As mentioned before, the US ‘Agency for Healthcare Research and Quality (AHRQ) have published a most comprehensive review update entitled ‘Noninvasive Nonpharmacological Treatment for Chronic Pain‘. It followed the AHRQ Methods Guide for Effectiveness and Comparative Effectiveness. The conditions included were:
- Chronic low back pain
- Chronic neck pain
- Osteoarthritis (knee, hip, hand)
- Chronic tension headache
Here are the main findings related to spinal manipulation:
LOW BACK PAIN
- Spinal manipulation was associated with small improvements compared with sham manipulation, usual care, an attention control, or a placebo intervention in short-term (3 trials) and intermediate-term (3 trials) function (strength of evidence SOE: low). There was no difference between spinal manipulation versus sham manipulation, usual care, an attention control, or a placebo intervention in short-term pain (3 trials), but manipulation was associated with a small improvement compared with controls on intermediate-term pain (3 trials) (SOE: low for short term, moderate for intermediate term).
CHRONIC TENSION HEADACHE
- Spinal manipulation therapy was associated with small improvements in function and moderate improvements in pain compared with usual care over the short term in one trial (SOE: low). Approximately a quarter of the patients had comorbid migraine.
It was noted that many trails failed to report on adverse effects (AEs). Non- serious AEs reported included mild to moderate increase in pain, local discomfort and tiredness (2 RCTs).
Hardly impressive, is it?
Yet, some chiropractors treating chronic pain claim they practice Evidence-based medicine. This review seems to disclose this claim as bogus. What chiropractors do practice on virtually all patients is spinal manipulation which generates more harm than it produces benefit.
Please note yet again that:
- many chiro trials fail to mention AEs (thus violating research ethics),
- clinical trials are always too small to give a reliable impression about safety,
- no post-marketing surveillance exists in chiropractic,
- we thus have to rely mostly on case reports and similar articles,
- and the collective evidence from such reports shows quite clearly that spinal manipulations are not safe,
- chiropractors tend to deny all of the above,
- this is because they have a monumental conflict of interest.
An international team of students of chiropractic have published a paper protesting against those chiropractors and chiropractic organisations that claim their treatments boost the immune system and thus protect the public from the corona-virus infection. Here their abstract:
The 2019 coronavirus pandemic is a current global health crisis. Many chiropractic institutions, associations, and researchers have stepped up at a time of need. However, a subset of the chiropractic profession has claimed that spinal manipulative therapy (SMT) is clinically effective in improving one’s immunity, despite the lack of supporting scientific evidence. These unsubstantiated claims contradict official public health policy reflecting poorly on the profession. The aim of this commentary is to provide our perspective on the claims regarding SMT and clinically relevant immunity enhancement, drawing attention to the damaging ramifications these claims might have on our profession’s reputation.
The World Federation of Chiropractic released a rapid review demonstrating the lack of clinically relevant evidence regarding SMT and immunity enhancement. The current claims contradicting this review carry significant potential risk to patients. Furthermore, as a result of these misleading claims, significant media attention and public critiques of the profession are being made. We believe inaction by regulatory bodies will lead to confusion among the public and other healthcare providers, unfortunately damaging the profession’s reputation. The resulting effect on the reputation of the profession is greatly concerning to us, as students.
It is our hope that all regulatory bodies will protect the public by taking appropriate action against chiropractors making unfounded claims contradicting public health policy. We believe it is the responsibility of all stakeholders in the chiropractic profession to ensure this is carried out and the standard of care is raised. We call on current chiropractors to ensure a viable profession exists moving forward.
In the paper, the authors also state that significant reputational damage can follow when unfounded claims are made that undermine public health policy… We call for a strong stance to be taken against these unsubstantiated claims and do not condone this unacceptable behaviour. As students, we are worried for the profession’s reputation and call on current chiropractors to ensure we have a viable profession moving forward.
Now that the students have realised that the immunity claim is bogus, it would be only a small step to realise that so many other claims chiropractors make on a daily basis are false as well. There may be a difference in terms of severity, but there is none in terms of principle. As responsible healthcare professional to be, the student must rebel against ALL false claims made in their name.
So, will these students and other like-minded chiropractors please not stop here. I urge them to have a serious look at the claims their profession makes. Subsequently, they ought to take the ethically appropriate action.
And what might that be?
