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

Maintenance Care is an approach whereby patients have chiropractic manipulations even when symptom-free. Thus, it is an ideal method to keep chiropractors in clover. Previous reviews concluded that evidence behind this strategy is lacking. Since then, more data have emerged. It was therefore timely to review the evidence.

Fourteen original research articles were included in the review. Maintenance Care was defined as a secondary or tertiary preventive approach, recommended to patients with previous pain episodes, who respond well to chiropractic care. Maintenance Care is applied to approximately 30% of Scandinavian chiropractic patients. Both chiropractors and patients believe in the efficacy of Maintenance Care. Four studies investigating the effect of chiropractic Maintenance Care were identified, with disparate results on pain and disability of neck and back pain. However, only one of these studies utilized all the existing evidence when selecting study subjects and found that Maintenance Care patients experienced fewer days with low back pain compared to patients invited to contact their chiropractor ‘when needed’. No studies were found on the cost-effectiveness of Maintenance Care.

The authors concluded that knowledge of chiropractic Maintenance Care has advanced. There is reasonable consensus among chiropractors on what Maintenance Care is, how it should be used, and its indications. Presently, Maintenance Care can be considered an evidence-based method to perform secondary or tertiary prevention in patients with previous episodes of low back pain, who report a good outcome from the initial treatments. However, these results should not be interpreted as an indication for Maintenance Care on all patients, who receive chiropractic treatment.

I have to admit, I have problems with these conclusions.

  1. Maintenance Care is not normally defined as secondary or tertitary prevention. It also includes primary prevention, which means that chiropractors recommend it for just about anyone.  By definition it is long term care, that is not therapeutically necessary, but performed at regular intervals to help prevent injury and enhance quality of life.  This form of care is provided after maximal therapeutic benefit is achieved, without a trial of treatment withdrawal, to prevent symptoms from returning or for those without symptoms to promote health or prevent future problems.
  2.  I am not convinced that the evidence would be positive, even if we confined it to secondary and tertiary prevention.

To explain my last point, let’s have a look at the 4 RCT and check whether they really warrant such a relatively positive conclusion.

FIRST STUDY For individuals with recurrent or persistent non-specific low back pain (LBP), exercise and exercise combined with education have been shown to be effective in preventing new episodes or in reducing the impact of the condition. Chiropractors have traditionally used Maintenance Care (MC), as secondary and tertiary prevention strategies. The aim of this trial was to investigate the effectiveness of MC on pain trajectories for patients with recurrent or persistent LBP.

This pragmatic, investigator-blinded, two arm randomized controlled trial included consecutive patients (18–65 years old) with non-specific LBP, who had an early favorable response to chiropractic care. After an initial course of treatment, eligible subjects were randomized to either MC or control (symptom-guided treatment). The primary outcome was total number of days with bothersome LBP during 52 weeks collected weekly with text-messages (SMS) and estimated by a GEE model.

Three hundred and twenty-eight subjects were randomly allocated to one of the two treatment groups. MC resulted in a reduction in the total number of days per week with bothersome LBP compared with symptom-guided treatment. During the 12 month study period, the MC group (n = 163, 3 dropouts) reported 12.8 (95% CI = 10.1, 15.5; p = <0.001) fewer days in total with bothersome LBP compared to the control group (n = 158, 4 dropouts) and received 1.7 (95% CI = 1.8, 2.1; p = <0.001) more treatments. Numbers presented are means. No serious adverse events were recorded.

MC was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific LBP but it resulted in a higher number of treatments. For selected patients with recurrent or persistent non-specific LBP who respond well to an initial course of chiropractic care, MC should be considered an option for tertiary prevention.

