MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.
One of my last posts re-ignited the discussion about the elementary issue of informed consent, specifically about informed consent for chiropractors. As it was repeatedly claimed that, in Australia, informed consent is a legal requirement for all chiros, I asked on Wednesday 11 November 2020 at 07:12

FOUR QUESTIONS TO DC + CRITICAL CHIRO (CC):

1) what does the law say about informed consent for Australian chiros?
2) what info exactly do you have to provide?
3) who monitors it?
4) what published evidence do we have about compliance?

CC then posted this reply:

Here we go again you demand evidence while providing little if any for your own assumptions (poor case studies do not count. The pleural of anecdote does not equal evidence whether it’s from chiro’s or you).
We have been over this many times over many years, I cite research/provide links yet you still find it challenging to take it onboard. It is human nature to feel obligated once making a public statement to defend it no matter how much evidence is sent your way. So not surprising.

“1) what does the law say about informed consent for Australian chiros?”
It is all freely available on the national regulators website (as you know and as I have referenced in the past):
https://www.chiropracticboard.gov.au/Codes-guidelines/Code-of-conduct.aspx
https://www.chiropracticboard.gov.au/Search.aspx?q=Informed+consent
Some research by chiropractors on this topic (cited many times in the past):
Risk Management for Chiropractors and Osteopaths. Informed consent
A Common Law Requirement (2004):
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051308/
Quick advanced PubMed with filters set to “Chiropractic” AND “Informed consent”.
https://www.ncbi.nlm.nih.gov/pmc/?term=(Chiropractic)+AND+Informed+consent
Not rocket science
Latest paper that you wrote an ill informed blog on and the comments were not going as you expected (So I expected you to double down like Donald Trump with a new blog within days. Your getting predictable).
https://chiromt.biomedcentral.com/articles/10.1186/s12998-020-00342-5
This paper questions the legal implications of vertebral subluxations with high powered legal input and is a broadside by evidence based chiropractors against vitalistic chiropractors. You respond a snide fantasy informed consent dialogue when you should be supporting the authors:
https://edzardernst.com/2020/11/informed-consent-why-chiropractors-dont-like-it/

“2) what info exactly do you have to provide?”
“4) what published evidence do we have about compliance?”
We have discussed this as well. It is a common law requirement for every profession and is checked upon re-registration by AHPRA every year and by the professional indemnity insurers every year. No informed consent, no registration and no professional indemnity insurance.
Checked AHPRA’s panel decisions and went back 5 YEARS and found ONE decision relating to informed consent:
https://www.ahpra.gov.au/Publications/Panel-decisions.aspx

“3) who monitors it?”
Another of your tired old arguments that we have discussed many times over the years.
In the UK there is the “‘Chiropractic Reporting and Learning System’ (CRLS)” but this is set up by the association representing chiropractors and not the registration board that advocates for patients. Right idea and step in the right direction, wrong organization.
Here years ago there was a trial of an adverse event reporting system in a Melbourne emergency department systematically collected relevant AE information on all professions which was sent to the relevant board for investigation.
It was supported by doctors and chiropractors while physio’s were not involved. A doctor involved told me it was killed off by ER doctors who “snivelled” about the extra paperwork.
There is no AE reporting system for physio’s, chiro’s, osteo’s, GP’s in private practice etc.
Over the years you have harped on and on about this topic as if it is a failing purely of the chiropractic profession when we have supported initiatives for its implementation.
You have also kept up with the research even commenting on an chiropractic researcher on AE’s Charlotte Leboeuf-Yde (who you highly regard) yet ignored until you could take issue with two sentences written in a blog then you wrote this hatchet blog:
https://edzardernst.com/2017/04/we-have-an-ethical-legal-and-moral-duty-to-discourage-chiropractic-neck-manipulations/
So you are asking for evidence yet willfully ignore an author who “I have always thought highly of Charlotte’s work”.

Stop the cynical cherry picked blogs and start supporting the researchers and reformers otherwise you are just someone standing on the sidelines blindly throwing grenades. You do not care who you hit or the damage you do to the chiropractors leading the reform you demand yet consistently fail to support.

____________________________________

I thought the tone of this response was oddly aggressive and found that CC had failed to understand some of my questions. Yet the link to the chiro’s code of conduct https://www.chiropracticboard.gov.au/Codes-guidelines/Code-of-conduct.aspx was useful. This is what it says about informed consent:

3.5 Informed consent
Informed consent is a person’s voluntary decision about healthcare that is made with knowledge and understanding of the benefits and risks involved. A useful guide to the information that chiropractors need to give to patients is available in the National Health and Medical Research Council (NHMRC) publication General guidelines for medical practitioners in providing information to patients.3 The NHMRC guidelines cover the information that chiropractors should provide about their proposed management or approach, including the need to provide more information where the risk of harm is greater and likely to be more serious, and advice about how to present information. Good practice involves:
a) providing information to patients in a way they can understand before asking for their consent
b) providing an explanation of the treatment/care recommended, its likely duration, expected benefits and cost, any alternative(s) to the proposed care, their relative risks/benefits, as well as the likely consequences of no care
c) obtaining informed consent or other valid authority before undertaking any examination or investigation, providing treatment/care (this may not be possible in an emergency) or involving patients in teaching or research, including providing information on material risks
 d) consent being freely given, without coercion or pressure
 e) advising patients, when referring a patient for investigation or treatment/ care, that there may be additional costs, which they may wish to clarify before proceeding
 f) obtaining (when working with a patient whose capacity to give consent is or may be impaired or limited) the consent of people with legal authority to act on behalf of the patient, and attempting to obtain the consent of the patient as far as practically possible
 g) being mindful of additional informed consent requirements when supplying or prescribing products not approved or made in Australia, and
h) documenting consent appropriately, including considering the need for written consent for procedures that may result in serious injury or death.
_______________________________________
This does indeed clarify some of my questions. Related to the fictional patient with neck pain who consults a chiropractor in my previous post, this means the chiro must inform the patient that:
  • the chiro suggests a manipulation of the neck;
  • this often involves forcing a spinal joint beyond its physiological range of motion;
  • the treatment will be short but needs repeating several times during the coming weeks;
  • the expected benefits are a reduction of pain and improvement of motion;
  • the total cost of the treatment series will be xy;
  • there are many other treatment options for neck pain;
  • most of these have a better risk/benefit profile than neck manipulation;
  • having no treatment for neck pain at all is likely to lead to full resolution of the problem over time.

Apart from any doubts that chiropractors would actually comply with these requirements, the question remains: is the listed information sufficient? Does it outline a truly a fully informed consent? I think that essential aspects of informed consent are missing.

  • The code does not explicidly require an explanation about the possible harms of spinal manipulation (i.e. 50% of all patients will suffer mild to moderate adverse effects lasting 2-3 days, and occasionally patients will have a stroke of which some have died).
  • Moreover, the code mentions EXPECTED benefits, but not benefits supported by evidence. Chiros may well EXPECT their treatment to work, but what does the evidence show? As often discussed on this blog, the evidence is negative or very week, depending how you want to interpret it. The code does not require a chiro to inform his patients about this fact.

So, the way I see it, the code does not expressedly demand the chiro to explain his patient that the treatment he is being asked to consent to is

  1. not supported by sound evidence for effectiveness,
  2. nor that the treatment is burdened with significant risks.

And what about the other questions listed above? An Australian chiropractor who will remain anonymous gave me the following answers:

Who monitors Informed Consent?
 
The short answer here is nobody monitors informed consent.  Typically informed consent is a side issue whenever a negligence claim is made.  Similarly, clinical records are a side issue as well.   Thus, when a patient alleges they were injured a complaint is lodged.  As part of the investigation consideration is given regarding the consent process.  If the analysis determines that the adverse outcome was maloccurence rather than negligence  but valid consent was not obtained, the practitioner will still face disciplinary action. 
 
As we are all too well aware, the Boards show little or no desire to be proactive.  I have yet to see any results from the pilot advertising audit project which began approximately 2 years ago.
 
What published evidence have we ab​out compliance?
 
Good question.  To my knowledge Langworthy & Flemming’s 2005 paper is the only one looking at compliance.  Their results suggest that the majority of respondents would be unable to successfully defend a negligence in consent liability charge.  In my experience providing expert opinions in Australian cases, valid consent was not obtained in a single case.  The most bizarre case had the practitioner their expert argue that consent obtained 7 years prior to the injury was still valid.  
 
Langworthy J.M., Cambron J. Consent: its practices and implications in United Kingdom and the United States chiropractic practice. J Manip Physiol Ther. 2007;(6):419–431.

_____________________________________

Yet, Australian chiropractors claim that they abide by the ethical imperative of informed consent. Are they taking the Mickey?

Perhaps not. Perhaps they are merely trying to make sure they do not lose the majority of their clientele. As I already pointed out in my previous post, fully informed consent would make most chiropractic patients turn round and run a mile.

66 Responses to The lack of chiropractic ethics: “valid consent was not obtained in a single case”

  • Prof. Ernst wrote: “As I already pointed out in my previous post, fully informed consent would make most chiropractic patients turn round and run a mile.”

    There has already been a confession about this from a chiropractor at an inquest in Canada (he allegedly caused a patient to suffer a stroke through neck manipulation).

    When pressed as to why he wasn’t telling his patients about the potentially catastrophic injuries and death which may result from neck manipulation, he said that­ if he were to tell them that “I can kill you” then “half of them would walk out”.

    Ref: https://www.chirowatch.com/Chiro-Lewis/oakley-closing.html (scroll down)

  • “there are many other treatment options for neck pain;”

    Like this?

    “Although randomized controlled trials could contribute data on the safety of botulinum toxin, they actually do not report serious or long-term adverse events of botulinum toxin.

    Pharmacovigilance data and case reports imply that botulinum toxin may be associated with serious adverse events such as botulism, generalized paralysis, dysphagia, respiratory depression, and even death.”
    https://www.karger.com/Article/Fulltext/370245

    “However, the association of botulinum toxin A with clinical benefit was small.”
    https://media.jamanetwork.com/news-item/botox-injections-associated-with-only-modest-benefit-for-chronic-daily-headaches-and-chronic-migraine-headaches/

  • I would be willing to bet that for medical providers of any type, informed consent is rarely given. Do conventional medical doctors who see a new patient every 10-15 min take the time to give IC? Do nurses when giving 8 shots at a “well-baby” visit give informed consent about all the shots? I doubt it. Maybe IC could be given online Before visits, by asking what someone is attending for and then giving them a list of possible treatments with possible outcomes, so that people could know before they arrive what is possible.

    • By your logic, one might be allowed to beat one’s partner, if the neighbour does it too?

    • Most doctors provide printed information as part of the consent process. Wherever possible consent is taken in advance of the procedure itself, so that the patient is given time to read the information carefully and have the opportunity to ask further questions before going ahead.

      In English law, the consent form is simply evidence that some sort of discussion has taken place and an indicator of the content of that discussion. Consent is deemed to take place when the patient holds out their arm for the injection, climbs onto the treatment couch or whatever.

      • I have around 20 procedures in my basic exam and treatment options. Each one listed on the form. We discuss each one. The patient initials the ones they consent to.

        Some don’t want cervical spinal manipulation, for example…no problem. It’s noted and we move on.

        Not that tough.

      • Consent might be “deemed” but that doesn’t mean it was informed. It has to be informed consent. All practitioners both CON-Men and alternative are lax on giving IC which is a major failure. Few are willing or able to take the time to give truly IC. That is why it should be provided before the visit as much as possible. California Health Freedom law requires it of all non-licensed practitioners; the patient must sign off on the practitioner’s training and mode of practice. I put it up on my website and require patients to read it before I see them.

  • If I recall, when informed consent started to be questioned in medicine, medical doctors were against it..they thought it would have a negative effect on patient outcomes. It was only when courts started ruling in favor of it that medical doctors were forced to comply.

    Of course i have informed consent. We go over minor and major possible AE. I have yet to have anyone walk out the door.

    Also there are expected and unexpected AE. Ernst doesnt seem to delve into that aspect of the topic.

    • @ DC

      in my view it always comes back to the risk/benefit ratio. If the likely benefit is significantly greater than the risk of the majority of the common adverse events and the patient accepts this then that is usually seen as acceptable. Sometimes there are rare adverse events that may be more serious – and these have to be weighed up as well.

      However if the likely benefit is close to zero and doing nothing may suffice as well or if there is an alternative therapy that is less risky that would achieve the same result – then it is clear that it is not worth accepting a level of risk for what is a marginal or zero benefit just to line the chiropractor’s pocket.
      It is fairly clear that the benefits of cervical manipulation are marginal at best and the risks are potentially severe – so the smart thing to do is to leave necks well alone if you’re a chiro. Of course we know that they’re too convinced of their own infallibility to do any such thing – but that would be the safest route.

      But the same principle applies everywhere else too – is any likely benefit worth any likely risk? And of course one may wish to try to narrow those down to percentages if available or consider that even ANY possibility of a certain adverse outcome would put one off a certain treatment.