I see two possibilities:
- Get rid of the abundance of lies that dominate chiropractic.
- Find a different, more honest profession.
As we have discussed repeatedly, chiropractors tend to be critical of vaccinations. This attitude is easily traced back to DD Palmer, the founding father of chiropractic, who famously wrote about smallpox vaccinations: ‘…the monstrous delusion … fastened on us by the medical profession, enforced by the state boards, and supported by the mass of unthinking people …’
In Canada, the anti-vaccination attitude of chiropractors has been the subject of recent media attention. Therefore, researchers explored the association between media attention and public dissemination of vaccination information on Canadian chiropractors’ websites.
In 2016, an international team of investigators identified all Canadian chiropractors’ websites that provided information on vaccination by extracting details from the regulatory college website for each province using the search engine on their “find a chiropractor” page. The researchers assessed the quality of information using the Web Resource Rating Tool (scores range from 0% [worst] to 100% [best]), determined whether vaccination was portrayed in a positive, neutral or negative manner, and conducted thematic analysis of vaccination content. Now the researchers have revisited all identified websites to explore the changes to posted vaccination material.
Here are their findings:
In July 2016, of 3733 chiropractic websites identified, 94 unique websites provided information on vaccination:
- 59 (63%) gave negative messaging,
- 19 (20%) were neutral,
- 16 (17%) were positive.
The quality of vaccination content on the websites was generally poor, with a median Web Resource Rating Tool score of 19%. Four main themes were identified:
- there are alternatives to vaccination,
- vaccines are harmful,
- evidence regarding vaccination,
- health policy regarding vaccination.
From 2012 to 2016, there was one single Canadian newspaper story concerning anti-vaccination statements by chiropractors, whereas 51 news articles were published on this topic between 2017 and 2019. In April 2019, 45 (48%) of the 94 websites originally identified in 2016 had removed all vaccination content or had been discontinued.
The authors of this investigation concluded that in 2016, a minority of Canadian chiropractors provided vaccination information on their websites, the majority of which portrayed vaccination negatively. After substantial national media attention, about half of all vaccination material on chiropractors’ websites was removed within several years.
I find these findings encouraging. They demonstrate that media attention can produce change for the better. That gives me the necessary enthusiasm to carry on my work in putting the finger on the dangers of chiropractic and other forms of so-called alternative medicine (SCAM). At the same time, the findings of this investigation are also disappointing. About half of all the chiropractors had not removed their misleading content from their websites despite the 51 articles highlighting the problem. This shows, I think, how deeply entrenched this vitalistic nonsense is in the heads of many chiropractor.
This means there is still a lot to do – so, let’s get on with it!
‘THE INTEGRATED HEALTHCARE COLLABORATIVE‘ claim to be a collection of the leading organisations within the field, who are committed to working together to improve healthcare in the UK. They believe that a truly integrated healthcare service would improve patient experiences, bring about better patient outcomes, and provide a framework for a more cost-effective delivery of healthcare services.
Their purpose is as follows:
To bring together professional associations and stakeholders within complementary, traditional and natural healthcare, to identify common areas of interest, and to collectively take forward agreed objectives to promote greater integration with conventional Western medicine.
- To increase public awareness, knowledge and understanding of complementary, traditional and natural healthcare.
- To raise issues in integrated healthcare with government and decision-makers.
- To provide information on complementary, traditional and natural healthcare to the media and interested parties.
- To promote the benefits to public health of greater provision and integration of complementary, traditional and natural healthcare.
- To develop co-ordinated strategies to help patients access accurate information on integrated healthcare.
- To facilitate better access to, and choice of, appropriate complementary, traditional and natural healthcare within the NHS.
- To empower the public to share responsibility for their own health and wellbeing.
- To encourage whole-person, individualised healthcare.
- To advocate collaboration with conventional Western healthcare professionals.
- To support the development of a robust and appropriate evidence base.
They sate that Integrated Healthcare involves combining the best of conventional Western Medicine with a range of complementary, traditional and natural therapies.
The IHC brings together the following leading organisations, who are Core Members and lead our work.
