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

cult

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To accuse anyone of an abuse of science is a hefty charge, I know. In the case of proponents of so-called alternative medicine (SCAM) doing science, it is, however, often justified. Let me explain this by using the example of chiropractors (I could have chosen homeopathy, faith heaalers, acupuncturists or almost any other type of SCAM professional, but in recent times it was the chiros who provided the clearest examples of abuse).

Science can be seen as a set of tools that is used to estabish the truth. In therapeutics, science is employed foremost to answer three questions:

  1. Is the therapy plausible?
  2. Is the therapy effective?
  3. Is the therapy safe?

The way to answer them is to falsify the underlying hypotheses, i.e. to demonstrate that:

  1. The therapy is not plausible.
  2. The therapy is not effective.
  3. The therapy is not safe.

Only if rigorous attempts at falsifying these hypotheses have falied can we conclude that:

  1. The therapy is plausible.
  2. The therapy is effective.
  3. The therapy is safe.

I know, this is rather elementary stuff. It is taught during the first lessons of any decent science course. Yet, proponents of SCAM are either not being properly taught or they are immune to even the most basic facts about science. On this blog, we regularly have the opportunity to observe exactly that when we read and are bewildered by the comments made by SCAM proponents. This is often clearest in the case of chiropractors.

  1. They cherry-pick the evidence to persuade us that their hallmark intervention, spinal manipulation, is plausible.
  2. They cherry-pick the evidence to persuade us that their hallmark intervention, spinal manipulation, is effective.
  3. They cherry-pick the evidence to persuade us that their hallmark intervention, spinal manipulation, is safe.

If they conduct research, they set up their investigations in such a way that they confirm their beliefs:

  1. Spinal manipulations are plausible.
  2. Spinal manipulations are effective.
  3. Spinal manipulations are safe.

In other words, they do not try to falsify hypotheses, but they do their very best to confirm them. And this, I am afraid, is nothing other than an abuse of science.

QED

And how can the average consumer (who may not always be in a position to realize whether a study is reliable or not) tell when such abuse of science is occurring? How can he or she decide who to trust and who not?

A simplest but sadly not fool-proof advice might consist in 2 main points:

  1. Never rely on a single study.
  2. Check whether there is a discrepancy in the results and views of SCAM proponents and independent experts; e.g.:
    • Chiropractors claim one thing, while independent scientists disagree or are unconvinced.
    • Homeopath claim one thing, while independent scientists disagree or are unconvinced.
    • Acupuncturists claim one thing, while independent scientists disagree or are unconvinced.
    • Energy healers claim one thing, while independent scientists disagree or are unconvinced.
    • Naturopaths claim one thing, while independent scientists disagree or are unconvinced.
    • Etc., etc.

In all of those cases, your alarm bells should ring and it might be wise to be cautious and avoid the treatment in question.

Jay Kennedy is an experienced chiropractor of some standing.

In “2018, ‘The American Chiropractor’ wrote this about Jay Kennedy:

Jay Kennedy, DC, is a 1987 graduate of Palmer Chiropractic College and maintains afull time practice in western Pennsylvania. He is the principal developer of the Kennedy Decompression Technique. Dr. Kennedy teaches his non-machine specific technique to practitioners who want to learn clinical expertise required to apply this increasingly mainstream therapy. Kennedy Decompression Technique Seminars are approved for CE through various Chiropractic Colleges.

‘The Dynamic Chiropractor’ published plenty of articles authored by Jay Kennedy.

I am telling you this because Jay Kennedy recently posted a comment which is far too important to be burried in the many other comments on this blog. I think it deserves full recognition and loud applause. I have therefore decided to take the unusual step and re-post it here as an entirely seperate post.

Here we go:

I was a DC for 30+ years and a notable one for the last 20 years. I taught 200+ seminars, wrote innumerable articles and taught at many chiropractic colleges. I had (3) private practices and was a technique “guru”: “Kennedy decompression technique” or KDT. We “certified” nearly 5000 DCs to be “decompression experts”!

Kdt still sells farcical traction-tables I developed and designed (labeled as “decompression systems”) as well as useless lasers, ultrasonic vibrators and other scam modalities to confound the DCs and milk the public. (I have been out of it for several years now).

I am not proud of the fact I made a lot of money both in practice and as a lying cultist-entrepreneur.

I have read your blog for several years and many of your books, especially related to Chiropractic. You are not mistaken and I do NOT believe you are biased, the fact that you define the practice as SCAM and a cult is absolutely the case. As has been said before it is “the world’s largest non-scientific healthcare delivery system”. I was fortunate many years ago to meet Stuart McGill PhD. It changed my practice considerably. I opened a gym and focused dramatically on exercise. I also had other income steams from selling bullshit equipment. The regrettable feature is chiropractors sell “treatments”…. Some of which superficially alter pain signals temporarily like many OTHER less expensive and less mendacious things. This “traps” many patients into an erroneous paradigm….one a DC is ready, willing and able to exploit. “Chiropractic treatments” NEVER get to the root of a problem, alter any disease-process or substantially improve a patient. Regrettably selling exercise simply WILL NOT garner the income that selling (and coercing) subluxation-elimination treatments will (and virtually NO DC has the experience or expertise a PT PhD has in that arena).

