The 2018 World Federation of Chiropractic ACC Education Conference was held on 24-27 October in London. It resulted in several consensus statements developed by the attendees. I happen to know this from a short report that has just been published; it can be found here.
Of the 10 points made in this consensus, I find only the following noteworthy:
“Chiropractic education programs have an ethical obligation to support an evidence-based teaching and learning environment.”
Perhaps it is me – English is not my first language – but I find the phraseology used in this sentence strangely complicated and confusing. I have been a teacher of medical students for most of my life, but I am not sure what an ‘evidence-based teaching and learning environment’ is. I know what ‘evidence-based’ means, of course. However, what exactly is:
- a teaching environment?
- a learning environment?
- and how does ‘evidence-based’ apply to either of the two?
Is there evidence that some environments are better suited than others for teaching?
Is there evidence that some environments are better suited than others for learning?
I suppose the answer must be YES!
The environment, i. e. the space and conditions in which teaching and learning happen should, for instance, be/include:
- quiet,
- not cramped,
- not too cold,
- not too hot,
- equipped with ergometric chairs and desks,
- well-lit,
- there should be visual aids,
- access to computers,
- a library,
- good mentoring and support,
- etc.
So, the consensus of the education conference wanted to optimise the environmental conditions of teaching and learning for chiropractic lecturers and students? Most laudable, I must say!
But still, it seems like a missed opportunity for an ‘Education Conference’ not to have stated something about the content of teaching and learning. Personally, I find it a pity that they did not state: Chiropractic education programs have an ethical obligation to be evidence-based.
Or is that what they really wanted to say?
Naaahh … come to think of it … they cannot possibly make such a demand.
Why?
Because, in this case, they would have to teach students not to become chiropractors.
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“The leading provider of osteopathic teaching for over 100 years” the honorable former British School of Osteopathy, now upgradet as University College of Osteopathy advertises itself quite similar as “evidence informed”
on its webpage they advertise as follows:
“… As the only degree-awarding institution in Europe, our evidence-informed approach to healthcare, clinical practice and research has been leading the profession for over 100 years.”
The good thing with this is that they still call themselves “in Europe” which will probably change if the Brexit will happen.
https://www.uco.ac.uk
This honorable institute was mainly involved in the elaboration of the alternative medicine WHO benchmarks for thraining in osteopathy
https://www.who.int/medicines/areas/traditional/BenchmarksforTraininginOsteopathy.pdf?ua=1
in which visceral manipulation and cranio sacral osteopathy / therapy and the knowledge about an iatromechanic and vitalistic so called involuntary mechanism are defined as core subjects.
https://www.who.int/medicines/areas/traditional/trm_benchmarks/en/
The reason why the WHO put osteopathy under the category “traditional / complementary and alternative medicine” was the lack of evidence.
Which is proofed in systematic reviews:
https://www.ncbi.nlm.nih.gov/m/pubmed/27936211/
https://www.ncbi.nlm.nih.gov/m/pubmed/29452579/
So how come that the University College of Osteopathy calls itself “evidence-informed”???
the other question could be:
If the University College of Osteopathy is promoting and aiming to join evidence based medicine which they are advertising as doing it already “for over 100 years”, why don’t they replace the so called 4 osteopathic principles (some say platitudes which would be realistic) by the standards /defaults /benchmarks of the Cochrane Collaboration / medical and natural sciences and delete the WHO benchmarks for training in osteopathy???
sorry for a quoting error
it should be:
“As the only degree awarding osteopathic institution in Europe …”
As far as I know the UCO does not teach cranial and visceral osteopathy at undergraduate level. They never did unlike other osteopathic schools in the UK.
So what?
WHO benchmarks for training in Osteopathy
Chapter 2.3 page 9
Osteopathic skills
… involuntary mechanism and visceral techniques
So, they don’t respect the silly WHO benchmarks.
they do, look at the curriculum of the UCO and we had this discussion here already.
You are right regarding cranial.
The “full training” in cranial was separated under Colin Dove long ago and is taught by the SCCO “postgraduate”. It was also part of the MSc. (ost) of the ESO partially.
The WHO benchmarks for training in osteopathy were elaborated under the guidance of all profiteers/ big schools. Mainly involved was the GOC together with the UCO, the Australians, the biggest Belgian/European school and last but not least the German physician Dr. med. representative who is a fellow of the SCCO England. So why should they not follow their own benchmarks which they have elaborated by their own?
No school teaching OMT Odteopathic Manipulative Therapy can provide enough Bologna Credit points for a B.Sc. or M.Sc. without a huge amount of visceral and some cranial “involuntary mechanism” speculative magic …
I am afraid there’s no cranial and visceral techniques taught at the UCO at undergraduate levels and part of the curriculum to become an osteopath.
The WHO benchmarks for training in osteopathy were elaborated under the guidance of all profiteers/ big schools. Mainly involved was the GOC together with the UCO, the Australians, the biggest Belgian/European school and last but not least the German physician Dr. med. representatives who is a fellow of the SCCO England. So why should the not follow their own benchmarks which they have elaborated by their
own?
No school teaching OMT Odteopathic Manipulative Therapy can provide enough Bologna Credit points for a B.Sc. or M.Sc. without a huge amount of visceral and some cranial “involuntary mechanism” speculative magic …
Osteopathy is NOT evidence-based!