  • @EE
    1. “the chiro suggests a manipulation of the neck”
    TICK
    2. “this often involves forcing a spinal joint beyond its physiological range of motion”
    TICK (Explain HVLA in detail).
    3. “the treatment will be short but needs repeating several times during the coming weeks”
    TICK (Treatments last 15-30 minutes depending on the presenting complaint, care plan discussed in detail. Additionally, if the patient just wants short term pain relief that is respected. It’s the patients choice not the chiro’s).
    4. “the expected benefits are a reduction of pain and improvement of motion”
    TICK (Outcomes/prognosis discussed/functional measures relevant to that patient discussed).
    5. “the total cost of the treatment series will be xy”
    TICK (ballooning out of pocket costs for surgery/dental here resulted in the government mandated this. Since what applies to one profession applies to ALL under AHPRA (national regulator that overseas all professions) Guess what. It applies to chiro’s as well.
    6. “there are many other treatment options for neck pain”
    TICK (I go through them and have good referral relationships with physio’s, pain specialists, neurosurgeons, orthopod’s, exercise physiologists etc to coordinate care).
    7. “most of these have a better risk/benefit profile than neck manipulation”
    Really Edzard? Are you sure?
    Lets check something as simple as mobilization v manipulation. What is the risk/benefit profile of mobilization? Is it safer than manipulation? Please cite research not your usual assumptions? (A friend had a similar discussion with a group of highly regarded physio researchers who made the same sssumption and asked them the same question. Is there research to support that mobilization is safer than manipulation? They thought about it and replied that they could NOT think of any. I had not considered this until my friend brought up this conversation). There is research that shows a simple range of motion places greater forces on the vertebral artery than manipulation.
    8. “having no treatment for neck pain at all is likely to lead to full resolution of the problem over time”.
    TICK Discuss doing nothing/acute v chronic/helping patient to understand and manage flares themselves etc.

    Now lets add OTHER aspects of informed consent:
    A. Diagnosis and clinical reasons for it.
    B. Care plan with expected outcomes and a reasonable time frame for achieving them.
    C. THE most important question of all to ask the patient – “Do you understand?” and addressing any patient concerns.

    “The code does not explicitly require an explanation about the possible harms of spinal manipulation (i.e. 50% of all patients will suffer mild to moderate adverse effects lasting 2-3 days, and occasionally patients will have a stroke of which some have died).”
    Edzard you have to understand how informed consent came about in Australia and the case that triggered it. Read this discussion on a legal firms website. Very Helpful:
    https://www.mauriceblackburn.com.au/about/media-centre/newsletters/medical-law/autumn-2012/legal-aspects-of-consent-to-treatment/
    Remember AHPRA regulates all health professions here in Australia so what applies to one profession applies to all. Classic case is advertising and testimonials. The trigger was chiropractors but it applies to all and has been in place for around 10 years. Have a look at this Google search with filters set to “physiotherapy”, “testimonials” and “Australia”:
    https://www.google.com/search?hl=en&as_q=physiotherapy+testimonials&as_epq=&as_oq=&as_eq=&as_nlo=&as_nhi=&lr=&cr=countryAU&as_qdr=all&as_sitesearch=&as_occt=any&safe=images&as_filetype=&tbs=
    Three years after the regulations came into force 3 of the physio’s on their board still had testimonials on their websites. I pointed this out on Twitter and within 3 weeks all had quietly made their websites compliant. If it was the chiro board you can guarantee that a critic/cynic would have gone through their website with a fine tooth comb.

    “Who monitors Informed Consent?”
    We have discussed this before and it is AHPRA (National Regulator) and the Chiropractic Board of Australia (Who answer to AHPRA) who check informed consent every year. My professional indemnity insurer also check every year PLUS they provide me with sample informed consent forms as does my association. It is NON-NEGOTIABLE.

    “Yet, Australian chiropractors claim that they abide by the ethical imperative of informed consent. Are they taking the Mickey?”
    No you are just ill informed when it comes to COMMON LAW REQUIREMENTS in Australia that relate to every profession not just chiropractors. Rules and regulations that apply to one apply to all.

    “Perhaps not. Perhaps they are merely trying to make sure they do not lose the majority of their clientele. As I already pointed out in my previous post, fully informed consent would make most chiropractic patients turn round and run a mile.”
    Your cynicism is showing.
    The problem with informed consent now is that patients have become blase and just sign (It’s been a common law requirement since 2000).
    I go through it in detail and note that I have done so in my clinical notes.

    Informed consent is about empowering the patient not selling the treatment (No matter who is selling their wares chiro/physio/neuro/ortho/proctologist).

  • @EE
    BTW 50% temporary soreness post treatment is shown in chiro AND physio research and is a non-issue.

  • So many comments to be made here.

    1) The Lana Lewis mishap and subsequent inquest occurred before material risk was the standard in consent. Bolam still applied in 1995 so it is not surprising that the chiropractor chose not to discuss stroke risk with Ms Lewis. The chiropractor’s words were unfortunate. It is noteworthy that Ms Lewis was an existing patient who had received neck manipulation on previous occasions without adverse reactions. The requirement changed following the Lewis inquest. Also, seven of the world’s foremost experts testified that Chiropractic is not the cause of stroke and was not a factor in Ms Lewis’ unfortunate death. Ms Lewis had a history of smoking and hyper- tension and a family history of heart disease all contributory factors in stroke causation. NB: it is acknowledged that Ms Lewis’ history could have excluded manipulative treatment as an option.

    2) Professor Ernst suggests that no patient would consent to chiropractic care if fully informed. This is only partially correct. There is a segment of the chiropractic community that adheres to the founder’s ideology. As discussed elsewhere, this is fruitloopery to which no-one can provide valid consent. Patients cannot consent to a nonsense. On the other hand, there is a significant segment of the chiropractic community that long ago rejected Palmerian dogma and practise evidence-based musculoskeletal manual medicine for which valid consent can and must be obtained.

    3) DC comments that they discuss minor and major possible AE and suggests that this is sufficient for informed consent. The whole point of the paper referred to in Prof Ernst’s previous post is that the informed consent process goes well beyond disclosing medically material fact. The practitioner must disclose material risks relevant to each individual patient and this may/does include practitioner specific information such as experience, conflict of interest etc… DC is urged to revisit the paper here: https://rdcu.be/caWKs

    4) Dr Money-Kyrle seems to believe that an information sheet, reading time with a question & answer session equals informed consent. It does not. Any practitioner believing that they have valid consent because their patient has signed a form will find it very difficult to defend any liability in a consent case.

    5) It is true that valid consent was not obtained in any of the negligence cases for which Oz chiro has provided an expert opinion. The same can be said for negligence cases brought against any other primary contact health care provider. An aggrieved patient bringing a negligence action will always say: ‘had I known this was going to happen, I would not have consented’. In other words, failure to obtain valid consent is not unique to chiropractors. To suggest this is the case is erroneous and misleading.

    • ps. I meant to include the link for the expert testimony in the Lewis inquest. Here it is: http://physicaltherapy.rehabedge.com/tm.aspx?m=47287&mpage=1&key=&#47287

    • so, you honestly believe that a dialogue between an Australian chiropractor (C) and a patient with neck pain (P) disclosing the following information is realistic and regularly results in the patient consenting?

      P: What do you suggest I do for my neck pain?
      C: I would perform a manual manipulation of your neck, if you agree.
      P: Why would this help?
      C: We used to think it can realign the vertebrae that are out of place; but most of us do not believe this any more; we now think it works via complex mechanisms that are not entirely understood.
      P: And my pain will disappear?
      C: Sometimes it does, yes.
      P: Ok, but what does the most reliable evidence say?
      C: It is not entirely clear cut.
      P: Could my pain get even worse with your treatment?
      C: About 50% of patients suffer from minor to moderate pain for 2-3 days afterwards.
      P: Anything else?
      C: In some cases, neck manipulation is followed by a stroke.
      P: How often has this happened?
      C: We know of about 500 such cases.
      P: How much will you charge?
      C: $ 60 per session.
      P: You mean I have to come back for more, each time risking a stroke?
      C: Yes, often we need several treatments.
      P: What are the alternatives?
      C: There are lots of other treatments for neck pain?
      P: Are they better or worse?
      C: About the same?
      P: Could I not just do some simple exercises?
      C: Yes, you could, and that would be about as effective as neck manipulation.
      P: And free of risks?
      C: Yes, more or less.
      P: And doing nothing at all?
      C: Might eventually also result in your complaint disappearing.
      P: Thanks for this information; you have convinced me, please go ahead and do your treatments.

      • Professor Ernst, before commenting on your comment, we need to establish some baseline information:

        1) Are you against neck manipulation full stop, end of story?

        2) Are you willing to concede that there are rational chiropractors who adhere to evidence based practice?

        3) Are you willing to concede that chiropractic is more than a technique? It is a registered health care profession in the 68 countries with legislation governing the profession. With registration comes legal requirements stipulating what is to occur in a patient encounter which includes, inter alia, obtaining informed consent?

        • I try to be where the best available evidence takes me on 1 and 2.
          on 3, I know of the different definitions of ‘chiropractic’ and the fact that chiros currently prefer to define it as a profession. yet, I am not sure that I agree with them.
          https://edzardernst.com/2020/02/so-what-is-chiropractic/

          • OK. But you have not answered the questions. Rephrasing: Where does the best available evidence take you of the question of neck manipulation full stop and rational chiropractors who adhere to evidence based practice?

            Whether you choose to agree or not, in the countries with legislation governing chiropractic, it is a profession and as such, chiropractors have a fiduciary relationship with their patients. Full stop. As I argued in my paper, those practitioners who adhere to the Palmerian subluxation ideology cannot fulfil their fiduciary duties. Rational chiropractors can and do.

          • I have asked you a straight forward question
            you responded pompously that we need first to establish some baseline information
            I provided it
            now please answer my question
            FULL STOP

          • @EE
            “I try to be where the best available evidence takes me on 1 and 2.”
            Your blog on Charlotte Leboeuf-Yde here would indicate otherwise:
            https://edzardernst.com/2017/04/we-have-an-ethical-legal-and-moral-duty-to-discourage-chiropractic-neck-manipulations/
            You highly regard her research which includes adverse events yet choose to ignore it until you could take issue with two lines in a BLOG then wrote this hatchet blog. You have endlessly harped on in regards to this issue yet fail to support the researcher who is providing you with the evidence you demand.

            This previous blog on this site is very educational on this topic:
            https://edzardernst.com/2018/08/until-the-precise-risks-from-chiropractic-manipulation-are-known-patients-are-better-served-by-other-treatments/
            Extremely poor science by doctors where assumptions were made. “Went to the chiro before the cervical artery dissection. The chiropractor did it”. Did they even bother to check the chiropractors clinical notes? Seems not.
            Now look at the comments:
            Michael Kenny who is a physiotherapist posts unprofessional comments about another health profession.
            Blue Wode instead of discussing the science tries to do a character assassination of the highly published and highly respected researcher, David Cassidy. He also cites blogs to refute research even though they do not.

            The vitalistic chiropractors are unlikely to change and the paper by Stan Inness and Keith Simpson discuss the legal implications. In the conclusion they write:
            “For us this raises several concerns for chiropractic. Can a patient ever provide informed consent for the removal of an entity (VS) without credible evidence / reasonable grounds? Can VS care ever meet the code of conduct standards when it lacks an evidence base and is practitioner-centered? What is the responsible educative or punitive action for CCEs, chiropractic educators and professional associations, given this knowledge? For the individual VS practitioner, it necessitates conversations about recommending a plan of care that seeks to remove a theoretical entity without quantification for diagnosis, monitoring or discharge. For others it requires disclosures of, among others, conflict of interest when recommending ‘inhouse’ products, and recency of training.”
            This is important and Edzard’s original blog here totally misses the point and instead applies his usual spin and bias.
            https://edzardernst.com/2020/11/informed-consent-why-chiropractors-dont-like-it/
            This is a LEGAL opinion piece with high powered legal input from:
            “The following legal professionals are acknowledged for their assistance. But-for their contribution some important legal aspects may have been overlooked.
            David Cheifetz, Retired Civil Litigation Barrister, Toronto, Canada.
            Michael Weir, Law Professor, Bond University, Queensland, Australia.
            Emma Cave, Professor of Healthcare Law, Durham Law School, UK.
            Nadia Sawicki, Georgia Reithal Professor of Law, Co-Director, Beazley Institute for Health Law and Policy, Loyola University Chicago School of Law, USA.”
            The vitalists may not want to change put may legally have no other choice.
            Maybe its time they leave the profession and the regulatory requirements that being registered as a chiropractor entail (including informed consent) and rename themselves “osteopractors” or “spinologists”.
            Très interesting.

        • @ JK Simpson

          and what, pray, is the benefit to the public or even an individual patient of this alleged “registered health care profession?” There would appear to be nothing unique to chiropractic that is beneficial – and what little marginal benefit there may be to chiropractic is not unique.

          If you restrict your base of chiropractors to “evidence based” operators and exclude the subluxation evangelists then it would seem that there is little on which to mount a system of “health care” at all and you just have glorified physical therapists. Only if these start trespassing on other fields such as TCM or Naturopathy can they claim to be offering “healthcare” although its validity can certainly be questioned – but one could certainly question the point of chiropractic in all of this surely?

        • @ JK Simpson @Critical_Chiro

          another point occurs to me – if I may.
          what exactly is the Chiro logic of treating migraine with neck manipulation?
          I guess subluxationists would argue that nerves are being impinged and that this is affecting the all important innate system – which as we all know it utter piffle.
          But how do so-called EBM chiros rationalize it?

          On the face of it there would appear to be little logic in cervical manipulation for a condition that has complex neurovascular and hormonal origins. The only justification would appear to be that it is just something that Chiros “do” regardless of logic, evidence or likely efficacy.

          It suggests another question – how many potential patients do Chiros turn away with the phrase “sorry there is nothing chiropractic can do for you – you need to see a proper doctor/physiotherapist/whatever?” I would be willing to bet an almost zero number.

          • You ask: what is a chiropractor doing treating migraine with neck manipulation. Not all migraines have complex neuromuscular and hormonal origins. Cervicogenic migraine is a recognised condition which responds to manual care which may include neck manipulation. Further, please understand that chiropractic is not only manipulation. Chiropractic therapy encompasses massage, exercise, advice, electrophysical therapies, sports therapy and tapping.