SECOND STUDY Back and neck pain are associated with disability and loss of independence in older adults. Whether long‐term management using commonly recommended treatments is superior to shorter‐term treatment is unknown. This randomized clinical trial 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 ages ≥65 years with back and neck disability for ≥12 weeks. Coprimary outcomes were changes in Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores after 36 weeks. An intent‐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 disability (ODI score –3.9 [95% confidence interval (95% CI) –5.8, –2.0] versus ODI score –6.3 [95% CI –8.2, –4.4]) and neck disability (NDI score –7.3 [95% CI –9.1, –5.5] versus NDI score –9.0 [95% CI –10.8, –7.2]) after 36 weeks, with no difference between groups (back ODI score 2.4 [95% CI –0.3, 5.1]; neck NDI score 1.7 [95% CI 0.8, 4.2]). The long‐term management group experienced greater improvement in neck pain at week 36, in self‐efficacy at weeks 36 and 52, and in functional ability, and balance.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.

THIRD STUDY A prospective single blinded placebo controlled study was conducted. To assess the effectiveness of spinal manipulation therapy (SMT) for the management of chronic nonspecific low back pain (LBP) and to determine the effectiveness of maintenance SMT in long-term reduction of pain and disability levels associated with chronic low back conditions after an initial phase of treatments. SMT is a common treatment option for LBP. Numerous clinical trials have attempted to evaluate its effectiveness for different subgroups of acute and chronic LBP but the efficacy of maintenance SMT in chronic nonspecific LBP has not been studied. Sixty patients, with chronic, nonspecific LBP lasting at least 6 months, were randomized to receive either (1) 12 treatments of sham SMT over a 1-month period, (2) 12 treatments, consisting of SMT over a 1-month period, but no treatments for the subsequent 9 months, or (3) 12 treatments over a 1-month period, along with “maintenance spinal manipulation” every 2 weeks for the following 9 months. To determine any difference among therapies, we measured pain and disability scores, generic health status, and back-specific patient satisfaction at baseline and at 1-, 4-, 7-, and 10-month intervals. Patients in second and third groups experienced significantly lower pain and disability scores than first group at the end of 1-month period (P = 0.0027 and 0.0029, respectively). However, only the third group that was given spinal manipulations (SM) during the follow-up period showed more improvement in pain and disability scores at the 10-month evaluation. In the nonmaintained SMT group, however, the mean pain and disability scores returned back near to their pretreatment level.SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.

FORTH STUDY Evidence indicates that supervised home exercises, combined or not with manual therapy, can be beneficial for patients with non-specific chronic neck pain (NCNP). The objective of the study is to investigate the efficacy of preventive spinal manipulative therapy (SMT) compared to a no treatment group in NCNP patients. Another objective is to assess the efficacy of SMT with and without a home exercise program.Ninety-eight patients underwent a short symptomatic phase of treatment before being randomly allocated to either an attention-group (n = 29), a SMT group (n = 36) or a SMT + exercise group (n = 33). The preventive phase of treatment, which lasted for 10 months, consisted of meeting with a chiropractor every two months to evaluate and discuss symptoms (attention-control group), 1 monthly SMT session (SMT group) or 1 monthly SMT session combined with a home exercise program (SMT + exercise group). The primary and secondary outcome measures were represented by scores on a 10-cm visual analog scale (VAS), active cervical ranges of motion (cROM), the neck disability index (NDI) and the Bournemouth questionnaire (BQ). Exploratory outcome measures were scored on the Fear-avoidance Behaviour Questionnaire (FABQ) and the SF-12 Questionnaire. Our results show that, in the preventive phase of the trial, all 3 groups showed primary and secondary outcomes scores similar to those obtain following the non-randomised, symptomatic phase. No group difference was observed for the primary, secondary and exploratory variables. Significant improvements in FABQ scores were noted in all groups during the preventive phase of the trial. However, no significant change in health related quality of life (HRQL) was associated with the preventive phase. This study hypothesised that participants in the combined intervention group would have less pain and disability and better function than participants from the 2 other groups during the preventive phase of the trial. This hypothesis was not supported by the study results. Lack of a treatment specific effect is discussed in relation to the placebo and patient provider interactions in manual therapies. Further research is needed to delineate the specific and non-specific effects of treatment modalities to prevent unnecessary disability and to minimise morbidity related to NCNP. Additional investigation is also required to identify the best strategies for secondary and tertiary prevention of NCNP.