No evidence since 1892 for reliability of diagnosis and clinical efficacy for OMT/OMM
Osteopathic Manual Treatment / Osteopathic Manual Medicine
neither for parietal osteopathy
https://www.ncbi.nlm.nih.gov/m/pubmed/30388155/
nor for cranial osteopathy
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5147986/
nor for visceral osteopathy
https://www.ncbi.nlm.nih.gov/m/pubmed/29452579/
Conclusion: Osteopathy is NOT evidence-based
https://edzardernst.com/2019/03/new-review-confirms-osteopathy-is-not-evidence-based/
In your « parietal osteopathy » link there’s : . In conclusion, there is some evidence suggesting that osteopathic care may be effective for people suffering from spinal complaints.
“Osteopathy is NOT evidence-based!”
Perhaps you are confused on the difference between evidence based and research based.
do you care to define the difference?
There is:
Science based
Evidence based
Research based
Google is your friend.
Iresine What’s your argument regarding the UCO?
They taught the visceral manipulation stuff in the regular trainings at BSO and at UCO the last years but the actual syllabus is not published in the internet. Do you think they changed it? Look at BSO and the other institutes in England, Canada, Australia, Belgium. Austria, Germany France, Italy, Japan a.s.o. everywhere is visceral and cranial teaching without any critical comment.
And they still teach visceral and cranial at the UCO because it is considered as the “top skills” all over the European and Commonwealth osteopathic manipulator scene and in the European physician’s osteopathic trainings and it is spreading all over the US osteopathic physician scene like a bushfire.
The UCO never made a critical comment on visceral or cranial osteopathy. They teach it see here:
https://www.uco.ac.uk/courses/osteopathy-cranial-field-reloaded
https://www.uco.ac.uk/courses/thorax-introduction-visceral-osteopathy
https://www.uco.ac.uk/courses/thorax-introduction-visceral-osteopathy
Again, the UCO never taught cranial or visceral at undergraduate level. The links you have shared tend to prove it. These courses are for postgraduates. You can see that the visceral course is an introduction to the subject. How could they propose an introduction to these topic to students who, according to you, had an extensive training in visceral osteopathy ?
1.) UCO NEVER disavowed from cranial or visceral manual techniques. Both are based on iatromechanism and vitalism essentially. So what does it matter? They are teaching it. Who cares wether it is under- or postgraduate?
2.) and they teach it undergraduate:
UCO page 10 of 18:
year 2 !! Unit
CORE osteopathic capabilities for clinical practice 2
…
3. you are also required to demonstrate a developing ability to apply a range a lot of other osteopathic techniques including functional and VISCERAL.
https://www.uco.ac.uk/sites/default/files/course_supporting_docs/MScPR_CIF_UCO_Aug2017_FINAL.pdf
.
Iresine
1) UCO never ever disavowed from cranial or visceral techniques and they teach it both as I have shown in my links.
Therefore again what’s your argument related to evidence?
2) Visceral manipulation is definitely part of the syllabus and in the second year of training the students must show their osteopathic capabilities for clinical practice 2 in which they are also required to demonstrate a developing ability to apply a range of other osteopathic techniques including functional and VISCERAL.
So again why should we discern between undergraduate and postgraduate regarding the issue of evidence?
Do you think that teaching nonsense only to postgraduates makes nonsense more professional?
Or do you think preventing undergraduates from nonsense and teaching it to postgraduates instead is an expression of responsibility and of evidence?
EE…”but I am not sure what an ‘evidence-based teaching and learning environment’ is.”
Why don’t you ask them to clarify or explain their statement?
if you understand it, please explain it to us.
if you don’t, I let you ask first.
@EE
Have you tried entering “evidence-based teaching and learning environment” into a google or Pubmed search?
yes
look into ‘flipped classrooms’ as an example.
THANKS
next time I am in a classroom, I will try to flip it
https://journals.lww.com/academicmedicine/Fulltext/2014/02000/The_Flipped_Classroom___A_Course_Redesign_to.17.aspx
The Flipped Classroom: A Course Redesign to Foster Learning and Engagement in a Health Professions School
priceless!
you are seriously trying to teach me to suck eggs.
I have been a teacher of med students most of my life and did so under more systems than you might imagine.
but thanks anuway
And yet you didn’t know what evidence based teaching and learning meant? Uh, OK.
you are not very good at understanding satire, are you?
@DC
I’m still trying to follow your ‘reasoning’, DC. Edzard’s original post clearly objected to the weasel word environment. We all understand the expression ‘evidence-based teaching’, but the World Federation of Chiropractic ACC Education Conference statement doesn’t say that.
You linked to an article about ‘flipped classrooms’. But I’m at a loss to understand how giving students lectures by “self-paced online videos” (a technique that’s been going on for decades in many UK medical schools) or “[using] class time to engage students in active learning exercises” has anything to do with evidence-based teaching or providing an ‘evidence-based teaching environment’.
In your latest comment you talk of ‘evidence-based teaching’ but you’ve conveniently dropped the word ‘environment’, which clearly demonstrates you still don’t comprehend the intention of the OP (or its satirical aspects).
Satire is the use of humor, irony, exaggeration, or ridicule to expose and criticize people’s stupidity or vices, (Oxford dictionary).
Since the OP appears to have none of those qualifiers (other than perhaps ridicule) and fails to demonstrate any stupidity or vice of the organization or its message, it fails as satire.
But yes, Ernst has been known to pull one or two words out of a piece and run with it rather than look at the overall intent. Perhaps that is the best he can do.
I did suspect that satire about chiropractic is not your cup of tea. thanks for the confirmation.
Perhaps it is you and the lack of second language mastery. It’s not difficult to extrapolate the meaning, but it is convenient to take a cheap swipe to twist the intent to prop up your position. I suppose I could do a similar thing with your name and suggest you might want to replace the “z” with a “t.” That seems to be a more fitting description. Of course it could just be because that fits my subjective assessment.
