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

Anyone who has been following this blog will have noticed that we have our very own ‘resident chiro’ who comments every single time I post about spinal manipulation/chiropractic/back pain. He uses (mostly?) the pseudonym ‘DC’. Recently, DC explained why he is such an avid poster of comments:

” I read and occasionally comment on this blog for two main reasons. 1. In my opinion Ernst doesn’t do a balance reporting on the papers his shares regarding spinal manipulation and chiropractic. Thus, I offer additional insight, a more balanced perspective for the readers. 2. There are a couple of skeptics who occasionally post that do a good job of analyzing papers or topics and they do so in a respectful manner. I enjoy reading their comments. I will add a third. 3. Ernst, from what I can tell, doesn’t censor people just because they have a different view.”

So, DC aims at offering additional insights and a more balanced perspective. That would certainly be laudable and welcome. Yet, over the years, I have gained a somewhat different impression. Almost invariably, my posts on the named subjects cast doubt on the notion that chiropractic generates more good than harm. This, of course, cannot be to the liking of chiropractors, who therefore try to undermine me and my arguments. In a way, that is fair enough.

DC, however, seems to have long pursued a very specific and slightly different strategy. He systematically attempts to distract from the evidence and arguments I present. He does that by throwing in the odd red herring or by deviating from the subject in some other way. Thus he hopes, I assume, to distract from the point that chiropractic fails to generate more good than harm. In other words, DC is a tireless (and often tiresome) fighter for the chiropractic cause and reputation.

To check whether my impression is correct, I went through the last 10 blogs on spinal manipulation/ chiropractic/ back pain. Here are my findings (first the title of and link to the blog in question, followed by one of DC’s originals distractions)

No 1

Chiropractic: “a safe form of treatment”? (edzardernst.com)

“It appears conventional medicine has a greater number of AE. This is not surprising.”
correct!
real doctors treat really sick patients

So the probability of an AE increases based upon how sick a patient is? Is there research that supports that?

No 2

Malpractice Litigation Involving Chiropractic Spinal Manipulation (edzardernst.com)

It would be interesting to know more about these 38 cases that weren’t included since that’s almost half of the 86 cases. What percentage of those cases involved SMT by a non chiropractor?

“Query of the VerdictSearch online legal database for “chiropractor” OR “chiropractic” OR “spinal manipulation” within the 22,566 listed cases classified as “medical malpractice” yielded 86 cases. Of these, 48 cases met the inclusion criteria by featuring a chiropractic practitioner as the primary defendant.”

No 3

Lumbar disc herniation treated with SCAM: 10-year results of an observational study (edzardernst.com)

there are three basic types of disc herniation

contained herniation
non-contained herniation
sequestered herniation

Some add a forth which are:

disc protrusion
prolapsed disc
disc extrusion
sequestered disc

where the first two are considered incomplete (contained) and the last two are called complete (non-contained) but they are all classified as a disc herniation.

You’re welcome

No 4

Multidisciplinary versus chiropractic care for low back pain (edzardernst.com)

Elaborate on what you think was my mistake regarding clinical significance.

No 5

Which treatments are best for acute and subacute mechanical non-specific low back pain? A systematic review with network meta-analysis (edzardernst.com)

An evidence based approach has three legs. If you wish to focus on the research leg, what does the research reveal regarding maintenance care and LBP? Have you even looked into it?

No 6

Meditation for Chronic Low Back Pain Management? (edzardernst.com)

CRITERIA in assessing the credibility of subgroup analysis.

https://www.nature.com/articles/s41433-022-01948-0/tables/1

No 7

Acute Subdural Hemorrhage Following Cervical Chiropractic Manipulation (edzardernst.com)

sigh, my use of the word require was pointing out that different problems require different solutions.

You confuse a lack of concern with my critical analysis of what some use as evidence of serious harm.

I have only used one other identifier on this blog. Some objected to my use of the word Dr in that identifier so I changed it to DC as it wasn’t worth my time to argue with them (which of course DC still refers to Doctor but it seemed to appease them).

In healthcare and particularly in manual therapy we look at increasing comfort and function because most come to us because…wait for it…a loss of comfort and function.

Yes, there is the potential to cause harm, I have never said otherwise. Most case reports suggest that serious harm is due to an improper history and exam (although other reasons may exist such as improper technique). Thus, most cases appear to be preventable with a proper history, exam and technique. That, is a different problem that, yes, requires a different solution.

So yes, spinal manipulation isn’t “required” anymore than physical therapy, NSAIDs, etc for most cases. The question is: does the intervention increase comfort and function over doing nothing and is that justified due the potential risk of harm….benefit vs risk.

Now, i shall excuse my self to prepare for a research presentation that deals with a possible new contraindication to cSMT (because I have a lack of concern, right?)