__________________________________________________________________________

I honestly do not think that the findings from these 4 small trials justify the far-reaching conclusion that Maintenance Care can be considered an evidence-based method… For that statement to be evidence-based, one would need to see more and better studies. Therefore, the honest conclusion, I think, is that maintenance care is not supported by sound evidence for effectiveness; as chiropractic manipulations are costly and not risk-free, its risk/benefit balance fails to be positive. Therefore, this approach cannot be recommended.

36 Responses to Chiropractic maintenance care: boosting chiropractic cash flow in perpetuity

  • EE…maintenance care is not supported by sound evidence for effectiveness; as chiropractic manipulations are costly and not risk-free, its risk/benefit balance fails to be positive.

    Compared to what? This? Pot calling the kettle black?

    “SIGNIFICANCE: There is very low quality evidence of the long-term efficacy, tolerability and safety of opioids for chronic low back, osteoarthritis and diabetic polyneuropathic pain within the context of open-label extension studies of randomized controlled trials. Drop out rate due to adverse events and deaths increase with study duration.”

    Bialas P, et al. Eur J Pain. 2019.

    • OPIOIDS FOR PREVENTION????

      • “Some studies explored the concept of Maintenance Care in terms of its rationale, as defined by chiropractors [11, 14, 20]. They clearly described Maintenance Care as a type of prolonged care delivered at regular intervals.”

        “previous episodes were, indeed, found to be the strongest predictor for recommending Maintenance Care [9].”

        “Maintenance Care sessions included a range of treatment modalities, from the ordinary examination/manual treatment to packages including exercise prescriptions, advice on ergonomics, diet, weight loss, and stress management, i.e. it included a program meant to motivate patients to maintain healthy lifestyle habits through empowerment [14]”

        “The current evidence suggests that exercise alone or in combination with education is effective for preventing LBP.” JAMA Intern Med. 2016 Feb;176(2):199-208

        • do you have a point?

        • “For chronic pain, long-term opioid therapy is associated with poorer patient-reported pain, function, and quality-of-life outcomes and may be less effective among individuals with mood disorders, centralized pain syndromes, neuropathic pain, and psychiatric disorders.3,4 Opioid therapy is also associated with numerous dose-related adverse effects, such as respiratory depression and overdose, as well as dependence, tolerance, worsened pain, depression, constipation, and confusion.5 Approximately 20% of individuals receiving long-term opioid therapy develop an opioid use disorder.6” JAMA Netw Open. 2018;1(2):e180236

          “Opioids are commonly prescribed for chronic back pain and may be efficacious for short-term pain relief. Long-term efficacy (> or =16 weeks) is unclear. Substance use disorders are common in patients taking opioids for back pain, and aberrant medication-taking behaviors occur in up to 24% of cases.” Ann Intern Med. 2007 Jan 16;146(2):116-27.

          “SIGNIFICANCE: There is very low quality evidence of the long-term efficacy, tolerability and safety of opioids for chronic low back, osteoarthritis and diabetic polyneuropathic pain within the context of open-label extension studies of randomized controlled trials. Drop out rate due to adverse events and deaths increase with study duration.” Bialas P, et al. Eur J Pain. 2019.

          But let’s not recommend/try a more conservative approach to try and maintain comfort and function and perhaps prevent recurrent episodes, eh?

          “These findings highlight atypical coordination of hip and trunk musculature potentially related to task demands in persons with rLBP even during remission from pain.” Journal of Electromyography and Kinesiology Volume 50, February 2020, 102378

          “Maintenance Care sessions included a range of treatment modalities, from the ordinary examination/manual treatment to packages including exercise prescriptions, advice on ergonomics, diet, weight loss, and stress management, i.e. it included a program meant to motivate patients to maintain healthy lifestyle habits through empowerment [14]”

          Do i have a point?..yah, you don’t appear to have anything better to offer.