I am so sorry to see that your intelligence does not seem to stretch far enough to see what the serious point of this satirical piece is. so let me make it simple for you: IF CHIRO SCHOOLS DID REALLY START EVIDENCE-BASED TEACHING THEY WOULD HAVE TO DISCOURAGE STUDENTS FROM BECOMING CHIROPRACTORS BECAUSE THERE SIMPLY IS NOT ENOUGH EVIDENCE TO SUPPORT IT. is that clear enough for you?
EE: IF CHIRO SCHOOLS DID REALLY START EVIDENCE-BASED TEACHING THEY WOULD HAVE TO DISCOURAGE STUDENTS FROM BECOMING CHIROPRACTORS BECAUSE THERE SIMPLY IS NOT ENOUGH EVIDENCE TO SUPPORT IT.
Really?
A 2010 review of scientific evidence on manual therapies for a range of conditions concluded that spinal manipulation/mobilization may be helpful for several conditions in addition to back pain, including migraine and cervicogenic (neck-related) headaches, neck pain, upper- and lower-extremity joint conditions, and whiplash-associated disorders.
Chiropractors may combine the use of spinal adjustments and other manual therapies with several other treatments and approaches such as:
Heat and ice
Electrical stimulation
Relaxation techniques
Rehabilitative and general exercise
Counseling about diet, weight loss, and other lifestyle factors
Dietary supplements
From: The National Center for Complementary and Integrative Health (NCCIH) is the Federal Government’s lead agency for scientific research on the diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.
https://edzardernst.com/2016/12/the-mainstreaming-of-quackery-the-role-of-the-nccih/
https://edzardernst.com/2019/01/a-review-of-a-new-years-message-from-nccihs-director-helene-langevin-m-d-january-2019/
That’s the best you can do? I suppose so.
yes
It appears that this is not the case Edzard, or is everyone else wrong? https://www.asa.org.uk/advice-online/health-chiropractic.html#approved
the list is not based on strong evidence and also not very long compared to the plethora of claims made by chiros. in any case, it would hardly suffice for evidence-based education, would it?
It’s based on best evidence (or in some cases sufficent evidence), not strong evidence.
the issue:
https://academicaffairs.arizona.edu/evidence-based-teaching-and-learning
https://www.criterionconferences.com/event/evidence-based-teaching-conference/
https://www.criterionconferences.com/event/evidence-based-teaching-conference/brochure/
OECD …the issue:
https://www.oecd.org/education/school/43023606.pdf
https://www.oecd.org/berlin/43024880.pdf
and at least Wiki
https://en.m.wikipedia.org/wiki/Evidence-based_education
… as far as I understand the term it is about finding evidence how to improve the teaching methods doesn’t matter what subject is. So you can improve the teaching in any religious subject as well or in achieving any profession doesn’t matter wether the subject itself is evidence based or not? That’s different from what the University College of Osteopathy is telling. They are relating their statement more directly to “healthcare, clinical practice and research”. I guess the intention is clear. They want to have the word “evidence” in their advertisement somehow. That could be misleading the public because there is no evidence neither for Chiropractic nor for OMT Osteopathic Manual Treatment. Couldn’t you improve the teaching in any methods of brain washing as well with “evidence based teaching and learning”??
So they should put the following sentence on top of their advertisement:
“Here you can achieve a degree of faith because there is no evidence for what you are learning neither for diagnosis nor for clinical efficacy.”
i am sure the don’t use the Berlin questionnaire and the Fresno test for assessing the effectiveness of education in evidence-based medicine. 🙂
In that PDF They are promoting a conference on chiropractic “evidence-based,
patient-centered, interprofessional and
collaborative – or EPIC – care”
If they evaluate the evidence well, the evidence based section of the conference would be short and argumentative.
@ Edzard
Blue Wode described Sam Homola as an evidence based chiropractor – Is Blue Wode wrong?
AN Other wrote: “Blue Wode described Sam Homola as an evidence based chiropractor – Is Blue Wode wrong?”
@ AN Other
A more pertinent question would be one that you have already asked – i.e. if all chiropractors practiced like Sam Homola, would the profession called chiropractic be OK to carry on existing?
Previous discussion here:
https://edzardernst.com/2018/06/malpractice-of-chiropractors-just-the-tip-of-an-iceberg/#comment-103990
My reply was that in such a scenario I didn’t think that it would be wise for chiropractic to carry on existing as there’s too much quack baggage associated with it.
Your solution was “to educate the public about what treatments they should expect from an evidence based therapist and therefore would choose a therapist on this basis”.
IMO, such a tactic is unrealistic as it places far too much pressure on the public. The real answer to the problem lies with the regulators who need to be proactive (instead of reactive) and be given powers to dramatically curtail the claims that chiropractors can make and treatments they are permitted to offer. But then that would likely destroy the chiropractic industry.
@ Blue Wode
But if an evidence based chiropractor can exist (as you claim), is Prof Ernst wrong?
Do you think the regulation of Physiotherapy is strong enough?
Do you think the regulation of Osteopathy is strong enough?
Public education and strong regulation is the best solution – not really an either/or – would you agree?
AN Other wrote: “@ Blue Wode – But if an evidence based chiropractor can exist (as you claim), is Prof Ernst wrong?”
@ AN Other
IMO, an evidence based chiropractor can *exist*, but possibly not for long…
QUOTE
“If a chiropractor limited his practice to musculoskeletal conditions such as simple backaches, if he were able to determine which patients are appropriate for him to treat, if he consulted and referred to medical doctors when he couldn’t handle a problem, if he were not overly vigorous in his manipulations, if he minimized the use of x-rays, and if he encouraged the use of proven public health measures, his patients would be relatively safe. But he might not be able to earn a living.”
