NO profession) as BS, castigate the “subies” and “believers” as BS “merchants”…all (except you) in dire need of “reform”. Ummm.
            So I extend my criticism with a bit more colorful and determined language and I demonstrate a “pattern” and am no longer a skeptic but now a carpet-bombing cynic. Ummm. You of course never answer anything instructively.
            So IF I towed-the-line and simply agreed with you, and reiterated your kinder-gentler excoriating language YOU decide is ok i.e. subluxationists’, “subies”, BS merchants, “the unreformed” etc. I’d be demonstrating righteous indignation and graciousness?
            I think you have spoken loud and clear…”chiropractic is BS, and it’s practitioners BS merchants”. It is NOT, nor ever was a science thus it can’t be reformed…and even if it could you offer nothing to “we” readers here that you are a capable “reformer” or what the parameters of such reform would be.
            IF random SMT (and it’s ALWAYS random) is “chiropractic” why the hell do you need 4-year, $200,000 educations (IF NOT indoctrination in the “big idea”?). My ex-wife (a DC) and (1) 12hr weekend seminar taught me how to do it….and I might add I’m very good at it.
            Neither YOU nor “they” can (or seem to care to) define “it”….yet you still feel the need to defend it, chastise those who criticize it and then explain to us and yourself that you contribute an important role in “healthcare”…..? What am I missing?
            Again I say: there’s the BS, merchant.

          • @Michael Kenny
            You truly are incapable of accepting researchers and reformers. To you all chiro’s are subluxation based.
            “You refer to your profession and it’s “big idea” (without which there would be NO profession) as BS” (If it’s not subluxation then it’s not chiropractic)
            “IF random SMT (and it’s ALWAYS random) is “chiropractic”. (Chiropractic is a technique).
            Do you not see the irony that your arguments are identical to the subluxationists.
            “So I extend my criticism with a bit more colorful and determined language”.
            I have to laugh. This language is standard for you.
            I am well aware that you will not change.
            Time for the monthly meeting where local neurosurgeons, orthopods, pain medicine specialists, GP’s, physiotherapists and shock horror chiropractors discuss patients, case studies, best practice, research etc. Tonight the keynote presentation is by a highly regarded physio researcher.
            Should I preach subluxation to them, bait and switch them?
            A room full of gullible specialists and doctors oh what fun.
            Seems they understand how I practice and refer. I refer to them as well. You do understand what a referral network is?

  • DC wrote on Sunday 04 November 2018 at 15:42 “Based upon the McDonald study a very small percentage still hold to [DD’s] original principle.”

    @DC

    You cannot escape the fact that, read scientifically, the McDonald survey results https://tinyurl.com/y9yvfhms are utterly damning for chiropractors. Further, it’s worth bearing in mind that the survey was sent out randomly to 1,102 practicing chiropractors, of whom 687 responded (63.3%). If one assumed those 687 represented the more ethical element of chiropractors (not an unreasonable view), then the results would show the chiropractic industry in an even more unfavourable light.

    • Regardless, look at how many chiropractors practice base upon DD original principles.

      Thus most of the profession has moved past DD original priniciple…granted, some more than others.

      Heck, even his son incorporated rehab for those cases that didn’t respond to ordinary chiropractic.

      • DC wrote: “look at how many chiropractors practice based upon DD original principles”

        @ DC

        Yes, look a the number of them:

        https://edzardernst.com/2017/01/educating-chiros/#comment-85292

        https://edzardernst.com/2016/10/top-model-died-as-a-result-of-visiting-a-chiropractor/#comment-83306

        I ask again, do you have any better data than these surveys (which were conducted after the McDonald one)?

        NB. When reading any survey in which chiropractors are respondents, a valid point made by Prof. Ernst should be factored in: “One of the problems is that one has to rely on the honesty of the participating therapists who could have a very strong interest in generating a reassuring yet unreliable picture…” [Ref. Ernst, E. Focus Altern Complement Ther 2008; 13: 41–2]

        • BW…apparently you don’t know DD original principle (see Richards original comment)

          “(DD) Palmer the elder is on record as stating that 95% of all diseases could be attributed to misaligned vertebrae, which impaired the flow of II within the body…”

          https://www.ncbi.nlm.nih.gov/pubmed/11611803

          How many chiropractors today hold to that principle?

          Apparently very few. Thus the profession has, and continues, to evolve…making Richards comment rather irrelevant.

          • DC wrote: “BW…apparently you don’t know DD original principle (see Richards original comment) [(DD) Palmer the elder is on record as stating that 95% of all diseases could be attributed to misaligned vertebrae, which impaired the flow of II within the body] https://www.ncbi.nlm.nih.gov/pubmed/11611803

            @ DC

            I am fully aware of DD’s original principle.