No 8

Double-sided vertebral artery dissection in a 33-year-old man. The chiropractor is not guilty? (edzardernst.com)

Hmmm, let’s change that a bit…

The best approach is to consider the totality of the available evidence. By doing this, one cannot exclude the possibility that NSAIDs and opioids cause serious adverse effects. If that is so, we must abide by the precautionary principle which tells us to use other treatments that seem safer and at least as effective.

So based upon the totality of the available evidence, which is safer and at least as effective: cervical spinal manipulation vs NSAIDs/opioids?

No 9

Chiropractic spinal manipulation is not safe! (edzardernst.com)

getting the patient to sign something describing the risks. This is apparently something chiropractors don’t do before a neck manipulation.

Apparently?

No 10

Vertebral artery dissection in a pregnant woman after cervical spine manipulation (edzardernst.com)

Most case reports fail on one of two criteria, sometimes both.

1. No clear record of why the patient sought chiropractic care (symptoms that may indicate a VAD in progress or not)

2. Eliminating any other possible causes of the VAD especially in the week prior to SMT.

I would have to search but I recall a case report of a woman presenting for maintenance care (no head or neck symptoms at the time) and after cSMT was dx with a VAD. Asymptomatic VADs are very rare thus there is a high probability that cSMT induced the VAD in that case, IMO.

Although not published I had a dialogue with a MD where a patient underwent a MRI, had cSMT the next day and developed new symptoms thus another MRI was shortly done and was dx with a VAD. I encouraged her to publish the case but apparently she did not.

There was a paper published that looked at the quality of these case reports, most are poor.

__________________________________

I might be mistaken but DC systematically tries to distract from the fact that chiropractic does not generate more good than harm and that there is a continuous flow of evidence suggesting it does, in fact, the exact opposite. He (I presume he is male) might not even do this consciously in which case it would suggest to me that he is full of quasi-religious zeal and unable to think critically about his own profession and creeds.

Reviewing the material above, I also realized that, by engaging with DC (and other zealots of this type), it is I who often gives him the opportunity to play his game. Therefore, I will from now on try harder to stick to my own rules that say:

  • Comments must be on-topic.
  • I will not post comments which are overtly nonsensical.
  • I will not normally enter into discussions with people who do not disclose their full identity.

 

19 Responses to Comments by a chiropractor: insights into quasi-religious zeal

  • Indeed what DC is doing and troubles you to the point you bother writing about it is to put Chiropractic in the same field and on the same terms as other medical / health care professions. Ask yourself why is it that you put such diffrent standards in criticing Chiropractic???

    • “Ask yourself why is it that you put such diffrent standards in criticing Chiropractic”
      In case you haven’t noticed: my blog is about so-called alternative medicine. And I think I apply similar standards across this field.

    • who says it ‘troubles’ me what DC does?
      YOU DO
      It does not trouble me at all, I merely tried to analyze the phenomenon, because I feel it is a special phenomenon if someone writes hundreds of comments of a particular nature – don’t you?

    • Ask yourself why is it that you put such diffrent standards in criticing Chiropractic???

      Dr. Ernst’s career was about holding alt-med to the same standards as mainstream medicine is usually held. People don’t usually ask for good evidence for alt-med, or they take evidence to be good when it isn’t.

      • Robin: Dr. Ernst’s career was about holding alt-med to the same standards as mainstream medicine is usually held.

        What are those standards? This?

        A widely cited expert, John Ioannidis, professor of epidemiology at Stanford University, claims that EBM is “becoming an industry advertisement tool.” Clinical research, one of the EBM pillars, is also far from perfect. Among the prominent figures in medicine who questioned research is Richard Horton, editor of The Lancet, who stated: “The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue. Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness” [1]. Marcia Angell, who served as the editor of The New England Journal of Medicine for over 2 decades, wrote: “It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines” [2]. Ioannidis, based on a theoretical model, concluded that “most published research findings are probably false” [3]. Earlier, he also argued that as much as 30% of the most influential original medical research papers later turn out to be mistaken or overstated [4]. https://www.karger.com/Article/Fulltext/487375

        • The cranks pile on John Ioannidis’ work on the reliability of science
          https://scienceblogs.com/insolence/2007/09/24/the-cranks-pile-on-john-ioannidis-work-o

          • “None of Ioannidis’ work should come as any shock to clinical investigators or scientists. Indeed, it did not.”

            So is this the standard? Can Pete even answer a question?

          • QUOTE
            The cranks pile on John Ioannidis’ work on the reliability of science

            Predictably, quacks and advocates of pseudoscience have jumped all over Ioannidis’ findings …

            Sadly, Ioannidis’ work rather easily lends itself to being misinterpreted by the pseudoscientists as a reason to dismiss the findings of science — as if doing so would make their pseudoscience correct absent good evidence for their position.