Ref. Spine Salesmen’ chapter of the book, The Health Robbers: A Close Look At Quackery In America. The entire chapter is posted here http://www.chirobase.org/12Hx/hr76.html and is well worth a read.
AN Other wrote: “Do you think the regulation of Physiotherapy is strong enough?”
It could be tighter. I’d like to see the c. 12% of physiotherapists who practice acupuncture being collectively advised to drop it:
https://edzardernst.com/2015/01/my-visit-to-the-anglo-european-college-of-chiropractic/#comment-63841
AN Other wrote: “Do you think the regulation of Osteopathy is strong enough?”
Not in the UK. It’s similar in many ways to chiropractic. IMO, the statutory regulation of chiropractors and osteopaths in the UK was extremely premature.
AN Other wrote: “Public education and strong regulation is the best solution – not really an either/or – would you agree?”
I would agree with strong regulation, but from the outside – which, as I have previously indicated, would likely destroy professions with exceedingly slim evidence to support them (i.e. chiropractic and UK osteopathy).
@ Blue Wode
In your opinion:
Does an evidence based chiropractor use the same treatments as an evidence based physiotherapist?
Does an evidence based osteopath use the same treatments as an evidence based physiotherapist?
BW: “The real answer to the problem lies with the regulators who need to be proactive (instead of reactive) and be given powers to dramatically curtail the claims that chiropractors can make and treatments they are permitted to offer. But then that would likely destroy the chiropractic industry.“
Destroy it? I’m not sure that would be chiropractics fate. Different? Certainly.
Regardless, in some areas, action is being taken.
Examples…
http://www.chirobc.com/ccbc/wp-content/uploads/2018/10/Efficacy-Claims-Policy-Final-Cover-letter.pdf
https://www.cbc.ca/news/canada/nova-scotia/chiropractor-hearing-disciple-vaccines-immunizations-1.4888061
@ DC
Whilst interesting, your links appear to represent a drop in the ocean. It all seems too little, too late, especially if the following comments by Preston Long DC, in his book, ‘Chiropractic Abuse: An Insider’s Lament’, are anything to go by:
QUOTE
“I believe that in order to survive as a profession, chiropractic must adopt the substance of a scientific health discipline and not merely a veneer. This would require abandoning subluxation theory, adopting ethical standards, and clamping down on the wide range of practices that are unproven and lack a scientifically plausible rationale. Unfortunately, having seen little progress in this direction during the past 25 years, I do not believe chiropractic has the ability to reform from the inside.”
Ref: https://sciencebasedmedicine.org/chiropractic-abuse-an-insiders-lament-2/
I suspect that Preston Long is correct with his summation for the following reasons:
The British Chiropractic Association has admitted recently that chiropractic’s future is threatened unless chiropractors tolerate each other. Its words, “unity need not mean uniformity”, are very telling:
Ref: http://www.mccoypress.net/i/bca_bennett_letter_december_2016.jpg
Chiropractic reform in Europe doesn’t seem to be obtainable. For example, not so long ago David Newell, Professor of Integrated Musculoskeletal Care, Director of Research, and Reader at the Anglo European College of Chiropractic University College, said:
QUOTE
“My dream would be to see the unification of as many chiropractors as possible under a common description of a model of chiropractic care. One that is patient centred, ethical, evidenced and uses scientific language to describe the use of different modalities and skills that chiropractors are trained to deliver competently and safely in the management of MSK problems…I would love to see the profession pulling together underneath such a model but I don’t think we are going to manage that globally. I don’t even think we are going to be able to pull everybody together in Europe…My passionate wish is for unity. I don’t want to see any more splits and disharmony than we already have. But I don’t think complete unification is achievable.”
Ref: https://tinyurl.com/y8fvw8nu
Even the President of the World Federation of Chiropractic (WFC), on pages 3-4 of a recent newsletter, confesses that:
QUOTE
“For thirty years the WFC has attempted to facilitate unity in the global chiropractic community. When it was realized that unity was unattainable the WFC sought unity with diversity. Neither objective has yet been achieved. At its recent meeting in Lima, WFC Council made the bold decision to shift away from endeavoring to promote unity. Instead, it was agreed that the priority of the WFC should be focused on the creation of trust, legitimacy and promoting the best available care. It was agreed that commonality based on high standards of care and protecting patient welfare are the professions strengths and should be at the core of our focus. 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…It is time to cease using labels to describe different sections of the chiropractic profession. Instead, we should focus on the core attributes that define a health professional, regardless of individual philosophy or practice dynamics.”
Ref: https://www.wfc.org/website/images/wfc/qwr/2018/QWR_2018JUL.pdf
There’s also this interesting, local survey undertaken by a physical therapist which appears to be consistent with the available surveys on how chiropractors practice:
QUOTE
“Based on my conversations with various individuals, market research, and examining the curriculum of the local chiropractic school near where I live and practice the chart below gives a good breakdown of the composition of different types of chiropractors in my area.” [Around 5% are strongly evidence-based.]
Ref: https://tinyurl.com/y73gsr97
Finally, here’s a 2016 paper that is far from optimistic about reform:
QUOTE
“The various clinical specialties and independent groups in the chiropractic profession are so different in their beliefs, practice styles, and political agendas that a common identity is unlikely to be created. Areas of disagreement, including advanced practice, vertebral subluxation, and the philosophy of chiropractic, continue to separate those in the profession. Doctors of chiropractic should accept that differences within the profession will remain for the foreseeable future and that the profession should allow each group to live peacefully and supportively alongside each other.”