          • so that’s your point: “But let’s not recommend/try a more conservative approach to try and maintain comfort and function and perhaps prevent recurrent episodes, eh?”
            and that’s my answer: BY ALL MEANS, LET’S – BUT FIRST SHOW THAT IT IS EFFECTIVE!

          • EE: BY ALL MEANS, LET’S – BUT FIRST SHOW THAT IT IS EFFECTIVE!

            Does the medical approach have the same criteria?

            “There is very low quality evidence of the long-term efficacy, tolerability and safety of opioids for chronic low back…” Bialas P, et al. Eur J Pain. 2019.

            “Existing evidence on the use of gabapentinoids in CLBP is limited and demonstrates significant risk of adverse effects without any demonstrated benefit.” PLoS Med 14(8): e1002369.

            “However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery.”  The Lancet 391(10137) · March 2018

            etc, etc, etc.

            Sure, let’s do the research. In the meantime, let’s not recommend not using approaches which appear to be effective in managing patients just because we just don’t have enough research to satisfy you.

            People are dying from the medical approach, hundreds a day. How many have to die before you think there is enough research that a conservative maintenance approach might just help prevent recurrent back pain and/or keep/lessen chronic back pain patients from drugs?

            But no, to you it’s all about chiro cash flow.

            Buy a vowel.

          • you are again trying to sell smelly red herrings.
            THIS IS ABOUT MAINTENANCE CARE: the regular treatment of people who have no symptoms at all

          • Who said a maintenance care has to be delivered only to the asymptomatic? A website from some chiropractor?

            “This is treatment of the symptomatic patient who has reached pre-clinical status or maximum medical improvement, where condition is resolved or stable”. Boisvert L. In: Advances in Chiropractic. Lawrence DJ, editor. Vol. 3. Chicago: Mosby Year Book Inc; 1996. p. 259

            “”… treatment, either scheduled or elective, which occurred after optimum recorded benefit was reached, provided there was no evidence of relapse.” Breen AC. Chiropractic in Britain. Ann Swiss Chiropractors’ Assoc. 1976;6:207–218.

          • I can find you even more refs that support my definition.
            but, on second thought, I won’t.
            in fact, you can sell your red herrings to someone else.
            I find exchanges with you similar to playing chess with a pigeon.

          • EE…I can find you even more refs that support my definition.

            Let me guess, more websites?

            “It is common for chiropractors to recommend “maintenance care (MC)”, i.e. preventive consultations/visits for recurrent and persistent musculoskeletal pain and dysfunction.” PlusOne September 12, 2018

          • Leaving the Tu quo que fallacy aside for the moment…Perhaps I missed it, but where was EE promoting opioid use for prevention of back pain? Or was it that he was promoting opioids for chronic LBP? I didn’t see that either so I’d appreciate seeing it. Thanks in advance!

          • I would not hold my breath

          • MH…Perhaps I missed it, but where was EE promoting opioid use for prevention of back pain? Or was it that he was promoting opioids for chronic LBP?

            I never said he was.

          • “Prescribing physical activity, including core strengthening, physical therapy, or yoga, is an important therapeutic intervention. Early return to work should be encouraged when appropriate. There is limited evidence to support workplace modification, medication, or steroid injection for nonspecific low back pain.”

            https://www.aafp.org/afp/2019/1201/p697.html?fbclid=IwAR0vWSvGPQGf9l10cgY0zDSpXWSiGvSbTM85HH_1vzGdML5TsV4v792svhQ

  • Meanwhile, whilst EE is waxing lyrically about the chiropractic profession and research, I would suggest the he contact all the universities that have awarded chiropractors with PhDs, (proper doctors) and review all the research that they did in order to get these higher degrees. He should then do a critique of these theses and if he finds fault with them contact the respective universities and make a complaint. Please publish your results Edzard. I bet you don’t.
    You should also have a listen to the following item on the radio in New Zealand about the ethics of some research that has been done in other areas of healthcare. (I bet you dont).
    https://www.rnz.co.nz/national/programmes/saturday/audio/2018723788/carl-elliott-on-the-importance-on-whistle-blowing

    Another perfect example by E.E. of the “Pot calling the kettle black”.