            Regarding your supplemental question: rational chiropractors are particularly skilful in recognising patients who will not respond to the modalities that they offer so your postulated answer of almost zero patients are advised chiropractic care will not help them is erroneous. This has been the case for decades. The 1979 New Zealand Royal Commission into Chiropractic examined this very question and drew the conclusion I have outlined. Again, I am not saying that all chiropractors are rational. I agree there are those who adhere to the Palmerian subluxation ideology who would never reject a patient. They are wrong and pose a danger.

          • @ JK SImpson

            may I enquire exactly what is your evidence for “cervicogenic migraine”? this entity would appear to be an entirely chiropractic invention.

            there is sufficient doubt about the diagnosis of “cervicogenic headache” itself by chiropractors – most headaches are of the tension type. It is highly doubtful that chiropractors have sufficient training to be proficient to diagnose the various manifestations of true migraine in all its forms – I would be very wary of them getting involved in treating migraine in any way.

            All the evidence suggests that many of the manifestations associated with migraines are part of the prodrome or aura rather than being “triggers” and that most of the alleged dietary and other “triggers” are in fact post hoc fallacies. It is all too easy to assume that a migraine is brought on by some food/drink./event and be fooled into avoiding it -especially if some Alt Med enthusiast is encouraging the notion by dint of Vega testing/Applied Kinaesiology or some other daft notion.
            Unfortunately amateurs who get involved in attempting to treat this condition so often muddy the waters by suggesting all manner of lifestyle, dietary and other changes that may be expensive and disruptive without being in any way effective. For example a local Alt Med practitioner recommends a Gluten Free diet to all migraine sufferers – which is expensive and very restrictive and totally evidence free as well.

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3857910/

            https://americanmigrainefoundation.org/resource-library/cervicogenic-headache/

            https://sciencebasedmedicine.org/cervicogenic-headache-and-cervical-spine-manipulation/

            https://www.uptodate.com/contents/cervicogenic-headache/abstract/3-7?utdPopup=true

            Suggesting that neck manipulation, massage or such like is likely to help with migraine is implausible. It is generally accepted that migraine has a neurogenic origin: there are most likely vascular, genetic and hormonal elements. Can you provide the slightest shred of evidence that chiropractic has a role to play in migraine rather than non-specific headaches?

    • JK Simpson wrote: “It is noteworthy that Ms Lewis was an existing patient who had received neck manipulation on previous occasions without adverse reactions. The requirement changed following the Lewis inquest. Also, seven of the world’s foremost experts testified that Chiropractic is not the cause of stroke and was not a factor in Ms Lewis’ unfortunate death. Ms Lewis had a history of smoking and hyper- tension and a family history of heart disease all contributory factors in stroke causation. NB: it is acknowledged that Ms Lewis’ history could have excluded manipulative treatment as an option.”

      @ JK Simpson

      Here’s another take:

      “On September 12, 1996, four days after her 45th birthday, Ontario resident Lana Dale Lewis died after suffering a stroke.
      Lewis had been treated for migraine headaches by chiropractor Philip Emanuele. After her final visit she complained about the manner in which her neck had been manipulated and the intense pain which ensued. A couple of days after this visit, Lewis suffered a stroke. This was followed a few days later by a second stroke, which resulted in her death.
      Dr. John Deck, neuropathologist from the Office of the Chief Coroner, Toronto, blamed the death on chiropractic manipulation. Deck said that there was no significant doubt in his mind that the chiropractic manipulation was the cause of the fatal stroke. His findings were certified by Dr. Robert Huxter, Regional Coroner for Ontario and by another Ontario coroner, Dr. Murray Naiberg.
      An inquest was held into the death and ran from 2002 to 2004. At the inquest the Lewis family was represented by lawyers Amani and Neil Oakley. The Oakley’s previous cases had usually involved medical malpractice or human rights. Prior to taking on the Lewis case, they knew very little about chiropractic. They thought that it was used only for back pain, but further research showed that some chiropractors claimed they could treat a wide range of ailments, including allergies and cancer.
      As the Oakleys delved deeper, they were shocked to learn how little evidence exists to back up the claims of chiropractors. While chiropractic uses a lot of jargon which sounds scientific, it is based on an untested hypothesis. Spinal manipulation is supposed to correct “subluxations” that interfere with the flow of innate energy through the body. According to chiropractic, this energy will flow properly only if the neck and spine are lined up properly.
      The technique that chiropractors use for neck manipulation is quite different from that used by other health practitioners such as physiotherapists. Apparently it can make alarmingly loud crunching and cracking noises.
      Chiropractors claim that everyone can benefit from their treatment. This includes healthy children, who they say may be suffering from subluxations caused by birth or normal childhood activities. They also claim that the risks of chiropractic treatment are small, and that the probability of a bad outcome is small. Amani Oakley however, whose firm now deals with many cases involving chiropractic, counters that claim with a question: if a treatment has no benefit, then is any risk acceptable?
      In a typical medical malpractice suit, the Oakleys generally argue that the treatment was not appropriate or was administered improperly. But it comes to chiropractic, they now take the position that someone coming in for maintenance care has no condition to be treated. If a specific ailment is being addressed, they argue there is insufficient evidence that the treatment accomplishes more than a placebo. In both cases, then, it seems inappropriate to take on any level of risk.
      Before becoming lawyers, both Amani and Neil Oakley had obtained science degrees and had worked in the field. This helped them realize, after they started to delve into the inquest’s issues, that chiropractic has no solid science to support it. During the inquest they drew on their research to discredit the witnesses called to support neck manipulations and they laid out before the jury the evidence that such adjustments were dangerous.
      Relying on arguments based on hard science, Amani was able to convince the jury in the Lewis case to return a verdict favourable to the family’s claims, even though she had to wrestle with countless procedural oddities. (For example, the counsel for the defence received three times as much time for its concluding statements since they had three sets of lawyers who represented the chiropractor, the chiropractic college, the chiropractors’ association and the chiropractors’ insurers.)
      The victory in the Lana Dale Lewis case cast a harsh light on chiropractic and raised the public’s awareness of the risks of treatment. According to Amani, more people who go to chiropractors now tell them, ‘Don’t touch my neck’.”

      Ref: https://tinyurl.com/y6psckl8

      Also see https://www.chirowatch.com/Chiro-Lewis/oakley-closing.html (scroll down)

      • I am very familiar with the Lewis inquest and the recommendations that emanated from it. Further, Philip Emanuele and I were in the same class at Canadian Memorial Chiropractic College (CMCC) graduating in 1982. At that time and to this day, CMCC teaches Palmerian subluxation theory in a historical context. We studied and practiced manual therapy for musculoskeletal conditions not subluxation detection and removal to restore innate intelligence flow. Neck manipulation correctly applied by properly trained practitioners to appropriately selected, consenting patients is safe, effective and cost effective treatment for a variety of conditions. Like any intervention, maloccurrence is possible but maloccurrence is not negligence.

        • JK Simpson wrote: “Philip Emanuele and I were in the same class at Canadian Memorial Chiropractic College (CMCC) graduating in 1982. At that time and to this day, CMCC teaches Palmerian subluxation theory in a historical context. We studied and practiced manual therapy for musculoskeletal conditions not subluxation detection and removal to restore innate intelligence flow.”

          @ JK Simpson

          “at that time [1982]”? I am compelled to question your integrity. Here’s an article from 1999:

          “Since practice is based on belief, any evaluation of chiropractic practice must take chiropractic beliefs into account. CMCC officials would like you to believe that its curriculum is solidly scientific and not subluxation-based. This claim can be directly examined by inspecting its chiropractic textbooks, visiting its library, auditing its classes, and watching how students manage patients in the school’s clinics. Considerable time and expert knowledge of the subject matter are necessary to conduct this type of examination. A second way to judge the quality of CMCC teaching is to examine the beliefs of its graduates. This is easy to do if you know where to look. Ample evidence exists that something is seriously wrong.

          For example:
          In 1997, the Association of Chiropractic Colleges issued a position paper strongly supporting the subluxation concept. The document was signed by CMCC president Jean Moss, D.C, and the presidents of 15 chiropractic colleges in the United States. The “Paradigm” section says this about subluxations:

          Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence [3].

          CMCC’s Web site includes the following description of CMCC’s 50-hour course in “Chiropractic Principles”:

          Chiropractic Principles (CP 202) is an intermediate level course designed to provide students with a basis for understanding the vertebral subluxation and the chiropractic adjustment as they apply to the role of chiropractic in optimizing health. A lecture programme covers a detailed discussion of the mechanisms involved in the subluxation and the adjustment. This is followed by a small group problem-based series of case studies. The case studies illustrate the various dimensions of chiropractic practice and integrate the concepts of the art, science and philosophy of chiropractic. Student awareness is developed toward issues of risk management and informed consent [4].

          Pediatric Chiropractic (1998), which CMCC uses as a textbook, states that “the chiropractor has an opportunity to normalize, if not minimize, the effects of vertebral subluxation complex. Thorough analysis and specific adjustments to the pregnant female and pediatric spine may have a far-reaching impact on whole body health.” [5] The chapter on spinal examination advocates the use of a Temp-O-Scope, an instrument inappropriately claimed to be useful for detecting “subluxations” by reporting differences in skin temperature on either side of the spine. The book also advises: “Rather than advising the parent(s) to vaccinate or not to vaccinate, the chiropractic doctor should focus on educating the parent(s) on the subject and allow the parent(s) to make the decision they feel is most appropriate for their child.” The book’s 27-page chapter on these “issues” is devoted mainly to adverse reactions, contraindications, and “failures.” Nothing in the chapter suggests that immunization is a good idea.

          CMCC’s bookstore sells homeopathic remedies and acupuncture and reflexology charts. Doing this encourages the outlandish beliefs associated with these practices.

          What CMCC Graduates Believe
          In a recent newspaper article, a York University spokesperson stated that the behavior of practicing chiropractors should not have anything to do with CMCC’s proposal to affiliate with the university [6]. I disagree. Suppose it could be shown that the majority of CMCC graduates held unscientific beliefs and engaged in unscientific practices. Wouldn’t that be evidence that something was radically wrong with their training and and that—at the very least—CMCC has failed to teach critical thinking? I believe it would. Here are some of my findings:

          In 1994, a well-designed survey asked Canadian chiropractors the extent to which they agreed or disagreed with 13 questions related to chiropractic philosophy and scope of practice. Of the 403 who responded, 65% said they had been trained at CMCC. Based on their scoring system, the researchers concluded that only 18.6% rejected traditional (subluxation-based) chiropractic philosophy and the rest either embraced it completely (22%) or partially (59.4%). [7]

          The Web site of the Ontario Chiropractic Association contains many highly questionable statements. This is significant because most of the Association’s members are CMCC graduates [7,8]. The page titled “What Is Chiropractic?” states:

          Chiropractors believe in whole body wellness. Wellness means many things to different people. To your chiropractor, wellness is the state of health where your body is free of interruption or interference to any part of your nervous system, enabling you full expression and enjoyment of life. Chiropractic care works to ensure that your nervous system is working fine, and this enhances your well being. Your chiropractor will discover any problems that are interfering with your nervous system and through hands-on-healing will work with you to eliminate them. After chiropractic care your body will be better able to heal itself. This, in turn, aids your body in maintaining optimum health and contributes to your overall wellness.

          The page titled “What Are Subluxations?” states:

          What are subluxations?
          Subluxations are problem areas of the spine that affect your entire nervous system. In these problem areas the spinal bones are misaligned or have lost their normal range of movement. This irritates or puts pressure on local nerves which interferes with the communication between your brain and body (and vice versa).

          How do subluxations happen?
          The stresses and strains of everyday living such as housework, gardening, desk work, lifting, or even sleeping on the couch can cause spinal problems. So can falls, accidents (especially car accidents), sports activities and injuries. In children subluxations can initially occur during the birth process, learning to walk, in play and from everyday childhood activities.

          What are some of the warning signs of subluxations?
          Symptoms such as headaches, back pain, neck stiffness, pain in your shoulders, arms or legs, numbness in your hands or feet, or nervousness are the most common signs of subluxations. But like a tooth cavity, most people will have a subluxation long before they notice any symptoms.

          How are subluxations corrected?
          Your chiropractor will reduce and correct subluxations with highly skilled adjustments to your spine. If the subluxations have been present a short time, you may only need a few adjustments. However long-term, chronic subluxations will require more frequent adjustments to retrain the problem areas of the spine to hold the vertebrae in their normal, healthy positions. As subluxations are corrected, your nervous system starts to function properly again and your body heals itself.

          How can I avoid subluxations?
          If you want to keep subluxations from reoccurring, or new ones from developing, it’s best to have periodic adjustments. Combined with a sensible diet and moderate exercise, chiropractic care can help you enjoy the best of health for the rest of your life. Seeing a chiropractor should go with everyone’s job!

          The page “Chiropractors and Children: Infants and Toddlers” stated:
          Babies are naturally healthy, happy and active. When they’re not, the reason could be a problem with their spine. Think about it. The nervous system, which controls every function of the body, is protected by the spine. A spinal bone that is out of alignment or not moving properly, (called a subluxation) may irritate or put pressure on local nerves. Communication between your brain and body (and vice versa) becomes hampered which may cause countless problems. Colic and irritability are examples of symptoms that can be caused by subluxations. . . .

          When should you first take your child to a chiropractor?
          As soon as possible after birth. Chiropractic care at an early stage could prevent many common childhood disorders from developing. But any age is a good time to start because a chiropractor will help your child’s body keep itself healthy which can lead to a lifetime of good health.