            With regard to the link you provided, I am unable to find the full text of the paper. However, I note that it was published in 1983 and is entitled ‘Seeking the rational alternative: the National College of Chiropractic from 1906 to 1982’.

            I’m not sure what your point is, but the National College of Chiropractic (now The National University of Health Sciences ) offers degrees in naturopathy, Oriental medicine, acupuncture, and massage, and describes itself as “a leader in the growing field of integrative medicine”. See ref. 21 here:
            https://www.chirobase.org/01General/today.html

            In addition to that, according to Samuel Homola DC, on pages 55-56 of his book, Inside Chiropractic, (published in 1999 by Prometheus Books):

            QUOTE
            “A 1998 fact sheet [Fact sheet on chiropractic. Lombard, IL: National College of Chiropractic, 1998] states that ‘chiropractic is not and does not profess to be an all-inclusive art of healing. It acknowledges limitation, and recognizes the need for consultation and referral, and is respectfully aware of the efficacy of other forms of therapy’. Yet the document also implies that chiropractic’s scope may be unlimited.”

            This is the pertinent section of the fact sheet:

            QUOTE
            “The basic distinguishing principle underlying the practice of chiropractic, differentiating it from the other healing arts and sciences, is the fact that disturbances of the nervous system produced by derangements within the spine and pelvis are often a primary or contributing factor in the pathological process of many common or seemingly intractable human ailments.”

            DC wrote regarding DD Palmer’s original principle: “How many chiropractors today hold to that principle? Apparently very few. Thus the profession has, and continues, to evolve…making Richards comment rather irrelevant.”

            DC, you need to back up your ‘apparently very few’ claim with convincing evidence. So far, of the studies I’ve linked to, you’ve cited the McDonald survey only and haven’t been able to defend your arguments.

          • from the McDonald paper…

            “10.9% believe the subluxation contributes to 100% of all visceral ailments”

            Now, that is not exactly DD principle as he wrote “all diseases” but it represents the general belief.

            So, the majority of chiropractors do not hold to that belief, they reject DD original principle.

  • There is a very important difference to being cynical and being skeptical. I am sure this is so wonderful. Thanks a lot.

  • DC wrote: “from the McDonald paper…’10.9% believe the subluxation contributes to 100% of all visceral ailments’ Now, that is not exactly DD principle as he wrote “all diseases” but it represents the general belief. So, the majority of chiropractors do not hold to that belief, they reject DD original principle.”

    So, given my responses to you, is it fair to say that the majority of chiropractors are entrenched in belief-based practices? If not, please explain why.

  • @uncritical: do these MDs meet with the local troupe-of-gypsies as well ? And graciously let them demonstrate their manipulation-skills, applied-kinesiology, leg-checks, posture-assessments, motion-palpation of “fixated” vertebra and energy-balancing tricks? Why not?
    Or perhaps, like you, they are reformed-gypsys and rely on evidence…and actually don’t DO anything….since there ain’t no evidence.
    I recently met a man who informed me there is indisputable evidence of Noah’s ark. You and he should compare notes.

  • DC wrote on Friday 09 November 2018 at 22:08 : “I know that most patients come to chiropractors for low back and neck pain. That most chiropractors perform spinal manipulation as part of their therapeutic process for those conditions. So i suspect most do spinal manipulation in an attempt to help relieve low back and neck issues.”

    @ DC

    You’ve dodged my question which was ‘Do you agree that most chiropractors manipulate or adjust putative vertebral subluxations in a misguided effort to restore and maintain health?’
    Ref. https://sciencebasedmedicine.org/subluxation-theory-a-belief-system-that-continues-to-define-the-practice-of-chiropractic/

    Here’s the problem:

    QUOTE
    “Chiropractic is perhaps the most common and egregious example of the bait and switch in medicine. The deception begins with the name itself – ‘chiropractic’ fails the basic test of transparency because it is not unambiguously defined. There are in fact numerous professions doing very different things and employing mutually exclusive philosophies under the banner of ‘chiropractic’. Therefore someone may go to see a chiropractor and think they will be seeing a medical professional who will treat their musculoskeletal symptoms, but in reality they will see the practitioner of a cult philosophy of energy healing.”

    Ref: https://sciencebasedmedicine.org/the-bait-and-switch-of-unscientific-medicine/

    • If one considers relieving low back and neck pain/dysfunction as “restore and maintain health”, then yes, most appear to have that purpose with spinal manipulation, along with exercise, ergonomics, etc.

  • I recall that around 98% of chiropractors do spinal manipulation.

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