    • Doctorates (PhD) are higher degrees awarded afer a viva voce examination based on a thesis and dissertation.
      That can be on any subject including imaginary ones: fairies; ghosts; any flights of imagination or delusion – if that is what has been researched and studied.

      The award of the PhD is for the quality of the study but confers no imprimatur on the subject studied and certainly does not allow any academic endorsement of the subject of the study (the flights of examination, bizzare recesses of human psychology, subluxations…).

      And for the umteenth time, tu quoque is a logical fallacy and pointless on this blog theme – we know ‘medicine’ has faults, and contributors to EE’s work generally try to expose and deal with them.
      GG’s point is…?

  • Meanwhile, whilst EE, BW, MK et al criticise the chiropractic profession about evidence based care, they should review articles like this one on evidence based dentistry…
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5004537/

    the dentists find it hard to claim to be evidence based, especially when you see articles like this

    https://www.dailymail.co.uk/health/article-2011372/Venners-crowns-Dentists-overuse-expensive-treatments-diagnosing-imaginary-condition-warn-experts.html

    appearing in the news media. This is probably the “tip of the iceberg”as far as non-evidence based care by dentists.

    • meanwhile some utter git tells me what I should and should not review on my own blog.

      • @EE
        For years I thought you would assess ALL the research on its merits and that you would be prepared to change your position when evidence appears then I read this blog by you:
        “We have an ethical, legal and moral duty to discourage chiropractic neck manipulations”.
        https://edzardernst.com/2017/04/we-have-an-ethical-legal-and-moral-duty-to-discourage-chiropractic-neck-manipulations/
        “Charlotte Leboeuf-Yde, DC,MPH,PhD, is professor in Clinical Biomechanics at the University of Southern Denmark and works at the French-European Institute of Chiropractic in Paris. She is a chiropractor with extensive research experience, for example, she was one of the first chiropractors to have studied adverse reactions of spinal manipulation.” – Edzard Ernst.
        “I have always thought highly of Charlotte’s work, however, her conclusion made me doubt whether my high opinion of her reasoning was justified.” – Edzard Ernst.
        So here is a researcher doing key research on a topic that you have been harping on for years who you “think highly of” whoswe research you have read yet ignore until you could take issue with two sentences in a BLOG then you write a hatchet BLOG.
        This is when I came to the realization that you cherry pick the research to fit your bias and ignore the research and researchers who challenge it.
        You have spent so much time making public statements from one point of view that you are incapable of change.
        Sadly that is human nature and to be expected.
        Facts don’t change peoples minds.
        We have the same issue with the vitalistic chiropractors that believe in subluxations.
        The two extremes using the same arguments.
        How ironic.

        “maintenance care is not supported by sound evidence for effectiveness; as chiropractic manipulations are costly and not risk-free, its risk/benefit balance fails to be positive. Therefore, this approach cannot be recommended.”
        In red at the top of your blog:
        “Please remember: if you make a claim in a comment, support it with evidence.”.
        Pot,kettle,black?
        Does this apply to Edzard Ernst?