          This page was removed about a week after I complained about it at the York hearing, but a copy is still online on the site of Ontario chiropractor George I. Traitses, D.C.

          The page titled “What Is an Adjustment” states:

          What causes these spinal problems?
          These problems are known as subluxations and can initially occur during the birth process. As your body grows and matures, falls, sports activities, accidents, bad posture or simply the stresses and strains of daily life can cause additional spinal problems to occur or can further irritate those that already exist. Left uncorrected, subluxations lead to conditions such as colic in infants, and headaches, back pain and generally poor health in adults.

          Many chiropractors advise everyone to have their spine checked and adjusted monthly or even weekly throughout their life, even if they have no symptoms. Two Canadian chiropractors who conducted an extensive literature search found no scientific evidence supporting the widely held chiropractic belief that periodic spinal adjustments improve health status [9]. Yet the Ontario Chiropractic Association’s page titled “Chiropractic Maintenance Care” states:

          Remember, how you feel does not always reflect how healthy you really are. As a spinal health expert your chiropractor realizes it is easier to prevent spinal problems than to correct them. That’s why a maintenance care program consisting of regularly scheduled chiropractic spinal examinations is being recommended to you.

          The page titled “Chiropractic: Getting the Most Out of It” states:
          A chiropractor adjusts your spine to reduce the problem areas —called subluxations*—which cause so many health conditions. When your spine is correctly aligned, it allows your nervous system to function properly, and your body can heal itself. Spinal adjustments give your body the opportunity to heal. *Ask your chiropractor for a brochure explaining subluxations.

          Dubious Practices
          Many Canadian chiropractors are engaged in practices that are unsubstantiated and lack a scientifically plausible rationale. A well-designed 1992 survey of Canadian chiropractors found:

          • Half the respondents from Ontario practiced Activator Methods, a method in which comparing the lengths of the patient’s legs enables the chiropractor to determine the position of spinal subluxations.
          • Forty-four percent said they used the meric system, which holds that specific spinal joints are associated with specific organs, requiring adjustment of certain vertebrae for diseases of those organs.
          • Twenty-three percent said they used applied kinesiology, a system which alleges that testing the patient’s arm strength enables the chiropractor to diagnose organ dysfunctions throughout the body that can be treated with dietary supplements.
          • At least ten other dubious methods were used by anywhere from 12% to 69% of the respondents. Several of these included subluxation-based treatment systems in which the chiropractor would manipulate the patient’s neck no matter where the problems were located.
          • The survey also found that 75.1% of the respondents (including 96.1% of the Ontario practitioners) were CMCC graduates [8].

          In 1999, a reporter from the Toronto Star visited 15 randomly selected local chiropractic offices as a prospective patient who wanted information. The reporter’s findings were consistent with the above examples:
          • All said they treated children. Eight offices had pamphlets stating that children should be treated from birth onward.
          • Five offered brochures or showed charts explaining how subluxations—described as subtle misalignments in the spine—cause many if not most diseases. These materials linked specific vertebra to specific organs and said that by moving the spine everything from gall bladders to hypertension to heart arrhythmia can be treated and improved.
          • Four offered live blood cell analysis, an invalid diagnostic test in which a sample of the patient’s blood is magnified and displayed on a television screen.
          • Three provided hair analysis to detect nutritional imbalances or diseases at a cost of $65 to $85. Hair analysis is not a valid test for assessing the body’s nutritional state.
          • Four offices offered ear candling, a procedure that is useless and potentially dangerous
          • Two used phony electrodiagnostic devices [10].

          A Devastating Report
          On December 12, 1999, Canada’s largest Internet network (CANOE) posted a very very comprehensive report by two reporters who attended the York hearing and spent two months investigating further. The report concluded:
          • CMCC misled and deceived York officials about studies, its association with medical institutions, and chiropractic practices
          • three leading Canadian chiropractors withheld information about a chiropractic death in 1996 that may soon be subject to an inquest because of their actions
          • a vast majority of chiropractors routinely treat babies and children with therapies that earned them at least $40 million last year
          • chiropractic neck manipulation could be responsible for as many as 150 strokes a year
          • the basic theory of chiropractic medicine remains unproven 100 years after its inception
          • York officials have done a shoddy job of evaluating CMCC and the chiropractic profession [11].

          The Bottom Line
          Despite its denials, it is very clear that CMCC has been turning out a defective product.”

          Ref: https://quackwatch.org/chiropractic/edu/york/

          For readers interested, I understand that the CMCC failed in its bid for affliation with York University.

          • @Blue Wode
            CMCC turns out well educated evidence based chiropractors.
            Once they graduate and are registered CMCC has zero influence how they practice just like GP’s, Physio’s, etc.
            Stop the generalizations and sweeping statements. Carpet bombing the profession is unacceptable and researchers like David Cassidy, Keith Simpson, Stan Inness and Charlotte Leboeuf-Yde are NOT acceptable collateral damage.
            BTW the pleural of anecdote does not equal evidence whether it is coming from a vitalistic chiropractor or yourself.

          • The NZ Royal Commission did far more than rely on testimonials. And to suggest that somehow Inglis, Fraser and Penfold were unqualified to consider the evidence is shortsighted. The summary of principal findings on Page 3 of the Report make no recommendations such as you laid out. Further, the Recommendations regarding remodelling chiropractic are nothing more than positive steps in the professionalisation process. Your reliance on Jarvis’ analysis which is clearly biased and his referencing to the NZ Report are inaccurate, suggests that you have not read the NZ Report in its entirety. I urge you to do so because it does not present the bleak picture of chiropractic Jarvis suggests. He chose not to publish the following:
            “Chiropractors should, in the public interest, be accepted as partners in the general health care system. No other health professional is as well qualified by his general training to carry out diagnosis for spinal mechanical dysfunction or to perform spinal manual therapy” p. 4

            Let’s, for sake of discussion, set the NZ Report aside. Since 1950 there have been 18 major government inquiries relating to the recognition of chiropractic worldwide with seven of these conducted in Australia. Their findings are very consistent: chiropractic care is safe, effective and cost-effective for relieving a host of musculoskeletal conditions such as low back pain, neck pain and some headaches. And before you go ‘but’ they have also made comment and recommendations about unsubstantiated claims made by Palmerian subluxation ideologues. In fact, it is the unsubstantiated claims that have prevented chiropractic being accepted into the Medicare system in Australia. So, unless you believe that there is a conspiracy to produce positive results, it is impossible to dismiss these findings.

            Your question regarding what went wrong to allow the New Zealand College of Chiropractic to become a Palmerian subluxation ideology teaching institution is a good question for which I do not have a good answer. I can say that rational chiropractors are not the least bit happy about this either.

          • @ JK Simpson

            none of this brings us any nearer to answering the question – how is a punter supposed to know whether any given chiro is EBM based or a Subluxation based loon? There seems to be no good distinguishing feature even among chiros.

            I recently did a trawl through chiros registered with the GCC in the UK. Well over 80% of them do not have websites.
            This would seem to indicate either that they are so pre-historic that they have not yet discovered the internet – in which case one might assume that they are acolytes of Palmer. Or alternately one might draw the conclusion that they do not wish to advertize their philosophy so brazenly and prefer to keep their ideas a secret – which is equally concerning.

            I find this a little strange – I would have imagined chiros would have all been up-to-date, hot-off-the-presses types, eager to get the word out and evangelizing about their much vaunted profession. Instead it seems they are incredibly shy and retiring – almost afraid they might be discovered by some poor long-suffering person with chronic back-pain or other malady.

            Or is it that the ASA and TSA in the UK has finally caught up with over-promising and under-delivering?

          • Thank you for the extensive list of historical material. Before addressing the gist of them, your questioning of my integrity is unwarranted and clearly ill-informed. Recall for a moment that this ‘discussion’ came about as a result of my most recent publication. That’s the one that clearly states that subluxation-based practitioners fail to uphold their fiduciary duties and are open to a negligence liability suit in consent. I have published also on unsubstantiated claims by subluxation-based chiropractors, appeal to fear fallacy by subluxation-based chiropractors, the irrationality of vitalistic ideology held by subluxation-based chiropractors. I am a rational chiropractor, with degrees in chiropractic, exercise physiology and a PhD in sociology. Indeed, I have been labelled a ’subluxation denier’ by those adhering to the Palmerian ideology. Now, back to the issue you raise. The documents you quote are all interesting and important. I ask, what can you tell us about CMCC in 2020. Here is a place to start: The Canadian Memorial Chiropractic College in 2018 officially endorsed the International Chiropractic Education Collaboration’s (ICEC) Position Statement on Clinical and Professional Chiropractic Education, joining many other institutions around the world with a similar approach to evidence-based, patient-centred contemporary chiropractic education. This position statement says, inter alia:

            “The teaching of vertebral subluxation complex as a vitalistic construct that claims that it is the cause of disease is unsupported by evidence. Its inclusion in a modern chiropractic curriculum in anything other than an historical context is therefore inappropriate and unnecessary”.

            It is important to distinguish between the concept of subluxation as being primarily a biomechanical dysfunction that may produce secondary local and remote signs and symptoms, and that of the vitalistic concept of subluxation originally described by D.D. Palmer as being a direct cause of neurologic dysfunction resulting in organ system dysfunction and which if not removed will result in a deterioration of health even up to clinical disease and death. And before you say anything, I agree, the term is a confusing anachronism that needs to be abandoned.

    • @ JK Simpson

      “Also, seven of the world’s foremost experts testified that Chiropractic is not the cause of stroke and was not a factor in Ms Lewis’ unfortunate death.”

      May we know how many of the “experts” were chiroquackers themselves – because that would significantly diminish the impact of their testimony? I personally wouldn’t rate the “expert” testimony of a chiroquacker on anything – but especially not on whether cervical manipulation could cause a stroke.
      We know that chiros don’t have a good relationship with EBM or science – even the supposedly mixed ones. But if they are trying to defend their ‘profession’ in court one can imagine their relationship with the truth getting even more out of whack than an imaginary subluxation.

      PS I am not convinced that being “a foremost expert in chiropractic” is convincing evidence of anything – knowing a great deal about an imaginary belief system still isn’t of much practical use to anyone unfortunately – and can be harmful as evidenced here.

      • With respect, if you took the time to follow the link which is to a physiotherapy page and read the biographies of the expert witnesses, you would discover that only one of them held a chiropractic qualification. Dr Scott Haldeman is a PhD neurologist who holds both a degree in chiropractic and medicine and is a medical board certified neurologist. The author of numerous research articles including stroke following manipulation. He is currently on staff at the University of California-Irvine as a Clinical Professor of Neurology. He is also an adjunct professor in the Dept. of Research at the Southern California University of Health Sciences in Los Angeles. Dr Haldeman is qualified to

        We are in agreement, chiropractors adhering to Palmerian subluxation ideology are engaged in fruitloopery. They endanger the lives of patients however, to ignore the contribution to musculoskeletal medicine that rational chiropractors make is shortsighted. If you want to discuss the chiropractic profession, please do so from an informed position.

        • @ JK Simpson

          with respect I would prefer the expert opinion of a vascular surgeon, neurosurgeon, an expert pathologist or a neuroradiologist in such a matter. Dr Haldemann appears to be something of an academic gadfly collecting an interesting array of disparate academic qualifications. Chiropractic? An MD? Neurology? Epidemiology? Whilst I am sure this is impressive academically I am not certain that it establishes sufficient credentials in any one specialty and I am not convinced that he is an expert in cerebrovascular injuries.

          It would seem at heart he is a chiropractor when all is said and done – at least that is how he always seems to play his cards.

          • If you are unwilling to accept that Scott Haldeman’s credentials deem him an expert in cerebrovascular injuries what would it take to convince you? For those unfamiliar with his body of work I offer this:

            He is Past President of the North American Spine Society, the American Back Society, the North American Academy of Manipulative Therapy, and the Orange County Neurological Society, and is currently Chairman Emeritus of the Research Council of the World Federation of Chiropractic. He is certified by the American Board of Neurology and Psychiatry and is a Fellow of the Royal College of Physicians of Canada and a Fellow of the American Academy of Neurology. He is a Diplomat of the American Board of Electrodiagnostic Medicine, the American Board of Electroencephalography and Neurophysiology and the American Board of Clinical Physiology. He also served on the US department of Health AHCPR Clinical Guidelines Committee on Acute Low Back Problems in Adults as well as four other Clinical Guidelines Committees. He presided over The Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders.

            Scott Haldeman sits on the editorial boards of six journals, and has published over 200 articles or book chapters, over 70 scientific abstracts, and has authored or edited seven books. He was awarded an honorary Doctor of Humanities degree from the Southern California University of Health Sciences and an honorary Doctor of Science degree from the Western States Chiropractic College. He received the David Selby Award from the North American Spine Society. A resident of Santa Ana, California, he maintains an active clinical practice.

            If this man is not qualified as an expert to comment on cerebrovascular injuries, I do not know who is.

          • @ JK Simpson

            re Scott Haldeman – he may be well credentialled in other regards but I do see that he has any cerebrovascular credentials or experience whatsoever. It is never a good idea to step outside one’s area of expertise and I suggest that the specialists that I mentioned would have a far greater expertise and knowledge of cerebrovascular structure, function, damage and repair than he would do.

            If you had an injury in a carotid artery or a branch thereof or in a veretbrobasilar artery would you wish to have Haldeman by your side or a competent vascular or neurosurgeon by your bedside? Or perhaps you would be content with a chiroquacker manipulating your subluxations?

            I think this is one of the biggest issues with chiros – knowing the limit of one’s competence which is far more restricted than most chiros like to admit.