- Alliance of Registered Homeopaths (ARH)
- Association of Energy Therapists (AET)
- Association of Naturopathic Practitioners (ANP)
- Association of Physical and Natural Therapists (APNT)
- Association of Reflexologists (AoR)
- Association of Traditional Chinese Medicine and Acupuncture (ATCM)
- British Complementary Medicine Association (BCMA)
- British Reflexology Association (BRA)
- Chinese Medical Institute and Register (CMIR)
- Craniosacral Therapy Association (CSTA)
- General Council and Register of Naturopaths (GCRN)
- Faculty of Homeopathy (FoH)
- Federation of Holistic Therapists (FHT)
- International Federation of Professional Aromatherapists (IFPA)
- Kinesiology Federation (KF)
- McTimoney Chiropractic Association (MCA)
- National Institute of Medical Herbalists (NIMH)
- Shiatsu Society UK (SSUK)
- Society of Homeopaths (SoH)
- Society of Teachers of the Alexander Technique (STAT)
- UK Reiki Federation (UKRF)
The IHC also provide revealing paragraphs about several so-called alternative medicines (SCAMs) on their website. This is where I have found a host of interesting statements. Here are just 6 examples:
- Chiropractic treatment mainly involves safe, specific spinal manipulation to free joints in the spine or other areas of the body that are not moving properly.
- Science is starting to understand the mechanism of action of ultra-high dilutions in the body, and homeopathic medicines are gentle, safe to use and in widespread use across the world.
- By testing … muscles the kinesiologist can get a picture of what is happening in your meridian system and how this may be affecting you.
- Radionics is a healing technique in which your natural intuitive faculties are used both to discover the energetic disturbances underlying illness and to encourage the return of a normal energetic field that supports health.
- Reflexology is a complementary therapy based on the belief that there are reflex areas in the feet and hands which are believed to correspond to all organs and parts of the body.
- [Reiki] is a tradition that is open to any belief system and benefits may include deep relaxation and the promotion of a calm peaceful sense of wellbeing.
And here are 6 corrections of the above-listed statements:
- Chiropractic involves unsafe spinal manipulation to free customers of their cash.
- Science has long understood that there is no mechanism that could possibly explain homeopathy.
- By testing muscles, the kinesiologist pretends to do something meaningful in order to be able to bill the customer.
- Radionics is a con technique that is counter-intuitive, implausible and unrelated to energy.
- Reflexologists believe to have shown conventional anatomy and physiology to be mistaken.
- Reiki is a tradition and a belief system demonstrably out of touch with reality.
If the IHC want to change their text and adopt my corrections, I would waive my fee for this efforts.
In March, 2020, the International Chiropractors Association (ICA), a US based chiropractic organization, posted a report claiming that chiropractic adjustments can boost immune function with the implication that it might be helpful in preventing COVID-19. In their report, the ICA stated that: “Although there are no clinical trials to substantiate a direct causal relationship between the chiropractic adjustment and increased protection from the COVID-19 virus, there is a growing body of evidence that there is a relationship between the nervous system and the immune system” and “The observation that those who use chiropractic regularly and do not become ill with cold, flu, or other community shared illnesses is frequent within the profession and should not be ignored”.
Such misleading information is obviously unethical, irresponsible and dangerous. It prompted some chiropractors to do the research and find out what evidence exists that chiropractic might affect the immune system. They have now published their findings in a paper; here is its abstract:
In the midst of the coronavirus pandemic, the International Chiropractors Association (ICA) posted reports claiming that chiropractic care can impact the immune system. These claims clash with recommendations from the World Health Organization and World Federation of Chiropractic. We discuss the scientific validity of the claims made in these ICA reports.
We reviewed the two reports posted by the ICA on their website on March 20 and March 28, 2020. We explored the method used to develop the claim that chiropractic adjustments impact the immune system and discuss the scientific merit of that claim. We provide a response to the ICA reports and explain why this claim lacks scientific credibility and is dangerous to the public. More than 150 researchers from 11 countries reviewed and endorsed our response.
In their reports, the ICA provided no valid clinical scientific evidence that chiropractic care can impact the immune system. We call on regulatory authorities and professional leaders to take robust political and regulatory action against those claiming that chiropractic adjustments have a clinical impact on the immune system.
It is not often that I praise the actions of chiropractors, I know. But today, I unreservedly applaud the above-quoted paper.
WELL DONE, AND THANK YOU.
(And while we are on the subject, may I encourage the authors to carry on their good work and do similar assessments of the rest of the hundreds of false claims made by so many of their colleagues day-in, day-out?)