            Perhaps the best analyses of the real significance of Ioannidis’ findings come from Steve Novella [see quote below] and Alex Tabbarok.

            All of these are good bits of advice for evaluating the scientific literature. From my perspective, it’s critical to evaluate the totality of the scientific evidence. Single studies may be produce questionable results, but eventually science will correct them. To me, this is the most telling difference between evidence-based medicine and “alternative” medicine, between scientific medicine and pseudoscience: the ability and willingness to change hypotheses based on the evidence. Indeed, Skeptico shows us an example of just this difference in discussing an HIV vaccine that was abandoned because studies showed that it doesn’t work:

            The difference between this and complementary and alternative “medicine” (CAM) is starkly shown. Real medicine is tested for efficacy, and abandoned if it doesn’t work. When was the last time any CAM treatment was publicly abandoned by its practitioners because they discovered it didn’t work?

            The answer is: Never.

            Alternative medicine mavens frequently accuse us “conventional” doctors of being “dogmatic” or otherwise unwilling to consider “different” ideas (specifically their ideas) about medicine and the treatment of disease. In actuality, it is supporters of alternative medicine and pseudoscience who tend to be far more dogmatic than any conventional physician.

            The misuse and abuse of Ioannidis’ work is, when you come right down to it, nothing more than a variant of the old crank chestnut of “science has been wrong before.” My usual response is: So what? Science has been wrong before, but it was generally scientists, not pseudoscientists, who found the error and corrected it. Moreover, they did it based on the evidence, not on cranks’ favored techniques of logical fallacies, cherry picking data (HIV/AIDS denialists’ and creationists’ favorite technique), and misrepresenting what science actually says (creationists’ favorite technique). It does not follow from the past mistakes of science that the science now is necessarily wrong.
            END of QUOTE [my emphasis]

            QUOTE [linked from above article]
            Are Most Medical Studies Wrong? by Steven Novella

            John Ioannidis has published a series of studies that demonstrate that most published medical studies turn out to be wrong, and when they are correct the effect size tends to be initially exaggerated. Ironically, while this work should serve to improve the quality of scientific medicine, it is being used by some cranks to attack the scientific basis of medicine.

            What struck me about Tabbarok’s analysis (which he did not point out directly himself) is that removing the consideration of prior probability will make the problem of false positive studies much worse. This is exactly what so-called complementary and alternative medicine (CAM) tries to do. Often the prior probability of CAM modalities – like homeopathy or therapeutic touch – is essentially zero.

            If we extend Tabbarok’s analysis to CAM it becomes obvious that he is describing exactly what we see in the CAM literature — namely a lot of noise with many false-positive results.

            https://theness.com/neurologicablog/index.php/are-most-medical-studies-wrong/
            END of QUOTE [my emphasis]

          • The cranks pile on John Ioannidis’ work on the reliability of science

            Hey Pete,

            Thanks, that’s a great article by Dr. Gorski. One of his greatest hits, I suppose. I recently started following his blog and not familiar with his old writings. I think the following paragraphs pretty much summarizes the entire article:

            Alternative medicine mavens frequently accuse us “conventional” doctors of being “dogmatic” or otherwise unwilling to consider “different” ideas (specifically their ideas) about medicine and the treatment of disease. In actuality, it is supporters of alternative medicine and pseudoscience who tend to be far more dogmatic than any conventional physician. If Ioannidis’ results are correct, the results of 1/3 of seemingly very important papers were ultimately refuted, resulting in the abandonment of accepted treatments once thought sound. Doesn’t that tell you something? It should! It tells me that “conventional” medicine changes its tests, understanding of disease, and treatments on the basis of new evidence and, more importantly, abandons treatments found to be ineffective or not as effective as newer therapies. This winnowing and optimization process may be very messy to watch. It may not happen as fast as we’d like, but happen it does eventually. Contrast this to alternative medicine, where there are still alternative medicine practitioners pushing Laetrile (despite the fact that it was shown to have no efficacy against cancer in well-designed clinical trials 25 years ago), chelation therapy for coronary artery and peripheral vascular disease (despite multiple randomized studies during the 1990’s showing it to be no better than placebo), and homeopathy (despite 200 years of science showing that it, too, is no better than an elaborate placebo). Unlike conventional medicine, alternative medicine does not change, other than to gussy up its woo with “science-y”-sounding terminology, especially quantum theory or to add another scientifically highly improbable “treatment” to its panoply of scientifically improbably treatments. (Hulda Clark’s Zapper, anyone?) More importantly, it almost never abandons therapies found by sound research to be ineffective, as Skeptico so ably (and sarcastically) pointed out.