  • JK Simpson wrote on Wednesday 18 November 2020 at 16:37: “rational chiropractors are particularly skilful in recognising patients who will not respond to the modalities that they offer so your postulated answer of almost zero patients are advised chiropractic care will not help them is erroneous. This has been the case for decades. The 1979 New Zealand Royal Commission into Chiropractic examined this very question and drew the conclusion I have outlined.”

    @ JK Simpson

    Allow me to interject on your discussion with John Travis:

    Re the 1979 New Zealand Chiropractic Report https://quackwatch.org/chiropractic/rb/NZ/nzjarvis/

    Its three-person panel consisted of a barrister, a chemistry professor, and a retired headmistress of a girls’ school. It relied heavily on testimonials, failed to appreciate the scientific process, and demonstrated bias. It doesn’t vindicate chiropractic, rather its recommendations were actually devastating to chiropractic: chiropractors should be strictly monitored, should not present themselves as doctors, should not encourage patients to consult a chiropractor in preference to a medical doctor for any condition, and should not mislead the public into believing that chiropractic is an alternative to medicine.

    Ref: https://sciencebasedmedicine.org/the-war-against-chiropractors/

    However, it seems to have been a complete waste of time as the New Zealand College of Chiropractic’s current curriculum “is informed by the same vitalistic understanding that chiropractic has of the body’s ability to self-regulate, self-organise and self-heal”.

    Ref: http://chiropractic.ac.nz/study-with-us/programme-structure/

    What went wrong?

    • @Blue Wode
      Please read the conclusion of Keith Simpson’s paper:
      “For us this raises several concerns for chiropractic. Can a patient ever provide informed consent for the removal of an entity (VS) without credible evidence / reasonable grounds? Can VS care ever meet the code of conduct standards when it lacks an evidence base and is practitioner-centered? What is the responsible educative or punitive action for CCEs, chiropractic educators and professional associations, given this knowledge? For the individual VS practitioner, it necessitates conversations about recommending a plan of care that seeks to remove a theoretical entity without quantification for diagnosis, monitoring or discharge. For others it requires disclosures of, among others, conflict of interest when recommending ‘inhouse’ products, and recency of training.”
      Could it be that both you and Keith are asking the same question?
      Does the legal implications of Keith and Stan’s paper not postulate a possible answer?
      The vitalists will not change. We can all agree on that point.
      They play politics very well to protect their “sacred trust/beliefs” and resist reform. Perhaps they will have no choice if they want to remain registered as a chiropractor and not have professional indemnity denied to them by the insurers.
      Now that this paper has been published the ripples will be propagating out.
      I have a feeling the impact of this paper will be felt way into the future.
      It will be interesting.

      • Critical_Chiro wrote: “The vitalists will not change. We can all agree on that point. They play politics very well to protect their ‘sacred trust/beliefs’ and resist reform.”

        @Critical_Chiro

        And there’s your problem. Bearing in mind that DD Palmer maintained that the tenets of chiropractic were passed along to him by a doctor who had died 50 years previously, why would anyone but chancers, charlatans, and fools study chiropractic in the first place?

        • We have been around this circle more than once but, for one last time. In order to have a considered conversation about chiropractic, one needs to begin with a full understanding of the entity known as chiropractic. You are correct in asking, why would anyone choose to study a craft whose founder received the basic theory from the spirit of a deceased medic; considered promoting the craft as a religion with himself as the spiritual leader; claimed to have answered the primary biological question: what is life; and whose vitalistic postulates are biologically implausible? The answer is of course, they would not. However, as has been pointed out before, not all chiropractors are adherents to Palmerian vitalistic subluxation ideology.

          The fact of the matter is that less than 10 years after the first ‘disciples’ [yes, they were known as disciples] graduated from the Palmer school, a split formed in the group along ideological lines. This has historically been described as the schism between ‘mixers and straights’ with acceptance or rejection of treatment modalities other than ‘the adjustment’ as the dividing point [1, 10, 11, 18]. This however is an overly simplistic and patently misleading understanding. Phillips framed the schism more accurately and succinctly around “believers and questioners”: those who believe the foundational vitalistic premises of Innate Intelligence (II) and Universal Intelligence (UI) should act as the guiding light of chiropractic versus those who question the relevance of basing patient care on unverifiable, a-priori assumptions and importantly, the role that science plays in both factions. For believers science is explanatory whereby science will prove what believers know. That is, “beliefs are based on evidence derived from observations that support the universal, the Major Premise”. This is in contrast to questioners for whom science is investigatory – “a search for understanding and clarification of what it is that chiropractors do, and determine if it is effective”. [19] p4. NB: This passage is from one of my publications which provides a comprehensive analysis of the schism within chiropractic. If you are so inclined, please read it. Doing so will make discussions such as these more conducive to a productive result. Here is the link: https://rdcu.be/ca2iz

          Now, back to your question: the answer is quite simple: rational chiropractic, which is not only manipulative therapy, is safe, effective and cost-effective for many musculoskeletal disorders and contribute to the health care system on multidisciplinary teams.

          Critical_chiro is correct: vitalists will not change. In fact, their entrenched beliefs become stronger when faced with evidence that said beliefs are wrong. There are numerous examples of this backfire effect playing out in the USA today. Another comes to mind: the anti-chiropractic critics on this forum. Are anti-chiropractic critics on this forum exhibiting the same entrenched beliefs and an unwillingness to examine the evidence and moderate their beliefs?

          • @ JK Simpson

            What a masterpiece of obfuscation.

            You still haven’t answered my question:

            You previously stated: “Philip Emanuele and I were in the same class at Canadian Memorial Chiropractic College (CMCC) graduating in 1982. At that time and to this day, CMCC teaches Palmerian subluxation theory in a historical context. We studied and practiced manual therapy for musculoskeletal conditions not subluxation detection and removal to restore innate intelligence flow.”

            Please explain how you deem my questioning your integrity as “unwarranted and clearly ill-informed” when it is transparent that in 1982 the CMCC did not teach Palmerian subluxation theory in “a historical context”. Once again, see https://quackwatch.org/chiropractic/edu/york/

        • @Blue Wode
          Please read Keith Simpson’s comments bearing in mind that the vast majority of chiropractic universities and colleges do NOT teach Palmerian dogma except in it’s historical context.
          It would seem that only the vitalists and the critics/cynics adhere to it.
          The irony that the both of you employ the same arguments to justify their beliefs in what constitutes chiropractic seems to elude you.

          • Critical_Chiro wrote: “@Blue Wode Please read Keith Simpson’s comments bearing in mind that the vast majority of chiropractic universities and colleges do NOT teach Palmerian dogma except in it’s historical context.”

            @ Critical_Chiro

            That may be so, but you have already confirmed this regarding chiropractic students: “Once they graduate and are registered CMCC has zero influence how they practice”

            That’s a big problem. For example, according to Edward Rothman, DC, a former senior lecturer at the UK’s Anglo European College of Chiropractic (now AECC University College), this is what can happen to graduate chiropractors…

            Quote:
            “…it is my perception that there are very few rational chiropractors willing to leave, what I have termed, the ritual induced placebo of our manipulative techniques, the monotherapeutic nature of the profession, and the unethical practice building…I am an American currently working at a chiropractic school in England…However, in the four years I have been in England, I have seen a change come over the profession there as more and more people take on American practice building methods and are attracted to irrational, illogical techniques and treatment pursuits, e.g., “occipito-sacral decompression in chiropractic paediatrics” (don’t even try to understand that one).”

            Link: http://tinyurl.com/32l9o5e

            So, not only do quite a few students turn to quackery, but, to me, it looks like he’s saying that it takes five years’ study to master a placebo intervention (which carries an unacceptable risk).

  • Professor Ernst,

    There was nothing pompous about my request to establish baseline information. Your answer was ambiguous so I rightly requested clarification which you have chosen not to provide. Unless, and until you do so, I see no point in attempting to answer your question regarding the hypothetical consent conversation, particularly when the same question has been addressed by another follower.

  • Critical_Chiro wrote on Wednesday 18 November 2020 at 23:10: “CMCC turns out well educated evidence based chiropractors. Once they graduate and are registered CMCC has zero influence how they practice just like GP’s, [sic] Physio’s, [sic] etc.”

    @ Critical_Chiro

    Maybe once they graduate they realise they can make more money by going down the quack route. This seems to be the reason:

    “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: Stephen Barrett, MD, (Quackwatch), p.175 of the ‘Spine Salesmen’ chapter of the book, The Health Robbers: A Close Look At Quackery In America

    Critical_Chiro wrote: “Stop the generalizations and sweeping statements.”

    I’m merely asking for proof to support assertions being made by chiropractors. Without provision of accurate data, it’s difficult to know the lie of the land.

    • Regarding Stephen Barrett’s comment. The reality is, given that uncomplicated low back pain is the number one cause of disability worldwide; that rational, evidence-based chiropractic is safe, effective and cost-effective in the management of uncomplicated low back pain and other musculoskeletal conditions; there is a global shortage of practitioners skilled in dealing with manual therapies dealing with low back pain and other musculoskeletal conditions; a chiropractor who follows Barrett’s guidelines will not only earn a living, they will be welcomed into the health care system. Here is some evidence to support this assertion and this is not cherry-picked. There is plenty more.

      In a 2004 study of four years’ data from a large California HMO published in the American Medical Association’s Archives of Internal Medicine, the 700,000 plan members with chiropractic and medical benefits had lower overall costs per person than the 1 million plan members with identical medi- cal benefits – but medical benefits only. The members with
      a chiropractic benefit elected to choose and substitute chi- ropractic care for a wide range of 654 ICD-9 codes covering NMS disorders such as spinal pain, rib disorders, neck pain and headache, extremity problems and myalgias and arthral- gias. Adding a chiropractic benefit reduced overall healthcare cost. Ref: Choudhry N, Milstein A (2009) Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans? An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending, Mercer Health and Benefits, San Francisco.

      • JK Simpson wrote: “In a 2004 study of four years’ data from a large California HMO published in the American Medical Association’s Archives of Internal Medicine, the 700,000 plan members with chiropractic and medical benefits had lower overall costs per person than the 1 million plan members with identical medical benefits – but medical benefits only.”

        @ JK Simpson

        With the data increasing illustrating that spinal manipulation is a placebo, it’s likely that a non-specific effect caused by touch was at play.

        For example, here’s the World Health Organisation’s 2003 bulletin on lower back pain: https://www.who.int/bulletin/volumes/81/9/Ehrlich.pdf

        It mentions chiropractic and the reasons people turn to it:

        “People with low back pain often turn to medical consultations and drug therapies, but they also use a variety of alternative approaches. Regardless of the treatment, most cases of acute back pain improve. At the time, people in such cases may credit the improvement to the interventions some of which clearly are more popular and even seemingly more effective than others (e.g. chiropractic and other manipulative treatments in which the laying on of hands and the person-to-person interaction during the treatment may account for some of the salutary results).”

        and that:

        “The spread of chiropractic and other manipulative treatments worldwide has won many adherents to this treatment, who perceive that it works better than others. This hypothesis was recently put to the test (25) and, although the respondents still favoured such approaches (chiropractic adjustment, osteopathic manipulation, and physical therapy) perhaps because of the time spent and the laying on of hands meta-analysis cannot confirm the superiority of manipulative treatments (or, for that matter, of acupuncture and massage (26)) over other forms of therapy, or even time as a healer (25), which substantiates the contentions of WHO’s document (1). In most instances, manipulative treatments are more expensive than others (apart from surgery) and not more helpful to outcome (26).”

        And here’s what three chiropractic staff members at the University of Glamorgan say:

        Quote
        “…we know patient satisfaction scores are usually quite favourable following chiropractic care, but it has also been shown that patients are very pleased and satisfied with chiropractic care whether they get better or not. Is it so bad that patients get well despite what we do?…Furthermore, it has been said that chiropractic’s greatest contribution to health care has been the development of a solid doctor-patient relationship. So, let’s not kid ourselves. It may not be what we say (subluxation, pinched nerve, tilted pelvis, herniated disc, sacroiliac syndrome, etc.), but simply the way in which we say it that stimulates some measurable change in patient’s general health care status. Some studies support this view.

        Ref. https://tinyurl.com/32odolf

  • JK Simpson wrote Thursday 19 November 2020 at 02:37: “Thank you for the extensive list of historical material.”

    You’re welcome.

    JK Simpson wrote: “Before addressing the gist of them, your questioning of my integrity is unwarranted and clearly ill-informed…The documents you quote are all interesting and important.”

    @ JK Simpson

    You stated: “Philip Emanuele and I were in the same class at Canadian Memorial Chiropractic College (CMCC) graduating in 1982. At that time and to this day, CMCC teaches Palmerian subluxation theory in a historical context. We studied and practiced manual therapy for musculoskeletal conditions not subluxation detection and removal to restore innate intelligence flow.” Ergo, how is my questioning your integrity “unwarranted and clearly ill-informed” when it is transparent that in 1982 the CMCC did not teach Palmerian subluxation theory in “a historical context”. Once again, see https://quackwatch.org/chiropractic/edu/york/

    Please explain what I’m missing.

    JK Simpson wrote: “It is important to distinguish between the concept of subluxation as being primarily a biomechanical dysfunction that may produce secondary local and remote signs and symptoms, and that of the vitalistic concept of subluxation originally described by D.D. Palmer as being a direct cause of neurologic dysfunction resulting in organ system dysfunction and which if not removed will result in a deterioration of health even up to clinical disease and death. And before you say anything, I agree, the term is a confusing anachronism that needs to be abandoned.”