The UK university at Teesside has announced its plan to offer a chiropractic degree. The course will be hosted by its School of Health and Life Sciences and the Department of Allied Health Professions. The designated course leader, Daniel Moore, explains:
“The benefit for us when we developed this curriculum from a blank canvas was not only exciting, but it granted an opportunity for us to do things in a slightly different way. The placement model is something I feel we may see more of in the future because the benefit it gives students is significant from a confidence point of view, and provides interaction with both the profession and patients from the first semester. We also could create our modules from scratch giving us the ability to build context into historically quite fixed modular content whilst staying mapped to the education standards. We also give all students iPads from the start of their degree which will allow us to collaborate and communicate in a really unique and beneficial way throughout the course.”
“I have always been interested in knowledge transfer, and how as individuals we learn and how we develop ourselves. Part of my draw to being a chiropractor was my wanting to help people become the best version of themselves. So it isn’t a great leap to the higher educational world where my goal now is similar, facilitating and leading people towards being the best chiropractor they can be. They can then move into the profession and make a positive impact themselves. I feel I can make a positive difference to the profession here, and that is important to me.”
“My goal in my mind is clear. To create chiropractors that are safe, competent and confident, to go into practice and add value to the chiropractic profession. I also hope I can create students that are excited to graduate and practice chiropractic, I feel we have a lot to offer as chiropractors and students should be excited about that opportunity.”
“I am from the North East of England, so have an affinity to this region. I am passionate about chiropractic and think my history, since being a student shows my willingness to represent that. I was a student member of the NMSK faculty of the College of Medicine as well as being on WIOC Student Council for 4 years. I then moved into practice where I took on delivery of CPD events for the RCC, qualified as an FA Medical Tutor, I was also involved in writing initial material for the RCC’s online Quality Standards offering, and have been involved in multiple British Masters Athletics Medical Team events with a great group of people over the years. I am a dad, to two wonderful boys and a husband to Elaine (also a chiropractor and BCA member). I keep myself fit, and race Cross Country Mountain Bikes and Cyclocross to a national level and plan on competing at the World Masters Championships this August all things being well. Now I lead the chiropractic course at Teesside and I am planning my PhD, I couldn’t be more excited about the opportunities that lay ahead.”
Allow me to add a few points and ask a few questions:
- Mr Moore wants to ‘create chiropractors that are safe, competent and confident’. How about creating therapists who are effective in curing or alleviating disease or symptoms? Has he perhaps realised that, in chiropractic, this is not possible? Do his peers at Teesside know that chiropractic does not generate more good than harm?
- I am fascinated to learn that Mr Moore is now planning to do his PhD. Should a higher degree not have been a precondition to becoming a course leader in academia?
- As far as I can see, Mr Moore has never published a single paper in the peer-reviewed literature. Should a track record in research not have been a precondition to becoming a course leader in academia?
- Does the University of Teesside know that even the most proper (and I fear the course does not even appear to be proper) teaching of nonsense must result in nonsense?
- Have they taken leave of their senses at Teesside university?
DD Palmer, the founder of chiropractic, famously claimed that 95% of all diseases are caused by subluxations of the spine and the rest by subluxations of other joints. He said and stated this theory in different forms not once but dozens of times, and it thus quickly became the mantra of chiropractic. When it was noted that subluxation, as imagined by Palmer and his son BJ, did not exist, chiropractors found themselves with a considerable amount of egg on their faces.
Ever since, they have tried to cover up the blemish, some by repeatedly re-defining subluxation, others by claiming that they do not believe in Palmer’s theory anyway. The issue was and is fiercely fought over even threatened to break up the profession. At present, we are being told incessantly that large chunks of the profession are reformed, have come to terms with their profession’s foundation in a fictional concept, and have now abandoned subluxation altogether.
Critics, in turn, are quick to point out that, if that is so, chiropractors lack a ‘raison d’être’. The best chiropractors of this persuasion could do, they say, is to re-train as physiotherapists who also use spinal manipulation but without the nonsensical chiropractic ‘philosophy’.
While this debate is ongoing and shows no sign of subsiding, it is relevant, of course, to ask what proportions of the chiropractic profession belongs to which persuasion. This paper evaluated the issue of the professional identity within the profession of chiropractic based on the literature from 2000 to 2019. Initially 562 articles were sourced, of which 24 met the criteria for review.