            In the end, contrary to the best efforts of cranks, pseudoscientists, and quacks to portray its conclusions as indicating that science is “basically fraudulent,” remember that Ioannidis’ work does not give any succor at all to advocates of pseudoscience, be they alternative medicine mavens, HIV/AIDS denialists, or any other. In fact, it is work like his that differentiates science and evidence-based medicine from pseudoscience and alternative medicine. Ioannidis looks at how we as a profession do biomedical research and clinical trials and finds the faults even in studies thought to be the gold standard, all with a mind to improve how we do research, suggesting more replication, more care, and to be cautious about initial findings. There’s also an irony in this, given what Ioannidis is saying and how cranks are representing it. That’s because Ioannidis would have no way of determining what percentage of scientific findings are “wrong” if science weren’t a self-correcting enterprise, if scientists hadn’t continued to work on the same problems and published findings that contradicted and ultimately refuted the early findings. Again, contrast that to how alternative medicine operates, where, once a treatment becomes popular (homeopathy, for example), no matter how much science shows it to be implausible or not to work, it is defended for over 200 years, even to the point of trying to explain it based on torturing the findings of the latest science.

            (emphasis mine)

            Even if an alt-med quack make a sincere effort to read the entire article, I doubt they would be able to grasp how science-based medicine works because some of the SBM constructs like study design, replicability, statistics, critical analysis, optimization etc. are foreign to them.

          • Ioannidis has, regretfully, gone down the rabbit-hole of late, publishing some utter bunk on the COVID pandemic., As Gorski has regretfully observed here. https://sciencebasedmedicine.org/what-the-heck-happened-to-john-ioannidis/

            Gorski and Novella, however, have also been guilty recently of placing ideology before science in other matters as Andy Lewis explains. https://www.quackometer.net/blog/2021/07/the-decline-and-fall-of-science-based-medicine.html

            Nobody’s perfect.

          • Robin: Dr. Ernst’s career was about holding alt-med to the same standards as mainstream medicine is usually held.

            What are those standards?

            I’d suggest one as:

            Research + time = change

  • Totally correct. It is not possible to pay attention to the disjointed speculations of people who adhere to theories that are mere products of fantasy. The fundamentals of chiropractic are as implausible as its practice. There is no way to discuss this question in the light of science, except to demonstrate its implausibility. Scientists and people in scientifically oriented professions are not required to test this myriad of far-fetched “theories”, some of which sound like psychotic delusions. Let us imagine for a moment that all the complexities of the pathogenesis of connective tissue diseases are due to one or more subluxations of the vertebrae! How can we discuss this nonsense in light of what we know about complex immunological phenomena? It is up to men of science to try to enlighten the population about these therapies. However, arguing with their adherents can result in adverse effects, valuing them or making them increasingly entrench themselves in defending their delusions. Science is the only human activity to experience genuine progress, the others have only experienced change, if that. This is your most relevant credential and your greatest glory.

    • When did I ever state I “… adhere to theories that are mere products of fantasy. The fundamentals of chiropractic…”?

      The topic of this particular blog post, it appears, is about me.

  • Gotta be honest, I was a bit disappointed in DC’s comments because they aren’t as wild as I expected them to be, but do still show the continual deflection tendency.
    Also shown by ‘Dr’ Almog: can any person of normal intelligence really have missed that you subject Chiro to the same standards as real medicine?

    I’m wondering whether a template post about what research is and what evidence actually is would help to stop them muddying the waters?

    • John, perhaps what you consider deflection is actually my attempt to put topics into both context and within the broader picture of chiropractic and healthcare for the conditions chiropractors typically address.

      But it is insightful what Ernst stated above as it explains a lot regarding how he views others comments:

      “…the fact that chiropractic does not generate more good than harm…”

      But I suppose that is off topic.

      • DC, Please keep doing what you do ! Edzard is an extreme person that try to masquerade as an evidence based researcher. We need more balanced opinions not the view of the world that is binary.

        • John, I don’t have time to go thru those 10 examples but it appears that most of my responses are to comments or claims that others made. I suspect their comments could/should be labeled as “off-topic”. So I guess I am guilty of responding to off-topic comments and apparently that has me labeled as being diversionary. Ita sit.

          • ‘DC’ wrote: John, I don’t have time to go thru those 10 examples but it appears that most of my responses are to comments or claims that others made. I suspect their comments could/should be labeled as “off-topic”. So I guess I am guilty of responding to off-topic comments and apparently that has me labeled as being diversionary. Ita sit.

            Yet ‘DC’ found the time to post 133 comments on those 10 blogs.

            disingenuous [adjective]: not candid or sincere, typically by pretending that one knows less about something than one really does.
            — Oxford Languages

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