    But it won’t be. As we’ve already heard from Critical_Chiro “The vitalists will not change.”

    For readers who might not be aware, the following terms either relate to, are synonyms for, or have been used or cited in connection with describing a (mythical) chiropractic subluxation or aspects of the (mythical) chiropractic Vertebral Subluxation Complex (VSC):

    Aberrant motion
    (Ab)normal articular sensory input
    Abnormal dysfunction
    Abnormal fixation
    Abnormal instantaneous axis of rotation
    Abnormal mechanics
    Abnormal motion or position
    Abnormal muscle function
    Abnormal nervous system function
    Abnormal spinal function
    Altered intervertebral mechanics
    Altered joint structure and function
    Altered nociceptive and proprioceptive input
    Altered regional mechanics
    Arthropathic
    Abnormal function
    (Ab)normal joint mechanics
    Abnormal joint motion
    Abnormal motion or position
    Abnormal muscle function
    Abnormalities of range of motion or coupling
    Abnormal nervous system function
    (Ab)normal regional sympathetic tone
    Abnormal restrictive barrier in or around joints
    Abnormal spinal function
    (Ab)normal structural relationship
    Acute joint locking
    Acute locking
    Adverse mechanical tension of the nervous system
    Altered alignment
    Altered joint motion
    Altered nervous system movement
    Altered physiological function
    Apophyseal subluxation
    Arthron (extremity joint subluxation — see also “vertebron”)
    Articular derangement
    Articular dyskinesia
    Articular juxtaposition
    Biomechanical distortion
    Biomechanical impropriety
    Biomechanical insult
    Biomechanical stress
    Blockage
    Blocking
    Bony displacement
    Bony maladjustment
    Bony lesion
    Cervical joint dysfunction
    Changes of the dynamic segment
    “Changes of thoracic segments”
    Chiropractic lesion
    Compensatory structural subluxations
    Comprehensive lesion
    ” … compromise proper function”
    Deconditioned syndromes
    Deviation of the bodies
    Errors of static or motor mechanics
    Facet joint syndrome
    Facet synovial impingement
    Facilitated spinal system
    Facilitated subluxation*
    Functional pathology
    Functional subluxation*
    Chiropractic subluxation
    Chiropractic subluxation complex
    Comprehensive lesion
    ” … compromise proper function.”
    Delayed instability
    Deformation behaviour
    Degenerative dynamic segment
    Derangement
    Derangement of the opposing joint surfaces
    Discoradicular conflict
    Disorder of the disc
    Disrelationship of the facets
    Displacement
    Disturbance in the mechanico-dynamics
    “(vertebrae) … don’t move enough, or they move too much.”
    Dynamic forceps
    Dynamic segment
    Dysarthric lesion
    Dysarthrosis
    Dysfunctional joint
    Dysponesis
    Dystopia
    Dysfunctional segments
    Engagement of the spinal segment in a pathologic reflex chain
    Erratic movement of spinal articulations
    Excursion (Conley) = (“Wandering from the usual path.” — Taber’s)
    Facet imbrication
    Facet joint dysfunction
    Facet syndrome
    Facilitated segment
    Facilitative lesion
    Fanning of interspinous space
    Fixation
    Fixed vertebra
    Focal tenderness
    ” … force other joints to move too much.”
    Functional block
    “(subluxations) … force other joints to move too much.”
    Functional compromise
    Functional deficit
    Functional defects
    Functional derangement
    Functional and structural changes in the three joint complex
    Functional disturbance
    Functional impairments of motion
    Functional spinal lesion
    Functional subluxation*
    Gravitational (im)balance of joints (with) reduced chronic, asymmetrical forces
    Harmful dysfunction of the neuromusculoskeletal system
    Hyperaemic subluxation
    Hyperanteflexion sprain
    Hypermobility
    Hypopmobility
    Hypokinetic aberration*
    Impairment
    (Im)properly direct(ed) coordinated, (in)harmonious motor programming
    Inability of the segment to articulate about its new axis
    Incomplete luxation
    Incomprehensible pattern of symptoms and clinical findings when compared to with examination of mechanical lesions in the extremities
    Instability of the posterior ligament complex
    Interdiscal block
    Internal joint derangement
    Internal vertebral syndrome
    Intersegmental instability
    Intersegmental subluxation
    Intervertebral blocking
    Intervertebral disrelationship
    Intervertebral dysfunction of the mobile segment
    Intervertebral joint subluxation
    Intervertebral obturations
    Intervertebral subluxation
    Joint bind
    Joint disturbances
    Joint dysfunction
    Joint immobilization
    Joint “instability”
    Joint movement restriction
    “Just short of a dislocation”
    Kinesiopathology
    Kinetic intersegmental subluxation
    Kinetic subluxation
    Lesion
    Less than a locked dislocation
    Ligatights
    Localised/referred pain
    Locked
    Locking
    Locked subluxation
    Locks up and restricts motion
    Lose their normal motion or position
    Loss of elasticity
    Loss of joint movement
    Loss of juxtaposition
    Loss of segmental mobility
    Low back dysfunction
    Malalignment
    Maladjustment (of a vertebra)
    Malposed vertebra
    Mechanical interferences
    Mechanical malfunctioning
    Mechanically infringe
    Manipulatable joint lesion
    Manipulatable lesion (adjustable subluxation!)
    Mechanical derangement
    Mechanical disorder
    Mechanical dysfunction
    Mechanical instability
    Mechanical irritation of the sympathetic ganglionic chain
    Mechanical musculoskeletal dysfunction
    Mechanico-neural interaction
    Metameric dysfunction
    Mild pubic diastasis
    Minor derangement
    Misalignment
    Misalignment of the fibrocartilaginous joint
    Motor unit derangement complex
    Motion restriction
    Movement restriction
    Multisegmental spinal distortion
    Musculoskeletal dysfunction
    Myopathology
    Nervous system impairment by the spine
    Neuro-articular dysfunction*
    Neuro-articular subluxation*
    Neuro-articular syndrome*
    Neurobiomechanical
    Neuro-dysarthric
    Neuro-dysarthrodynic
    Neurological dysfunction
    Neurodystrophy
    Neurofunctional subluxation*
    Neuro-mechanical lesion*
    Neuromuscular unit
    Neuromuscular dysfacilitation
    Neuromuscular dysfunction
    Neuropathology
    Neuropathophysiology
    Neurospinal condition
    Neurospinal distortions
    Neurostasis (Wilson)
    Occult subluxation
    Offset
    Orthokinetics
    Ortho-spondylo-dysarthrics
    Osteological lesion
    Osteopathic lesion
    Osteopathic spinal lesion
    Osteopathic spinal joint lesion
    Pain and debility without recognisable pathology
    Painful intervertebral dysfunction (“PID”)
    Painful minor intervertebral dysfunction (“PMID”)
    Palpable changes
    Paravertebral subluxation
    Partial dislocation
    Partial or incomplete separation
    Partial fixation
    Partial luxation
    Pathogenic interaction of spine and nervous system
    Pathophysiological mechanics
    Pathologically altered bradytrophic tissue
    Pathologically altered dynamic segment
    Pathomechanics
    Pathophysiology
    Perverted function
    Physiologic displacement
    Physiologic lock the motion segment
    Positional dyskineria
    Posterior facet dysfunction
    Posterior joint dysfunction (“PJD” — see “three-joint complex”!)
    Posterior joint syndrome
    Post-traumatic dysautonomic
    Prespondylosis
    Primary dysfunction
    Primary fibromyalgic syndrome
    Pseudosubluxation
    Putative segmental instantaneous axis of rotation
    Reflex dysfunction
    Reduced mobility
    Regional dysfunction
    “Relative as absolute lack of space within the intervertebral foramen”
    Residual displacement
    Restricted motion
    Restriction
    Restriction of unisegmental mobility
    Reversible with adjustment/manipulation
    Sagittal translation (Conley)
    Sectional subluxation
    Segmental dysfunction
    Segmental instability
    Segmental movement restriction
    Segmental vertebral hypomobility
    Semiluxation
    Simple joint and muscle dysfunction without tissue damage
    Shear strain distribution
    Slight luxation
    Slightly luxated
    Slightly misaligned vertebra
    Soft tissue ankylosis
    Somatic dysfunction
    Spinal dysfunction
    Spinal fixation
    Spinal hypomobilities
    Spinal irritation
    Spinal joint blocking
    Spinal joint complex
    Spinal joint dysfunction
    Spinal joint malfunction
    Spinal kinesiology
    Spinal lesion
    Spinal mechanical dysfunction
    Spinal pathophysiology
    Spinal segmental facilitation
    Spinal segmental instability
    Spinal subluxation
    Spine restriction
    Spino-neural conflict
    Spinostasis (Wilson)
    Spondylodysarthric lesions
    Sprain
    Stable cervical injury of the spine (see also “instability” above)
    Static intersegmental subluxation
    Static subluxation
    Strain
    Strain distribution
    Structural abnormalities
    Structural derangement
    Structural disrelationship
    Structural intersegmental distortion
    Structural lesions
    “Stuck”
    Subtle instability
    Sub-luxation
    Subluxation
    Subluxation complex
    Subluxation complex myopathy
    Subluxation syndrome
    Subluxes
    Three joint complex
    Tilting of the vertebral body
    Tightened, deep, joint related structures
    Total fixation
    Translation
    Unresolved mechanical tension or torsion
    Unstable lumbar spine
    Unstable subluxation
    Vertebragenous syndromes
    Vertebral derangement
    Vertebral displacement
    Vertebral dysfunction
    Vertebral dyskinesia
    Vertebral factor
    Vertebral genesis
    Vertebral induction
    Vertebral lesion*
    Vertebral pathology
    Vertebral subluxation
    Vertebral subluxation complex
    Vertebral subluxation syndrome
    Vertebrally diseased
    Vertebroligamentous sprain strain
    Vertebron (see also “arthron”)
    Wedged disc
    Zygopophyseal pathophysiology

    42 Terms for a Sacroiliac Subluxation

    Abnormal pelvis biomechanics
    Altered sacroiliac mechanics
    Changed motor pattern (in muscles)
    Change in relation
    Displacement
    Disturbed normal relationship
    Distorting the normal mechanics
    Downslips (see also “upslips”)
    Dysarthria
    Dysarthric syndrome
    ” … effect on body mechanics”
    Instability of the pelvic joints
    ” … irritation of the nerves is possible … ”
    Joint binding
    Joint dysfunction
    Joint lesion
    Joint motion restriction
    Joint slip
    Joint syndrome
    Limitation of motion
    Malposition
    Malrotation
    Mechanical dysfunction
    Misplaced
    Misplacement
    Motions are restricted
    Partial luxation
    Primary dysfunction
    Restrictions
    Rotatory slips
    Shear dysfunction
    Shear mechanism
    Slight luxation
    Slip
    Slipping sacroiliac joints
    ” … stick at the limit of normal motion …”
    Strain
    Strain and laxity
    Tilts (anterior, posterior)
    Upslips (see also “downslips”)
    Vertical slipping of the innominate on the sacrum

    Synonyms
    59 Synonyms or Metaphors for the “Spinal Adjustment”

    Arthral alignment
    Atlas therapy
    Biokinetic remediation
    Bone setting
    Chiropractic manipulation
    Chiropractic manipulative therapy
    Corrective spinal care
    Disengage
    Diversified-type force application to release the segment at its articulation
    Facet adjusting
    Fix
    Flexion distraction manipulation
    Functional restoration
    Gentle adjusting
    Gently relieve the locked subluxation
    High velocity facet adjusting
    Human readjustments
    Joint manipulation
    Low force/amplitude manipulation
    Manipulation
    Manipulative surgery
    Manipulative therapy
    Manipulatory
    Manual adjustment
    Manual cavitation
    Manual medicine
    Manual reflex neurotherapy
    Manual therapy
    Manual treatment
    Mechanical treatment of the nerve centres.
    Mobilisation
    Neuro-mechanical spinal chiropractic management
    Neuromechanical correction*
    Neurotherapeutic
    Neurotherapy
    Orthokinetics
    Orthopedic orthokinetics
    Osteopathic manipulative therapy
    Osteopathic osteological adjustment
    Physiatry
    Physical medicine
    Readjustment
    Reconstructive measure
    Reduced
    Reduction
    Reduction of dislocation
    Release of intraarticular pressure
    Replacement
    Repositioning
    Restoration of mobility
    Slipped into place
    Specific mobilization
    Spinal adjustment
    Spinal manipulative therapy
    Spinal manual therapy
    Spondylotherapy
    “Springing the spine”
    Vertebral adjustment*
    Vertebral medicine

    * Unreferenced

    Ref: Rome PL. Usage of chiropractic terminology in the literature — 296 ways to say “subluxation.” Chiropractic Technique 1996;8:1-12.

    @ JK Simpson

    In view of the above, how does a chiropractic customer distinguish between an evidence-based chiropractor and a quack one? Any ideas?

    • @BW: Heroic response. A quack and a wrestler both share a similar trait…you can never effectively pin them down.

    • In view that the author of your list is a subluxation based vitalistic chiropractor who has scooped up every term possible to justify his dogma. He did write 2 interesting papers in 1991/92 on Illi’s ligament otherwise 25 odd papers on vertical submarines/vertebral subluxation (Which are not even indexed in PubMed).
      Do you have anything better as that huge list which ironically also encompasses 99.9999999999999% physiotherapy terminology as well.
      You really should read something before just doing a huge copy and paste and think it represents evidence.

      “how does a chiropractic customer distinguish between an evidence-based chiropractor and a quack one?”
      WE have had this conversation endlessly over the years Blue.
      Caveat emptor.
      As when looking for a surgeon, physio, ortho etc do your homework. Some are superb and some I would not touch with a 50 foot barge pole no matter how many letters after their name.