        Latest research from my library (only the most recent 5 with no cherry picking):
        Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis.
        Paige NM, Miake-Lye IM, Booth MS, Beroes JM, Mardian AS, Dougherty P, Branson R, Tang B, Morton SC, Shekelle PG. JAMA. 2017 Apr 11;317(14):1451-1460. doi: 10.1001/jama.2017.3086.
        Are Nonpharmacologic Interventions for Chronic Low Back Pain More Cost Effective than Usual Care? Proof of Concept Results from a Markov Model.
        Herman PM, Lavelle TA, Sorbero ME, Hurwitz EL, Coulter ID. Spine (Phila Pa 1976). 2019 May 1. doi: 10.1097/BRS.0000000000003097.
        Conservative Spine Care Pathway Implementation Is Associated with Reduced Health Care Expenditures in a Controlled, Before-After Observational Study.
        Weeks WB, Pike J, Donath J, Fiacco P, Justice BD. J Gen Intern Med. 2019 Mar 18. doi: 10.1007/s11606-019-04942-7.
        Cost-effectiveness of spinal manipulation, exercise, and self-management for spinal pain using an individual participant data meta-analysis approach: a study protocol
        Brent Leininger, Gert Bronfort, Roni Evans, James Hodges, Karen Kuntz and John A. Nyman. Chiropractic & Manual Therapies. 201826:46. 13 November 2018. Doi: 10.1186/s12998-018-0216-9
        The Nordic Maintenance Care Program: Does psychological profile modify the treatment effect of a preventive manual therapy intervention? A secondary analysis of a pragmatic randomized controlled trial.
        Eklund A, Jensen I, Leboeuf-Yde C, Kongsted A, Jonsson M, Lövgren P, Petersen-Klingberg J, Calvert C, Axén I. PLoS One. 2019 Oct 10;14(10):e0223349. doi: 10.1371/journal.pone.0223349.
        Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis.
        Paige NM, Miake-Lye IM, Booth MS, Beroes JM, Mardian AS, Dougherty P, Branson R, Tang B, Morton SC, Shekelle PG. JAMA. 2017 Apr 11;317(14):1451-1460. doi: 10.1001/jama.2017.3086.

        • @CC
          Next time you want to impress with a copy-pasted reference-dump, please try to make an effort and read the material you refer to first. I just wasted precious time finding and reading some of the abstracts from your list*. I gave up after reading three items, totally irrelevant to the subject, and boringly bad science as well.
          Familiar words in the titles and author names that are known to have worked in the field is not enough to determine the relevance of a paper and certainly not enough to determine if there is evidence to be found in the reference. You have been around long enough on this blog to have learnt at least some of the principles of evaluating evidence, right?
          Next time, please make an effort to at least read what you refer to and try to eliminate that which is totally irrelevant. And also, please supply a link to an accessible abstract or full text of each item so we can avoid to waste time on copuing and searching for them. It would also help if you added a few words to each reference to help us understand why you think it points to relevant evidence.

          * And now, the time I have spent on trying to teach some unimportant incognito basic manners in discussing matters scientific, is hopefully not wasted as well?
          Back to sleep…

          • @BG
            ” I just wasted precious time finding and reading some of the abstracts from your list”.
            You read just the abstracts?
            Then write:
            “Familiar words in the titles and author names that are known to have worked in the field is not enough to determine the relevance of a paper”.
            “Next time, please make an effort to at least read what you refer to”.
            “You have been around long enough on this blog to have learnt at least some of the principles of evaluating evidence, right?”
            “And now, the time I have spent on trying to teach some unimportant incognito basic manners in discussing matters scientific, is hopefully not wasted as well?”
            Based on reading the abstracts?
            Hmmmmm.

          • @CC
            😀

            I know what I wrote. Do you know what you posted 😉

          • I’m rather fond of you Björn Geir. 🙂
            You are prepared to listen and make concessions when presented with evidence.
            A rarity here. :-0

      • Meanwhile, whilst Prof.Ernst is resorting to insults, he should look at the top of the page and read and remember the following quote, “Please remember: if you make a claim in a comment, support it with evidence”.

        Again, the pot calling the kettle black.

  • I think some commenters here need to understand the tu quoque fallacy. The question is simple. Is there any evidence that regular chiropractic attention (I’m not sure I should call it `care’) is effective as a preventive strategy for any condition, in subjects with no pathology or symptoms? What happens in other scenarios is irrelevant.

    • What resource states that chiropractic maintenance care is just for those with no pathology or no symtoms? Is that the general consensus among chiropractors?