The review confirmed three previously stated professional identity subgroups:
- a vitalistic approach pro subluxation,
- a approach contra subluxation,
- a centrist or mixed view.
Whilst these three main chiropractic identity sub-types exist, the terminology used to describe them differs. Research aimed at categorising the chiropractic profession identity into exclusive sub-types found that at least 20% of chiropractors have an exclusive vertebral subluxation focus. However, deeper exploration of the literature shows that vertebral subluxation is an important practice consideration for up to 70% of chiropractors.
The review also found that practising chiropractors consider themselves to be primary care or primary contact practitioners with a broad scope of practice across a number of patient groups not limited to musculoskeletal management.
So, if I understand these findings correctly, they confirm that chiropractors like to see themselves as physicians who are able to treat most conditions that present themselves in primary care. At the same time, their majority considers that vertebral subluxation is an important practice consideration. This clearly suggests they are likely to treat most conditions by adjusting spinal subluxations. In turn, this implies that DD Palmer’s dictum, ‘95% of all conditions are caused by subluxations of the spine’, is still adhered to by about 70% of all chiropractors.
If this is so, the best advice I can give to the general public is this: if you have a health problem, the last person you should consult is a chiropractor.
I have almost got used to seeing that any health crisis brings the worst out of charlatans. In the present pandemic, this has been true for SCAM merchants such as the:
and, of course, the chiropractors.
Perhaps one can even forgive such behaviour on an individual level – sadly, it seems to be a human trait to turn every misery into a business opportunity. But when professional organisations behave in this manner, I have less understanding.
In that context, this press release by the INTERNATIONAL CHIROPRACTORS ASSOCIATION seems revealing:
March 16, 2020 (Falls Church, VA) In these challenging times associated with the COVID-19 Pandemic, the International Chiropractors Association (ICA) is issuing a statement reaffirming chiropractic as an essential healthcare service. Everyone is under extraordinary levels of stress.
Chiropractic Services represent an essential and necessary component of the health care program of millions of patients of all ages and all walks of life in the United States and worldwide. Timely and consistent access to chiropractic care is essential to the maintenance of the health and wellbeing of this patient population, particularly during times of stress.
The association encourages jurisdictions at all levels to acknowledge and respect that chiropractic is an essential healthcare service even during a pandemic.
It is important to recognize that as of mid-March 2020, there are no recognized cures in conventional medicine or alternative health approaches for COVID-19. There are no vaccines, no drugs, no natural remedies, no alternative therapies that have been tested and the outcomes peer reviewed to meet any evidence-based standard. The public has the right to seek their own pathway to health and well-being. For millions of Americans, that pathway includes regular chiropractic care. For individuals such as those recovering from injury or suffering back pain, chiropractic care is essential on their road to recovery.
ICA President, Stephen P. Welsh, DC, FICA stated, “While Coronavirus-19 has everyone’s attention, it cannot be forgotten that health promotion and non-opioid pain management through chiropractic adjustments of the subluxation is essential and should not be curtailed or restricted because of this pandemic. With churches, schools, restaurants, museums being closed, the ICA reminds authorities that the offices of doctors of chiropractic should be treated no differently than the offices of medical doctors – as an essential health care service.”
Did I state that I have less understanding for this? To be honest, I feel slightly sick reading the press release!
The ICA state that one of their objectives is to ‘promote the highest professional, technical, and ethical standards for the doctor of chiropractic while safeguarding the professional welfare of its members and the public.’ I highly recommend that the ICA take a step back and inform themselves what professionalism and ethics really mean.
The ‘Corona-Virus Quackery Club’ (CVQC) is enjoying a fast-growing membership. As mentioned in previous posts, it consists of:
Chiropractors have been keen to join since weeks. They have a long tradition of claiming that their ‘adjustments’ boost the immune system, and therefore it was to be expected that they also jump on the corona-bandwagon.
Some chiropractors seem to believe that the corona-virus pandemic is a fine business opportunity or, as one put it, the perfect opportunity to have a heart to heart with patients about their immune and nervous systems! Remember, if germs automatically caused disease, the human race wouldn’t be around to debate the issue. Many forget that Louis Pasteur, the father of the germ theory recanted his belief. On his deathbed he observed, “It’s the soil, not the seed.” In other words, without the right environment, germs can do little harm.