Ref: https://www.ncbi.nlm.nih.gov/pubmed/27920616
DC, as you can see, it’s unlikely that chiropractors could achieve enough consensus to push for proper regulatory reform – or, to quote from the Preston Long comment at the start of my post…
“Unfortunately, having seen little progress in this direction during the past 25 years, I do not believe chiropractic has the ability to reform from the inside.”
Reform does not require unity of the profession.
Actually, it’s no longer a goal for some…
“Chiropractic has a long history of intraprofessional fighting over treatment philosophy, making the goal of total professional unity unachievable.”
https://www.acatoday.org/News-Publications/Newsroom/News-Releases/New-Brand-Positions-ACA-Chiropractors-for-Higher-Standards-Future-Opportunities
Is it too little too late? Will the profession eventually self implode? Perhaps. Time will tell.
Meanwhile, IMO, evidence based chiropractors may be able to help…as it seems help is needed…
“Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, LBP ranked highest in terms of disability (YLDs), and sixth in terms of overall burden (DALYs). The global point prevalence of LBP was 9.4% (95% CI 9.0 to 9.8). DALYs increased from 58.2 million (M) (95% CI 39.9M to 78.1M) in 1990 to 83.0M (95% CI 56.6M to 111.9M) in 2010. Prevalence and burden increased with age. LBP causes more global disability than any other condition. With the ageing population, there is an urgent need for further research to better understand LBP across different settings.”
261070129_The_global_burden_of_low_back_pain_Estimates_from_the_Global_Burden_of_Disease_2010_study
AN Other wrote on Sunday 13 January 2019 at 17:50: “@ Blue Wode In your opinion: Does an evidence based chiropractor use the same treatments as an evidence based physiotherapist? Does an evidence based osteopath use the same treatments as an evidence based physiotherapist?”
I don’t know. Just because a chiropractor or an osteopath is deemed to be evidence based, it doesn’t mean that they actually are. For example, this survey https://tinyurl.com/ycfhybsd by McGregor et al, which many chiropractors think shows that only 18% of chiropractors deliver inappropriate treatment, doesn’t carry the good news that they think it does.
It concludes: “Chiropractors holding unorthodox views may be identified based on response to specific beliefs that appear to align with unorthodox health practices. Despite continued concerns by mainstream medicine, only a minority of the profession has retained a perspective in contrast to current scientific paradigms.”
If you read the paper, McGregor’s 1st, 3rd, 4th, 5th, and 6th subgroup descriptions (Table 1) don’t seem to exclude the unethical chiropractor element. In other words, 5 of the 6 subgroups could easily indulge in chiroquackery – (1) “Wellness”, (3) “general probs”, (4) “organic-visceral”, and (5/6) “subluxations”.
According to Science Based Medicine author, Jann Bellamy: “The survey was of Canadian chiropractors, most of whom graduated from Canadian Memorial Chiropractic College, which appears to have a more orthodox orientation than, for example, Life or Palmer…the groups not included in the unorthodox category doesn’t mean the others are necessarily free of unorthodox views.”
Ref: https://sciencebasedmedicine.org/a-cure-for-chiropractic-2/#comment-1942827476
With regard to any evidence based chiropractors or osteopaths who might practice in exactly the same manner as a physiotherapist, it has to be asked why they didn’t train as a physiotherapist in the first place.
@ Blue Wode
In a previous discussion you said:
“an evidence based chiropractor, in my opinion, would employ joint mobilisation techniques, muscle stretching, massage and soft tissue techniques, and instruction on self-care, exercises, and coping tactics. I would expect manipulation to be used very, very sparingly.”
Would you not agree that an evidence based physiotherapist or an evidence based osteopath would practice (use treatments) similar to what you described above for an evidence based chiropractor, in your opinion?
@ AN Other
Haven’t I answered that question already?
A reminder:
“Just because a chiropractor or an osteopath is deemed to be evidence based, it doesn’t mean that they actually are [example given]…With regard to any evidence based chiropractors or osteopaths who might practice in exactly the same manner as a physiotherapist, it has to be asked why they didn’t train as a physiotherapist in the first place.”
@ Blue Wode
So, if an evidence based physiotherapist can earn a living, why can’t an evidence based osteopath or chiropractor do the same, if they are practicing in the same way?
Also, what are your thoughts on what David Colquhoun said on this blog regrading Osteopaths?
“I think that it’s a mistake to talk about osteopathy in general. They vary greatly. At one end of the spectrum are those who sell nonsense like craniosacral osteopathy, and claim to cure diseases. At the other end there are some who appreciate evidence, and practice in a way that’s indistinguishable from the best physiotherapists (i.e. no acupuncture).”
AN Other wrote: “So, if an evidence based physiotherapist can earn a living, why can’t an evidence based osteopath or chiropractor do the same, if they are practicing in the same way?”
@ AN Other
Because of the poor overall reputation of chiropractors and osteopaths – i.e. both professions continue to be mired in quackery. Some might manage to make a decent living, but unless there’s serious reform, I doubt it’s many. Also, as I’ve asked before, why would chiropractors or osteopaths who practice in exactly the same manner as a physiotherapist not have trained as a physiotherapist in the first place? Do you know the answer to that?
With regard to David Colquhoun’s comments, he’s correct in that osteopathy does vary greatly. In the U.S., osteopaths they are on a par with MDs, but in the U.K. they are similar to chiropractors in that they lack standardisation and therefore – in my opinion – are best avoided.
physios do similar stuff as chiros and osteos for musculoskeletal conditions, but we must not forget that they look after a lot more conditions and situations [intensive care, pulmonary, cardiovascular, neurological, etc]
@ Blue wode
You said:
“why would chiropractors or osteopaths who practice in exactly the same manner as a physiotherapist not have trained as a physiotherapist in the first place? Do you know the answer to that?”