      • Critical_Chiro wrote: “In view that the author of your list is a subluxation based vitalistic chiropractor who has scooped up every term possible to justify his dogma. He did write 2 interesting papers in 1991/92 on Illi’s ligament otherwise 25 odd papers on vertical submarines/vertebral subluxation (Which are not even indexed in PubMed). Do you have anything better as that huge list which ironically also encompasses 99.9999999999999% physiotherapy terminology as well.”

        @ Critical_Chiro

        I see that the author of the list – Peter L. Rome, who clearly doesn’t impress you – was admitted as a Fellow of the International College of Chiropractors in September 2020:

        QUOTE
        “To celebrate the magnitude of this achievement, ACA [Australian Chiropractors’ Association] President Dr Anthony Coxon was fortunate enough to present the award to Dr Rome in person”
        https://www.chiro.org.au/members-admitted-into-icc/

        Rome received the award as recognition from the International College of Chiropractors for his “contribution towards the advancement of the profession” and “immense literature contributions over the years”. Apparently he has received various college and ACA awards and was a member of several ACA Committees as well as the Chiropractic Registration Board. Since 1991, he authored or co-authored over 25 papers which are listed on the Index to Chiropractic Literature. Many of these published papers “are related to the fundamental chiropractic tenet with eight papers on the topic of subluxation”.

        He also co-authoried this Vertebral Subluxation Complex dossier
        https://cdn.vortala.com/static/uploads/3/2011/11/VSC_Position_Statment_AUKC.pdf

        It was commissioned by the vitalistic Alliance of UK chiropractors:
        https://www.zenosblog.com/wp-content/uploads/2010/11/AUKC_Oct_Newsletter.pdf

        Critical_Chiro wrote: “….“how does a chiropractic customer distinguish between an evidence-based chiropractor and a quack one?” WE have had this conversation endlessly over the years Blue. Caveat emptor. As when looking for a surgeon, physio, ortho etc do your homework.”

        @ Critical_Chiro

        But how do chiropractic customers know what to look for when “doing their homework”? How many of them will be aware of the chiropractic ‘bait and switch’?
        https://sciencebasedmedicine.org/the-bait-and-switch-of-unscientific-medicine/

      • The thing is orthopedic surgeons are not members of a quackery profession. And there are viable, normative determinants as to their qualifications and professional accreditation. Chiroquackery isn’t analogous since there is no normative data to appeal as to “proper or improper” quackery dispensation. “I felt better” doesn’t cut the mustard.
        And what do you “critical” Chiroquackers say about Activator and the other dental impacters used to realign spines “better and safer” than manipulation? Are there “good” Activator (faux)doctors? What about “good” Thompson or Gonstead peddlers? And are you “critical” ones really in a position to countermand or diminish your compatriots “Technique’s”? By what criteria can you make sweeping, carpet statements about another DCs choice of treatment?

        • With respect, if you are the MK I suspect you are, you should know better than to persist in using derogatory titles. Kindly argue respectfully. Your use of Chiroquackers etc, does nothing to promote productive intellectual exchanges. Indeed, your comments only crashh and burn which is unfortunate because if you are the MK I suspect, your expertise might even be considered authoritative and informative. That said, my paper provides the answer to your query. All health care professionals, including chiropractors, operate under the same social contract and have the same fiduciary relationship with their clients. They have to meet the same criteria for their interventions and predictions, towit there must be a logical, defensible, reasonable basis for the proposed intervention. Peer professional opinion that is irrational does not fulfil this criteria. Ergo, any practitioner using the interventions you list may find difficulty in defending a negligence in consent case. You ask: Are rational chiropractors in a position to question or colleagues techniques or may I add, more importantly, their ideology? What would make you think we are incapable of doing so? Again, I refer to my consent paper, my vitalism paper, my appeal to fear paper and a host of other papers examining chiropractic techniques.

          Before you go off on a rant, yes, we as a profession are late to the party but, as the Limboro case [see my consent paper] demonstrates, there positive signs that we are moving in the right direction.

          Out of curiosity, how long has orthopaedics embraced evidence based medicine? To save you time, it is a relatively new phenomenon. The Journal of Bone and Joint Surgery, in recognition of the need to integrate clinical expertise with the best available systematic research, introduced a new section, “Evidence-Based Orthopaedics in the year 2000. In 2003, the Journal of Bone and Joint Surgery decided that all clinical articles submitted for publication would have to include a level of evidence rating to classify the quality of study. in a very recent article published February 2008, the Osteoarthritis Research International (OARSI) group published the second of two articles describing their recommendations for the management of hip and knee osteoarthritis, which they arrived at through a critical appraisal of existing guidelines, a systematic review of the recent research evidence and the consensus of a body of multi-disciplinary experts in primary care, rheumatology orthopaedics and EBM. How long does it take for best practice recommendations to filter down into clinical practice? When l last looked at this topic the answer was approximately 15 years. My point, the pot should not call the kettle black. Play nice.

    • Questioning someone’s integrity is a polite way of calling them a prevaricator aka: a liar. Questioning, for example, Donald Trump’s integrity is appropriate. There are literally thousands of examples of his lack of integrity, in business, in office and on the golf course. However, to question my integrity is inappropriate and frankly, deeply offensive. You assert that I misrepresent my experience at CMCC.

      You offer as evidence a link to a piece produced in 1995 by Stephen Barrett entitled Evidence of Unscientific Teachings at Canadian Memorial Chiropractic College (CMCC) which, admittedly, paints a bleak picture of my alma mater. On the other hand, CMCC claims it has for several decades promoted itself as being an evidence-based program, with a model of care focusing on chiropractic as a primary contact health care profession with expert knowledge in spinal and musculoskeletal health. Wherein is the truth?

      Regarding your statement about my integrity. Firstly, to assert that Barrett’s representation is what I experienced firsthand at CMCC from 1978-1982 is erroneous. Barrett’s 1995 piece was produced 13 years after I graduated, and I can assure you that the course I was exposed to matched the CMCC position outlined above. I cannot comment on curriculum changes in the years after I graduated. I do know that the curriculum today is as it was when I was studying there. Of note, when I was at CMCC, its President was Ian Coulter. Ian Coulter, PhD, is a senior health policy analyst at the RAND Corporation, where he holds the Samuel Institute Chair in Policy for Integrative Medicine. He is a full professor in the School of Dentistry, UCLA, in the Division of Public Health and Community Dentistry; a professor at the Pardee RAND Graduate School; and a research professor at the Southern California University of Health Sciences. Amongst his many publications are condemnations of Palmerian ideology. Do you suppose he would have presided over a Palmerian subluxation-based ideology program? Here is a link to an interview with Professor Coulter: https://chiropracticscience.com/tag/ian-coulter/

      Secondly, if you are the least bit familiar with my publications, you would understand my dismay at your assertion. Recall for a moment the basis of this thread. Are you able to produce a single instance where I have done anything but call out Palmerian subluxation ideology labelling it a historical relic that has no place in 20th or 21st century health care? I will save you time: there are none. Kindly withdraw your baseless assertion.

      Regarding the Rome paper you cite: Usage of chiropractic terminology in the literature — 296 ways to say “subluxation.” Chiropractic Technique 1996;8:1-12. I have known Peter Rome for many years – nice guy but a Palmerian ideologue. I use his paper in a lecture which is entitled: Subluxation – dogma or science? NB: this title is also the title of a paper well worth reading. doi: 10.1186/1746-1340-13-17 Rome states in his paper “with so many attempts to establish a term for such a clinical and biological finding, an entity of some significance must exist. I challenge listeners with an analogy: a simple Google Scholar search for the term ‘tooth fairy’ yields >42k results. With so much written about the tooth fairy, surely an entity of some significance must exist. I have long argued for abandoning this confusing term within the chiropractic context.

      You ask a valid question: how does a chiropractic customer (or another health care professional) distinguish between an evidence-based chiropractor and a quack one? Curtis and Bove provided useful guidelines in 1992 remain valid today. A competent chiropractor:
      • Mainly treats musculoskeletal conditions using manual techniques
      • Does not routinely radiograph patients
      • Does not unnecessarily extend treatment duration
      • Responds in writing to a referral and offers a treatment plan
      • Does not charge a ‘front-end’ lump sum payment for the whole treatment program
      • Holds acceptable educational credentials
      • Is willing to have a physician visit the office to observe care

      Curtis, P., & Bove, G. (1992). Family physicians, chiropractors, and back pain. J Fam Pract, 35, 551-555.

      • JK Simpson wrote: “Questioning someone’s integrity is a polite way of calling them a prevaricator aka: a liar…to question my integrity is inappropriate and frankly, deeply offensive…you assert that I misrepresent my experience at CMCC.”

        @ JK Simpson

        I did not assert that you misrepresented *your* experience at CMCC.

        You stated “At that time and to this day, CMCC teaches Palmerian subluxation theory in a historical context”

        I asserted that it is transparent that in 1982 *the CMCC* did not teach Palmerian subluxation theory in “a historical context”. See https://quackwatch.org/chiropractic/edu/york/

        Basically, you were misrepresenting the apparent facts.

        JK Simpson wrote: “You offer as evidence a link to a piece produced in 1995 by Stephen Barrett entitled Evidence of Unscientific Teachings at Canadian Memorial Chiropractic College (CMCC) which, admittedly, paints a bleak picture of my alma mater.”

        Indeed, it does.

        JK Simpson wrote: “CMCC claims it has for several decades promoted itself as being an evidence-based program”

        It might have claimed that, but the reality appears to be very different.

        JK Simpson wrote: “Regarding your statement about my integrity. Firstly, to assert that Barrett’s representation is what I experienced firsthand at CMCC from 1978-1982 is erroneous.”

        Again, I’m not talking about what you experienced, I’m talking about your statement regarding the CMCC – i.e. that when you studied there “At that time and to this day, CMCC teaches Palmerian subluxation theory in a historical context”. The Quackwatch piece paints a different picture.

        JK Simpson wrote: “I do know that the curriculum today is as it was when I was studying there.”

        In that case, if the Quackwatch piece is correct – and I see no reason to doubt it – that’s rather worrying.

        JK Simpson wrote: “Of note, when I was at CMCC, its President was Ian Coulter. Ian Coulter, PhD, is a senior health policy analyst at the RAND Corporation, where he holds the Samuel Institute Chair in Policy for Integrative Medicine…Do you suppose he would have presided over a Palmerian subluxation-based ideology program?”

        Going by the Quackwatch piece, he did:
        “Despite its denials, it is very clear that CMCC has been turning out a defective product.”
        Ref. https://quackwatch.org/chiropractic/edu/york/

        JK Simpson wrote: “Regarding the Rome paper…I have known Peter Rome for many years – nice guy but a Palmerian ideologue.”

        Yet despite his ‘Palmerian ideologue’, he was admitted as a Fellow of the International College of Chiropractors in September 2020:

        QUOTE
        “To celebrate the magnitude of this achievement, ACA [Australian Chiropractors’ Association] President Dr Anthony Coxon was fortunate enough to present the award to Dr Rome in person”
        Ref. https://www.chiro.org.au/members-admitted-into-icc/

        For readers who may have missed this, Rome received the award as recognition from the International College of Chiropractors for his “contribution towards the advancement of the profession” and “immense literature contributions over the years”. Apparently he has received various college and ACA awards and was a member of several ACA Committees as well as the Chiropractic Registration Board. Since 1991, he authored or co-authored over 25 papers which are listed on the Index to Chiropractic Literature. Many of these published papers “are related to the fundamental chiropractic tenet with eight papers on the topic of subluxation”.

        Rome also co-authored this Vertebral Subluxation Complex dossier
        https://cdn.vortala.com/static/uploads/3/2011/11/VSC_Position_Statment_AUKC.pdf
        …which was commissioned by the vitalistic Alliance of UK chiropractors:
        https://www.zenosblog.com/wp-content/uploads/2010/11/AUKC_Oct_Newsletter.pdf

        It’s also worth noting that Rome graduated from the Canadian Memorial Chiropractic College (CMCC) https://www.chiro.org.au/members-admitted-into-icc/

        JK Simpson wrote: “You ask a valid question: how does a chiropractic customer (or another health care professional) distinguish between an evidence-based chiropractor and a quack one? Curtis and Bove provided useful guidelines in 1992 remain valid today. A competent chiropractor: • Mainly treats musculoskeletal conditions using manual techniques • Does not routinely radiograph patients • Does not unnecessarily extend treatment duration • Responds in writing to a referral and offers a treatment plan • Does not charge a ‘front-end’ lump sum payment for the whole treatment program • Holds acceptable educational credentials • Is willing to have a physician visit the office to observe care Curtis, P., & Bove, G. (1992). Family physicians, chiropractors, and back pain. J Fam Pract, 35, 551-555.”

        But how widely is that advertised? And who advises the general public to beware of the chiropractic ‘bait and switch’?
        Ref. https://sciencebasedmedicine.org/the-bait-and-switch-of-unscientific-medicine/

        • …you assert that I misrepresent my experience at CMCC…

          The most dangerous rationalisation in clinical work: “In my experience…”.

        • Blue Wode, I attended CMCC from 1978-1982. During this period I ‘experienced’ the CMCC curriculum. During that time Palmerian subluxation theory was taught in a historical context. I cannot produce my class notes or unit guides so you will have to take my word for it although I have been in contact with several of my classmates all of whom confirm this position. I have conceded that Stephen Barrett’s 1995 exposé is not pretty and suggestive of a curriculum shift. I have not fact checked the piece. You have yet to explain how a 1995 exposé can be presented as evidence of what the curriculum was 17 years prior. Until you can make that argument, your questioning of my integrity is inappropriate. A retraction would be appreciated.