Chiropractors and other health care workers are at greater risk due to patient or client interactions and are encouraged to take extra precautions when it comes to cleaning and disinfecting surfaces and skin or close contact.
“Every chiropractic practice has been touched by coronavirus [fears],” says Bill Esteb, DC, who has created and is circulating a coronavirus and chiropractic guide on how to avoid contracting the virus.
“We wanted to create a tool that chiropractors could use as a conversation springboard. Chiropractors need to remind their patients that germs don’t automatically cause disease. And that ‘catching’ the coronavirus, or anything else, requires a hospitable environment.”
The only way to catch anything, says Esteb, is to become a hospitable host. Flipping the message, Esteb in his coronavirus and chiropractic guide says here is “How to Catch the Coronavirus”:
- Eat a Poor Diet — Make sure your body lacks the vitamins, minerals, enzymes and micronutrients needed to keep itself in good repair.
- Avoid Adequate Rest — Stay up late and use sugar, tobacco, coffee and energy drinks as needed.
- Become Dehydrated — Reduce the effectiveness of your natural defense mechanisms by shunning adequate water.
- Stop Exercising — Reduce the efficiency of your lymphatic system, which requires movement to circulate this important germ-fighting fluid.
- Think Negative Thoughts — Worry that you’ll be a victim. Closely monitor news reports about outbreaks, fearing the advancing pandemic.
- Rarely Wash Your Hands — Use your dirty hands and fingers to rub your eyes, pick your nose or wipe your lips.
- Skip Your Chiropractic Adjustments — Handicap your nervous system, the master system that controls your entire body. Wait until symptoms are clearly present.
“Following these suggestions is the way to become a suitable host for any number of germs or microbes,” Esteb says. “The tongue-in-check approach keeps the subject light. It stimulates more instructive patient conversations. It helps reduce appointment cancellations.
“Most people have an inappropriate fear of germs. And while this poster and patient handout won’t eliminate it, use it to explore the value of ongoing chiropractic care as a preventive strategy.”
The Internet is full with messages of this type. Here is just one example: The best defense for the Corona Virus is to be healthy when you are exposed to the virus. Get adjusted to boost your immune system. Check out this video blog on what you can do to be healthy and prepare your body to fight off the corona virus.
Perhaps the worst excesses can be found on Twitter:
The objective of this analysis was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain. The researchers employed a retrospective cohort design for analysis of health claims data from three contiguous US states for the years 2012-2017.
They included adults aged 18-84 years enrolled in a health plan and with office visits to a primary care physician or chiropractor for spinal pain. Two cohorts of subjects were thus identified:
- patients who received both primary care and chiropractic care,
- Patients who received primary care but not chiropractic care.
The total number of subjects was 101,221. Overall, between 1.55 and 2.03 times more nonrecipients of chiropractic care filled an opioid prescription, as compared with recipients.
The authors concluded that patients with spinal pain who saw a chiropractor had half the risk of filling an opioid prescription. Among those who saw a chiropractor within 30 days of diagnosis, the reduction in risk was greater as compared with those with their first visit after the acute phase.
The short answer is NOTHING MUCH! And certainly not what many chiros make of them.
They do not suggest that chiropractic care is a substitute for opioids in the management of spinal pain.
There are several reasons. Perhaps the most important ones are that such analyses lack any clinical outcome data, and that comparing one mistake (opioid-overuse) whith what might be another (chiropractic care) is a wrong apporoach. Imagine a scenario where half to the patients had received, in addition to their usual care, the services of:
- a paranormal healer,
- a crystal therapist,
- a shaman,
- or a homeopath.
Nobody would be surprised to see a very similar result, particularly if all of these practitioners were in the habit of discouraging their patients from using conventional drugs. Or imagine a scenario where half of all patients suffering from spinal pain are entered into an environment where they receive no treatment at all. Who would not expect that this regimen does not dramatically reduce the risk of filling an opioid prescription? But would that indicate that zero treatment is a good solution for managing spinal pain?
The thing is this:
- If you want to reduce opioid use, you need to prescribe less opioids (for instance, by re-educating doctors to do as they have been told in med school and curb over-prescribing).
- If you discourage patients to use opioids (as many other healthcare professionals would), many will not use opioids.
- If you want to know whether chiropractic is effective in managing spinal pain, you need to conduct a well-designed clinical trial.
Or, to put it simply:
CORRELATION IS NOT CAUSATION!