No I don’t know the answer either. I did ask David Colquhoun the same question but he didn’t know either. He said he was going to ask the osteopath (UK based and trained) he interviewed the same question but he has never got back to me.
You said:
“Because of the poor overall reputation of chiropractors and osteopaths – i.e. both professions continue to be mired in quackery”
Poor overall reputation – in who’s opinion?
Many osteopaths in Europe trained first as physiotherapists. They certainly have done for some reasonable reasons.
money?
If you compare the earnings between physio and osteos, the latter earn much less.
I think this depends on what country we are talking about.
On which country are they earning more than the physiotherapists ?
I am not sure, Germany or France perhaps?
Not in France apparently:https://osteofrance.com/perch/resources/pdf/cpsalaireosteopathes2015.pdf
The top annual incomes for osteopaths are around 50.000 euros and around 65.000 euros for the physiotherapists
Indeed most of the
European and Commonwealth osteopathic manipulators studied physical therapist before they osteopath for some reasonable.
1) simply because in a lot of countries you have to be physical therapist first because without you are not allowed to practise hands on (if you are not a physician) because the osteopathic profession does not exist in the national health care systems officially in most countries.
2) because of the physical therapist’s profession is pushed to the fringe of the medical system by the newest regulations of the national health care systems which has a severe effect on their income which forces the physical therapists to find a new marketing.
3) because it is the best way to believe the brainwashing ideology that osteopaths are better than medical doctors because “As a doctor A.T. Still has to watch the death of his children and therefore he found a new system of healing by hands on.” (which is story telling for gullible half-whits.)
4) because to be physical therapist before becoming an osteopathic manipulator makes you the best victim to believe in iatromechanism and vitalism and in phrenology (direct relationship of skull and brain to access the pituitary gland via cranial touch).
Do you need some more good reasons?
BW: “For example, this survey https://tinyurl.com/ycfhybsd by McGregor et al, which many chiropractors think shows that only 18% of chiropractors deliver inappropriate treatment…”
Actually, the study looked at “… the survey was designed to elicit information pertaining to divergent perspectives (strata) held by chiropractors.”
Other studies indicate this minority tends to strongly promote “chiroquakery”.
@ DC
I’m not sure what your point is. I’ve shown, repeatedly, that c. 60%-90% of chiropractors are not evidence based.
This 2008 study puts the figure at c. 70% of U.S. chiropractors:
http://www.chiro.org/LINKS/ABSTRACTS/Survey_of_US_Chiropractor_Attitudes.shtml
And that’s the ones who admit to it.
“It was also very interesting to note that the vast majority of our sample (89.5%) agreed or strongly agreed with the statement “I am interested in learning or improving the skills necessary to incorporate EBP into my practice”.”
https://chiromt.biomedcentral.com/articles/10.1186/s12998-015-0060-0
@ DC
That study was published over 10 years ago. If you re-read my comment above you will be reminded that chiropractors, on a global scale, are now closing ranks and tolerating all practice styles in a blatant struggle for survival. See:
https://edzardernst.com/2019/01/evidence-based-chiropractic-education-would-mean-that-students-cannot-become-chiropractors/#comment-108859
Tell you what Blue Wode. I only care about those who wish to promote an evidence based care within the chiropractic model. We could debate if it’s 10% or 50% of chiropractors….seems pointless to debate it here since you are not actively involved in supporting EB chiropractors.
EB chiros are often referred to as “subluxation deniers” as they reject the use of the term and the often used definitions and descriptions of subluxation by the fundamentalists.
The word subluxation has no agreed upon meaning so a survey inquiring about a “subluxation-based practice”, without providing the participants with a clear definition, means basically nothing.
Regardless, EB chiropractors forge onward, those chiropractors that wish to join them are free to do so, provided they leave behind the silliness.
Example of progress, IMO… https://www.liebertpub.com/doi/abs/10.1089/acm.2018.0218?rfr_dat=cr_pub%3Dpubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&journalCode=acm
AN Other wrote on 14 January 2019, 17:22:45 : “Poor overall reputation – in who’s opinion?”
According to a California survey in 2004, when compared to medical doctors, chiropractors are:
• 2x more likely to be involved in malpractice
• 9x more likely to be practicing fraud
• 2x more likely to transgress sexual boundaries
Ref: https://www.jmptonline.org/article/S0161-4754(04)00131-9/fulltext
Also, I understand that, after more than 120 years, the utilisation rate for chiropractic is between 7-10% only (maybe fractionally more, depending on the reliability of the stats).
@ Blue wode
What is the satisfaction rate of patients of chiropractors? Is that figure important?
Also what is the utilisation rate of physiotherapy in the US?
I have found one study which says it is 4.5% of population over a 6 month period (having 1 visit)
http://www.kantarhealth.com/docs/publications-citations/trends-in-physical-and-occupational-therapy-utilization-in-the-us-and-western-europe
AN Other wrote: “@ Blue wode What is the satisfaction rate of patients of chiropractors? Is that figure important?”
@AN Other
I don’t know what the rate is, but patient satisfaction is not of great relevance in scientific health matters. See: https://tinyurl.com/yayhyx8z
With regard to the utilisation rate of physiotherapy in the US, I don’t know what it is, but given that I have illustrated above that chiropractors, globally, are admitting that they are wholly reluctant to embrace reform, this is what chiropractors are looking at:
QUOTE
“As I warned in Bonesetting, Chiropractic and Cultism [4], if chiropractic fails to specialize in an appropriate manner, there may be no justification for the existence of chiropractic when there are an adequate number of physical therapists providing manipulative therapy. Many physical therapists are now using manipulation/mobilization techniques. Of the 209 physical therapy programs in the US, 111 now offer Doctor of Physical Therapy (DPT) degrees [28]. Some of these programs have been opened to qualified chiropractors. According to the American Physical Therapy Association [34], “…Physical therapy, by 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists. Consumers will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services. Physical therapists will be practitioners of choice in patients’/clients’ health networks and will hold all privileges of autonomous practice…” It matters little who does spinal manipulative therapy as long as it is appropriate and evidence-based.”