          I can comment on Barrett’s assertion that a study of graduate attitudes and beliefs is demonstrative of the program they graduated from. This is not a sound argument. Anyone who has been involved in university education will confirm the reality of the hidden curriculum as well as the influence of outside sources. It is not the least bit surprising that a percentage of graduates of any program hold different ideologies relative to those taught in their undergrad course.

          • JK Simpson wrote: “I have conceded that Stephen Barrett’s 1995 exposé is not pretty and suggestive of a curriculum shift. You have yet to explain how a 1995 exposé can be presented as evidence of what the curriculum was 17 years prior. Until you can make that argument, your questioning of my integrity is inappropriate.”

            @ JK Simpson

            It appears that the Canadian Memorial Chiropractic College (CMCC) enjoys a remarkable amount of ‘curriculum shifting’. Indeed, it seems to stay awfully quiet about some of its dubious activities:

            First, we have subluxationist Peter Rome graduating from the CMCC in May 1969. As already pointed out, Rome recently achieved the exalted rank of admission as a Fellow to the International College of Chiropractors having authored or co-authored over 25 papers many of which are related to the fundamental chiropractic tenet with eight papers on the topic of subluxation:

            QUOTE
            “To celebrate the magnitude of this achievement, ACA [Australian Chiropractors’ Association] President Dr Anthony Coxon was fortunate enough to present the award to Dr Rome in person”
            Ref. https://www.chiro.org.au/members-admitted-into-icc/

            Rome also co-authored this Vertebral Subluxation Complex dossier
            https://cdn.vortala.com/static/uploads/3/2011/11/VSC_Position_Statment_AUKC.pdf
            …which was commissioned by the vitalistic Alliance of UK chiropractors:
            https://www.zenosblog.com/wp-content/uploads/2010/11/AUKC_Oct_Newsletter.pdf

            You stated that you attended the CMCC from 1978-1982 and that “Philip Emanuele and I were in the same class at Canadian Memorial Chiropractic College (CMCC) graduating in 1982. At that time and to this day, CMCC teaches Palmerian subluxation theory in a historical context. We studied and practiced manual therapy for musculoskeletal conditions not subluxation detection and removal to restore innate intelligence flow.”

            The implication here is that during your student days at the CMCC it was wholly evidence-based, and yet, curiously, by the 1990s, it appeared to have taken a huge step backwards:

            QUOTE
            “The Ontario Chiropractic Association officially states that babies should be examined by a chiropractor ‘as soon as possible after birth’.” Over 75% of all Ontario chiropractic association members were trained at the CMCC. This fact alone, plus their textbooks and notes would mean that chiropractors were taught these ideas about infants and children at CMCC.”

            Ref. https://www.chirowatch.com/chiropractic-cpsletter.html

            More:

            QUOTE
            “Pediatric Chiropractic (1998), which CMCC uses as a textbook, states that “the chiropractor has an opportunity to normalize, if not minimize, the effects of vertebral subluxation complex. Thorough analysis and specific adjustments to the pregnant female and pediatric spine may have a far-reaching impact on whole body health.” [5] The chapter on spinal examination advocates the use of a Temp-O-Scope, an instrument inappropriately claimed to be useful for detecting “subluxations” by reporting differences in skin temperature on either side of the spine. The book also advises: “Rather than advising the parent(s) to vaccinate or not to vaccinate, the chiropractic doctor should focus on educating the parent(s) on the subject and allow the parent(s) to make the decision they feel is most appropriate for their child.” The book’s 27-page chapter on these “issues” is devoted mainly to adverse reactions, contraindications, and “failures.” Nothing in the chapter suggests that immunization is a good idea.
            CMCC’s bookstore sells homeopathic remedies and acupuncture and reflexology charts. Doing this encourages the outlandish beliefs associated with these practices.”

            Ref. https://quackwatch.org/chiropractic/edu/york/

            In 1998, a CMCC fact sheet stated:
            “An integral component of [CMCC] students’ clinical education is the exposure to multidisciplinary environments and the opportunity to work in co-operation with other health care professionals. For example, interns and graduate students work as part of teams at: … Sunnybrook Hospital, Chedoke-McMaster Hospital, St. Michael’s Hospital, and Princess Margaret Hospital.”

            In fact, hospital officials denied these claims outright. There are written statements testifying that there were no formal contracts or relationships with St. Michael’s or Sunnybrook. Moreover, there’s information that this is also the case for Chedoke-McMaster and Princess Margaret (courtesy of a Globe and Mail writer who verified this information independently). The close ties between conventional medicine and chiropractic implied by the CMCC simply do not exist.

            Ref. https://tinyurl.com/yycj9zsy

            On page 177 of the book ‘Spin Doctors: The Chiropractic Industry Under Examination’ by Paul Benedetti and Wayne MacPhail, there’s this:

            “CMCC used the RAND study in its submissions to York [University] to bolster its case [for affiliation]. CMCC officials also didn’t mention another important RAND study, “The Appropriateness of Manipulation and Mobilization of the Cervical Spine”. The 1996 study…is not as favourable to the use of manipulation and mobilization for the upper spine. The panel found only 11 % of 736 indications for cervical manipulation were judged appropriate.”

            Ref. https://tinyurl.com/yy9vl3l2

            Then there’s the famous 1998 reply by the CMCC to a Canadian Pediatric Society statement about paediatric chiropractic claims and practices. It’s a point by point rebuttal. For example:

            5. Statement Five: There is no scientific evidence whatsoever that the so-called chiropractic spinal adjustment results in any correction to a child’s spine. These adjustments are ineffective and useless.
            Response: The statement that chiropractic spinal manipulation (adjustment) is ineffective and useless as a treatment to correct a joint dysfunction in a child’s spine is unfounded. Literature supports that manipulation for neuromusculoskeletal dysfunctions is effective.

            7. Statement Seven: Parents should regard with extreme scepticism claims made by some other parents that their infants or children have been cured by chiropractic adjustments for such conditions as: infantile colic, recurrent ear infections, learning disorders, asthma, chronic abdominal cramps or bed-wetting. However well-meaning, such personal testimony is unreliable and is not a substitute for scientific fact. Parents should read the June 1994 issue of Consumer Reports magazine in which the clear recommendation is made not to allow any chiropractor to solicit children for chiropractic treatment.

            Response: Personal testimony is relatively unreliable and is no substitute for scientific fact. Parents know better than anyone how well their children have responded to any treatment or therapy — chiropractic, medical, or other. To dismiss their observations as only worthy of “extreme scepticism” is insulting.

            Ref. https://tinyurl.com/y6auo9w9

            In 1999, chiropractor and recent CMCC graduate, James Gregg, appeared on the radio to tell listeners that it was okay to treat infants and children with manual therapy for otitis media. However, questions were asked:
            QUOTE
            “…has he abandoned all scientific knowledge? Why does he oppose the accepted medical pediatric treatment for infectious disease, simple immunizations, and other aspects of preventive health, and replace it with the Innate Intelligence thing?…Is his chiropractic knowledge based on what he paid for at the CMCC, or has he arisen about those roots, and obtained inspiration from pediatric chiropractors at hotel conferences at the Novatel, or elsewhere? Would you trust your newborn baby to someone with 30 hours’ worth of pediatric chiropractic taught at the CMCC, or 120 hours in marketing sessions held at a hotel?

            More: https://www.chirowatch.com/ckgl-990126gregg.html

            Into the noughties…

            “What’s really quite curious is the fact that the leaders of CMCC swear that they do not teach their students any anti-vaccine rhetoric. Yet, their bookstore sells books full of anti-vaccine propoganda. Do these folks learn this from other chiropractors at weekend meetings at the Novatel Hotel near the airport, or what?”

            Ref. https://www.chirowatch.com/Chiro-anti-vax/ptw001101szalay.html

            June 11, 2002: Attitudes toward vaccination: a survey of Canadian chiropractic students – CMAJ

            QUOTE
            “A landmark study completed at the CMCC (Canadian Memorial Chiropractic College) in Toronto reveals that anti-vaccine attitudes were developed by young chiropractic students as they progressed through the four year program. When they entered this “scientific” chiropractic college 40% of them had already rejected vaccination as invalid or had no educated opinion. Were these folks screened for admission because they already mistrusted the allopathic medical system? Didn’t they all have basic science backgrounds from Canadian or U.S. universities? Had they ever heard of smallpox, or polio, or diphtheria?”

            At this point it is worth re-posting what JK Simpson wrote: “You have yet to explain how a 1995 exposé can be presented as evidence of what the curriculum was 17 years prior. Until you can make that argument, your questioning of my integrity is inappropriate.”

            Now we move on to Jean Moss DC, former president of the Canadian Memorial Chiropractic College, who admitted that the school taught students to examine infants to see if their spines and muscles are developing properly:

            QUOTE:
            “There are cases where adjustments to children’s spines are necessary, after a fall or trauma, she explains. And in some chronic ear infections the muscles around the ear and the face become very spastic and painful and by working on those you can reduce the pain, through chiropractic treatment.”

            Ref. https://www.chirowatch.com/York/tstar991022harvey-quacks.html

            Jean Moss attended CMCC and graduated in 1970 (a year after vertebral subluxation fan Peter Rome). She began a private practice and joined the CMCC faculty on a part-time basis in 1971. She then went on to hold a number of increasingly responsible roles at CMCC that culminated in her appointment as president in 1990. She retired as president in 2014, but during her presidential tenure she signed the Association of Chiropractic Colleges’ position paper that strongly supporting the subluxation concept. The “Paradigm” section says this about subluxations:

            QUOTE
            “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence.”

            This is an approach that has been rejected by medical science.

            @ JK Simpson

            So there is my argument. How can you possibly say that when you attended the CMCC from 1978-1982 that “At that time and to this day, CMCC teaches Palmerian subluxation theory in a historical context. We studied and practiced manual therapy for musculoskeletal conditions not subluxation detection and removal to restore innate intelligence flow”?

            Are you seriously saying that from 1982 through to 2020 the CMCC has been teaching manual therapy for MSK conditions only?

            Because it just doesn’t add up.

  • @BW
    “But it won’t be. As we’ve already heard from Critical_Chiro “The vitalists will not change.”
    So change will need to be forced upon them.
    Do you not think that Keith Simpsons paper is doing just that Blue?
    Do you not thing that lawyers will also read this paper and use it in court?
    Do you not think that associations who remain silent for the sake of “unity with diversity” and proposed private vitalistic colleges who are attempting to turn their backs on 30 years of university based/evidence based education will read this paper?
    Do you not think that professional indemnity insurers will read this paper and reevaluate their risk, premiums and be selective in who they insure?
    It will only take one case in court to set the precedent then it will be all over red rover for subluxation and high time IMHO.

  • John Travis wrote on Thursday 19 November 2020 at 23:11: “I recently did a trawl through chiros registered with the GCC in the UK. Well over 80% of them do not have websites. This would seem to indicate either that they are so pre-historic that they have not yet discovered the internet – in which case one might assume that they are acolytes of Palmer. Or alternately one might draw the conclusion that they do not wish to advertize their philosophy so brazenly and prefer to keep their ideas a secret – which is equally concerning.”

    What an interesting comment. Could it also be that business is so bad that many of them can’t afford websites?

  • John Travis asks exactly what is your evidence for “cervicogenic migraine”? this entity would appear to be an entirely chiropractic invention.

    Apologies. I should have correctly referred to cervicogenic headache mimicking migraine symptoms. This is not a chiropractic invention. You provided a link to the American Migraine Foundation’s Cervicogenic Headache page. The very same organisation includes cervicogeinic headache in its list of different types of headache. Common migraine and cervicogenic headache have many traits in common, so many that they may be confused.
    “When the pain in your head is actually caused by pain in your neck, you probably have a cervicogenic headache. The pain usually comes from the neck or from a lesion on the spine, which is often confused with pain in the back of your head. It’s common for this type of headache to require physical therapy in addition to medication or other treatment.” https://americanmigrainefoundation.org/resource-library/what-type-of-headache-do-you-have/

    Manual therapists of all types have had patients present with what appears to be migraine with or without aura that responds to treatment to the neck be it manipulative or mobilisation. In cervicogenic headache, the following symptoms and signs provide the clue to the correct diagnosis and treatment: decreased range of cervical motion; mechanical precipitation of attack, either by neck movements or by external pressure over the greater occipital nerve of the C2 root or cervical joints; ipsilateral shoulder/arm pain; unilaterality without side-shift. Similar findings are usually not made in migraine. Typical migraine symptoms, such as nausea, vomiting, photophobia, and phonophobia also occur in cervicogenic headache, but less frequently and to a lesser degree. There you have it.

  • Professor Ernsts states: I have asked you a straight forward question
    you responded pompously that we need first to establish some baseline information
    I provided it
    now please answer my question
    FULL STOP

    Professor Ernst, you continue to avoid my rather simple questions. I expect that you have been deposed by barristers and therefore would know that your answers to my initial questions are ambiguous and of necessity, require clarification.

    So, let’s play one more round. For the purpose of this exercise we will accept into evidence your statement that you try to be where the best available evidence takes you.

    1) Does the best available evidence support the use of neck manipulation? Yes or No.

    2) Does the best available evidence confirm that there are rational chiropractors adhering to the principles of evidence based practice? Yes or No.

    3) There is government legislation regulating the practice of chiropractic in 68 countries. With registration comes legal requirements stipulating what is to occur in a patient encounter which includes, inter alia, obtaining informed consent? Yes or No.

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