      Once the definition is clear (i think it is from what i shared earlier) then one can look at the evidence and also what other approaches are used in other healthcare disciplines (ex opioids and NSAIDs)

      • DC, A majority of chiropractors’ websites that I have seen recommend maintenance care, after a condition has resolved. That’s not of course a scientific evaluation, just my impression. This doesn’t mean primary prevention, although I have seen such recommended. I currently have a complaint in with the GCC against a practice that advertised routine chiropractic for new-borns without any pathology. I can’t give you details as it’s sub-judice of course.

  • Meanwhile, whilst Les Rose is confusing the Tu quoque fallacy with that of the “pot calling the kettle black”, as the chiropractic profession is expected to have a higher standard of care than other health professions, this appeared in regards to the explanation for a reaction to a change in medication.

    https://www.rnz.co.nz/news/in-depth/404933/epilepsy-patients-angry-at-being-told-symptoms-all-in-their-heads

    If you really wanted to study a profession that is seriously “woo related” look at the shake, bake and fake that the physiotherapists use in an attempt to treat conditions.

    Prof. Ernst, did you do a course in manual therapy in Germany many years ago?

    • GibleyGibley
      See https://en.wikipedia.org/wiki/Tu_quoque

      At first glance it seems reasonable to say that “the chiropractic profession is expected to have a higher standard of care than other health professions”. But chiropractors expose themselves to this by basing their practice on implausible mechanisms. If they believe in subluxations and innate intelligence, as many do, they attract perhaps more criticism than science-based professions might.

      However I agree that much of physiotherapy is poorly evidenced, and that applies to other specialisms such as surgery. The difference is partly in the area of harms. Established specialisms, eg physiotherapy and surgery, at least have reasonably robust systems in place for recording safety. The Chiropractors Act 1994 says nothing about safety monitoring. So extra public scrutiny seems justified.

      I will now break my rule and cite an anecdote. I have used chiropractic and physiotherapy, for the same condition, low back pain. The former failed, the latter succeeded. I try not to let this colour my opinions!

      • @Les Rose
        “Established specialisms, eg physiotherapy and surgery, at least have reasonably robust systems in place for recording safety.”
        Does physiothaerapy have an adverse event reporting system?
        A recent physio paper:
        Comparing the range of musculoskeletal therapies applied by physical therapists with postgraduate qualifications in manual therapy in patients with non-specific neck pain with international guidelines and recommendations: An observational study.
        https://www.sciencedirect.com/science/article/abs/pii/S2468781219304667
        “High velocity-thrust manipulation is applied frequently (33.8%)”.
        Here in Australia there are 4 times more physio’s than chiro’s so the sheer volume of high velocity thrust manipulations applied by physio’s to the cervical spine is larger than we thought.
        Recently here there was this newspaper article:
        https://www.abc.net.au/news/2019-08-05/concerns-over-the-rise-of-resistant-superbugs/11377930
        “Mr Fox had developed a clot on his brain following a neck manipulation by a physiotherapist, officially known as a carotid artery dissection.”
        That is the only reference to the physio in the whole article. One wonders how the article would have been written if “physio” was replaced with “chiro”?
        Do the physio’s have any robust system for recording safety?
        None that I know of.
        There was an attempt here around 5 years ago to bring in a standardized adverse event reporting system in hospital emergence departments to accurately capture accurate data free from medical assumptions and dogma and refer it to the relevant registration board for investigation in Melbourne. Chiro’s supported it but it went no further due to “snivelling” (quote at the time from a medical pain specialist in Melbourne who also supported it) from the doctors. Frustrating.

        • To clarify:
          “Standardized Adverse Event reporting system for ALL professions chiro, physio, osteo, GP etc”

          • yes, but for chiros it is the most urgent because the evidence suggests that they seem to have the biggest problem.

          • @Edzard Ernst
            Not really we just have critics who ignore similar behavior in other professions like the physio’s then claim their evidence based.
            The physio’s have very little in the way of a critical culture and those that do like SomaSimple lament that they are voices in the wilderness. They also have No external critics holding them to account.
            The ABC article above is a classic example. I pointed it out to you, Blue Wode and Friends of Science in Medicine on Twitter and the response was silence.
            Says it all.

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