Ref: http://jmmtonline.com/documents/HomolaV14N2E.pdf
FYI, here’s the latest example of chiropractic professional interests conflicting with public health and science:
At the British Chiropractic Association’s 2018 Autumn Conference, the President’s Lecture, delivered by Alison Dantas, CEO, Canadian Chiropractic Association, showed a slide entitled ‘Moving past what divides us’:
https://chiropractic-uk.co.uk/wp-content/uploads/2018/10/09.15-Alison-Dantas.pdf (p.15)
Why not resolve ‘what divides us’?
@ Blue Wode
Some people think Patient satisfaction is of relevance in scientific health matters:
https://emj.bmj.com/content/21/5/528?int_source=trendmd&int_medium=trendmd&int_campaign=trendmd
Also, do you have a link to the full paper your referenced (Ref: https://www.jmptonline.org/article/S0161-4754(04)00131-9/fulltext)
If the utilisation rate of physiotherapy is less than chiropractic, what do you think that means?
AN Other wrote: “Some people think Patient satisfaction is of relevance in scientific health matters: https://emj.bmj.com/content/21/5/528?int_source=trendmd&int_medium=trendmd&int_campaign=trendmd ”
@ AN Other
What I said was that patient satisfaction was not of *great* relevance in scientific health matters and that it wasn’t a reliable measurement. The paper that you cite is addressing non-specific effects in emergency medicine and does not, in any way, excuse the paucity of evidence for chiropractic treatment:
QUOTE
“A systematic review was undertaken to identify published evidence relating to patient satisfaction in emergency medicine…The three most frequently identified service factors were: interpersonal skills/staff attitudes; provision of information/explanation; perceived waiting times. Seven controlled intervention studies were found. These suggested that increased information on ED arrival, and training courses designed to improve staff attitudes and communication, are capable of improving patient satisfaction.”
AN Other wrote: “Also, do you have a link to the full paper you referenced (Ref: https://www.jmptonline.org/article/S0161-4754(04)00131-9/fulltext)”
The full text isn’t freely available online. However, in 2003, Chiropractic Economics wrote a piece on the study entitled ‘Study suggests ethics a problem for the profession’:
QUOTE:
“ORLANDO, FLA — The chiropractic profession is experiencing a true crisis in ethics, Dr. Stephen Foreman, a California researcher and author, told attendees at the annual FCLB conference. “The incidence rate for disciplinary actions in chiropractic is double that for medical profession, especially with fraud actions and sexual violations.”
Foreman based his statements on an unpublished retrospective study of disciplinary actions of chiropractors and medical doctors in California. He said he selected California for his analysis not only because he practices in that state, but also because California publishes disciplinary actions on its Web site, http://www.chiro.ca.gov. The statistics were easily accessible, he said.
Also, he said that California has the largest number of chiropractic schools, the greatest number of licensed chiropractors and the largest number of licensed medical doctors in the nation.
Foreman plans to publish the results from his study.
Foreman’s study took into account differences in numbers of California-licensed chiropractors (11,095) vs. medical doctors (104,000). He also noted that he studied disciplinary actions given by the board in a five-year period for chiropractors, compared to 18 months for MDs, but his final analysis also accounted for these differences.
“Two-thirds of all the complaints were in fraud and sex,” said Foreman. “What this says is that we have major problems in ethics,” he said. “The majority of actions are true ethical problems, compared to drugs, alcohol and clinical competency.”
Foreman guessed at the causes of ethical problems within chiropractic, stressing that he had no data to substantiate his opinions. He said he believes:
• An excessive number of non-serious people are allowed into chiropractic because of standards. “Serious students work hard, get good grades and get degrees,” he said.
• There is a failure to remove questionable students from programs. “These are people who cheat on tests,” he explained.
• Economic environment caused by changes in reimbursement and the cost of education contribute to the cause. “It’s harder to make money today and cost of education is high. This causes desperation,” Foreman speculated.
• We have a propensity to allow too many disciplined doctors to return to practice. “Practice is not a right; it is a privilege. It should be hard to get back into the profession,” he observed.
Foreman challenged board members to improve the ethical climate. He urged boards to increase their diligence in investigating and handling complaints and to demand higher education and admission standards for license status.
“Higher standards will bring in more serious people,” said Foreman.
[QUOTE ENDS]
Ref: https://tinyurl.com/yb7xlad3
AN Other wrote: “If the utilisation rate of physiotherapy is less than chiropractic, what do you think that means?”
Highly judicious referral patterns to phyisotherapists by MDs?
@ Blue wode
Why are you talking about the quality of evidence for chiropractic treatment?
You may feel that patient satisfaction was not of *great* relevance in scientific health matters but I believe it is and that is why people are doing research on it. So I guess we are going to just have to agree to disagree on that matter
Where did you get the following figures from that study if it is not freely available online:
According to a California survey in 2004, when compared to medical doctors, chiropractors are:
• 2x more likely to be involved in malpractice
• 9x more likely to be practicing fraud
• 2x more likely to transgress sexual boundaries
I don’t think I saw these figures mentioned in the Chiropractic Economics article you cited.
Also people in the states can see a physio without MD referral – do you think there is another reason(s) for a possible lower utilisation rate of physiotherapy than chiropractic?
aggressive advertising
@ Edzard
Agree
Perhaps a more relevant percentage..
Individuals with back pain
12-month utilization 31.0% (26.2-37.3)
Lifetime utilization 31.9% (24.6-46.0)
https://chiromt.biomedcentral.com/articles/10.1186/s12998-017-0165-8
very different figures here:
https://www.ncbi.nlm.nih.gov/pubmed/30558605
Taken together…around 25% saw a chiropractor. Not “very different”.
DC wrote on Tuesday 15 January 2019 at 12:41: “Tell you what Blue Wode. I only care about those who wish to promote an evidence based care within the chiropractic model…The word subluxation has no agreed upon meaning so a survey inquiring about a “subluxation-based practice”, without providing the participants with a clear definition, means basically nothing….Example of progress, IMO… https://www.liebertpub.com/doi/abs/10.1089/acm.2018.0218?rfr_dat=cr_pub%3Dpubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&journalCode=acm ”
@DC
I think you need to examine ‘evidence based’ chiropractic more carefully. For example, your link reveals that “Chiropractic care may have value in improving patient outcomes and decreasing opioid use…A diverse group of U.S. private sector medical facilities have implemented chiropractic clinics, and a wide variety of facility stakeholders report high satisfaction with the care provided.”
As we know (see above), patient satisfaction is not a reliable measurement, and chiropractic is not the answer to the opioid crisis. See https://edzardernst.com/2017/02/opioid-over-use-chiropractic-megalomania-and-six-probing-questions/
Also, note that Christine Goertz DC, a co-author of the study you link to, was lead author of a study critiqued here: https://tinyurl.com/yc387mgn
Snippet:
“This trial follows the infamous ‘A+B versus B’ design. It will almost always generate a positive result – so much so that it is a waste of time to run the study because we know its findings before it has started. And if this is so, the trial is arguably even unethical.”
“Patient clinical outcomes, patient satisfaction, provider productivity, and cost offset were identified as markers of clinic success.”
@ DC
I’m not convinced.
Three of the four authors seem to have vested interests in positive outcomes for chiropractic – i.e. two of the authors are from Palmer Chiropractic College, and one – as already pointed out – is a chiropractor who uses highly dubious research methods.
Also note that the abstract says that chiropractic care *may* have value in improving patient outcomes and decreasing opioid use and that purpose of the qualitative study was *to describe* organizational structures, care processes, and *perceived value* of chiropractic integration within U.S. private sector medical facilities.
I agree that deeper studies need to be done.
@DC: SO the logical, semantical and/or logistic problem of chiroqackery persists; WTF DO YOU EB persons DO if not involved in subluxation hunting & killing??? Isn’t manure by other name still manure? Don’t you at some point have to tell the ignorant mark that you found an “area of restricted motion” (which you’ve decided through anthroposophical-fiat to actually be a valid health-issue…though not in any way remotely similar to a subluxation, as arcane as that sounds) and that a “manipulative-thrust” will magically restore the motion? And that means something? WTF am I missing here? Do u practice manipulation like a McKenzie-certified PT, Cyriax, Mulligan or any number of those equally self-aggrandizing snipe-hunters? IF subluxation doesn’t exist then what have you replaced it with in these heady-EB days of wine & roses? Do you simply sell gym memberships and Gatorade? Sincerely, yours in confusion.
AN Other wrote 16 January 2019, 12:55:04: “You may feel that patient satisfaction was not of *great* relevance in scientific health matters but I believe it is and that is why people are doing research on it. So I guess we are going to just have to agree to disagree on that matter.”
@ AN Other
FYI, apparently you don’t need to be a healthcare professional to achieve patient satisfaction. For example, about a decade ago, a study was conducted in which an actor pretended to be a faith healer. It set out to discover how much of the healing effect came from the interaction with the healer rather than any ‘subtle energy’ the healer might be sending the patient. In order to imitate the healer the actor was of a similar age and appearance and for the purpose of the study both the actor and the healer wore similar clothes both were called ‘Fred’ both used the same music and both said and did the same things. Both men worked with chronic asthma sufferers who hadn’t had much improvement with conventional treatments. All the patients improved and there was no statistical difference between the groups, although there was a slight tendency for the *actor’s* patients to improve more.
Ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1839019/
So, I think that patient ‘satisfaction’ has similarities to the elicitation of a placebo response – something that cannot be relied upon in clinical practice. See https://tinyurl.com/y9qur74q
Indeed, the thickness of carpets in chiropractic clinics was mentioned in this valid criticism of the much-touted (by chiropractors) Meade et al study and its dubious positive outcomes…
https://www.ebm-first.com/chiropractic/the-meade-report-criticism/1194-peter-dixon-chair-of-the-general-chiropractic-council-seems-to-be-a-bit-careless-about-evidence.html
AN Other wrote 16 January 2019, 12:55:04: “Where did you get the following figures from that study if it is not freely available online: According to a California survey in 2004, when compared to medical doctors, chiropractors are: • 2x more likely to be involved in malpractice • 9x more likely to be practicing fraud • 2x more likely to transgress sexual boundaries”
See item 7 here:
https://www.patheos.com/blogs/unreasonablefaith/2009/04/7-things-you-need-to-know-about-chiropractic-therapy/
AN Other wrote 16 January 2019, 12:55:04: “Also people in the states can see a physio without MD referral – do you think there is another reason(s) for a possible lower utilisation rate of physiotherapy than chiropractic?”
Because physiotherapists are not known to indulge greatly (if at all) in scaremongering/brainwashing regarding (chiropractic practice-building) ‘preventative/maintenance/wellness care’ visits for the whole family?