Interestingly when you do seminars as a chiropractor, most states make you sign a waiver stating that you will not disparage Chiropractic or discuss information that minimize the value of Chiropractic. Can you imagine medical seminars or a scientific seminar having such a waiver? Chiropractic is and has always been a moneymaking scheme. That doesn’t exclude the fact there are many chiropractors who buy into it as a supreme truth….just like Muslims who murder with the thought of getting directly to Heaven to start porking some virgins.

I have discovered most DCs are on the low IQ scale, have poor critical thinking skills and rarely question their golden-goose (or perhaps more sympathetically; never venture outside the bounds of the profession and its rhetoric and hyperbole. They have been effectively able to compartmentalize Chiropractic from rightful and accurate criticism). Most of the successful ones are of course entrepreneurs with ravenous appetites for money, prestige and approval (and have little or no interest in the “truth”…..oops I described myself I guess).

The majority however struggle to get by and are constantly seeking SOMETHING that might actually work. Thus 70%+ use and advertise “decompression”, Activators (and other ridiculous “adjusting guns”), drop-tables, energy-techniques, orthotics and whatever other nonsense some company advertises in Chiropractic Economics with a testimonial of how much money can be made. It always fascinated me that if “subluxation-reduction or elimination” was the solution for disease and pain WHY did the profession embrace all of these other nonsensical modalities? If your guess is: “chiropractic doesn’t really work”…give yourself a beer.

When you graduate as a DC you CAN ONLY be in private SCAM practice….no other opportunities exist. Is it really any wonder that lying is the only avenue available to support a practice and an income stream? Nope.

______________________

I wish to express my thanks to Jay for his courage and honesty in writing these lines.

The comment sections of this blog have provided plenty of reason to suspect that chiropractic is a cult, a health cult to be precise. A health cult is defined as a system for the cure of disease based on dogma set forth by its promulgator. The promulgator, in this case, is DD Palmer. As discussed previously, he ‘invented’ chiropractic and promoted many extraordinary claims and ideas, e.g.:

  • I was the first to adjust the cause of disease
  • Chiropractors adjust causes instead of treating effects
  • 95% of all diseases are caused by subluxations of the spine
  • Vaccination and inoculation are pathological; chiropractic is physiological
  • It was my ingenious brain which discovered [chiropractic’s] first principle; I was its source; I gave it birth; to me all chiropractors trace their chiropractic lineage
  • Among the wonderful achievements of this century, the discovery and development of chiropractic is preeminent; it is destined to replace all methods which treat effects
  • Dis-ease is a condition of not ease, lack of ease
  • His magnetic cure for cancer involved freeing the stomach and spleen of poisons
  • Chiropractic is a science of healing without drugs
  • Wants to turn chiropractic into a religion (as this would avoid chiropractors being sued for practising medicine without a license)

Since DD Palmer, the chiro-cult has changed. In fact, it has split into two camps. The ‘straights’ have become a Palmer worship cult, while the rest delude themselves of being based on evidence. That the former are cultists is impossible to deny. The latter reject such allegations but, in my mind, they too belong to a cult.

Let me explain.

The criteria for a cult can be defines as follows:

  1. Charismatic Leader: the ‘mixers’ might no longer worship Palmer, yet they are far from free of his ‘philosophy’; after all, they went to chiro-school where they were educated in the Palmer tradition.
  2. Isolation: chiropractors seek surprisingly little co-operation with other healthcare professionals and thus tend to be isolated.
  3. Control: chiropractors are under tight control of their professional bodies, peers, journals, etc. which all make sure that heretic ideas are kept at bay.
  4. Deception: chiropractors are masters of deception in persuading the public and their patients of the value of spinal manipulations, regardless of the actual evidence.
  5. Us vs. Them Mentality: chiropractors tend to create an “us vs. them” mentality, demonizing real doctors and promoting group cohesion.
  6. Exploitation: chiropractors have a long history of exploiting their patients; maintenance care is just one of many examples.
  7. Fear Tactics: chiropractors are scare mongers, for instance, when they diagnose subluxations even in perfectly healthy people and claim that this invented diagnosis needs urgent adjustments.

What, you don’t agree with these arguments?

In this case let me quote a different set criteria that might help to decide whether chiropractic might be a cult. Here they are:

  1. Absolute authoritarianism without accountability
  2. Zero tolerance for criticism or questions
  3. Lack of meaningful financial disclosure regarding budget
  4. Unreasonable fears about the outside world that often involve evil conspiracies and persecutions
  5. A belief that former followers are always wrong for leaving and there is never a legitimate reason for anyone else to leave
  6. Abuse of members
  7. Records, books, articles, or programs documenting the abuses of the leader or group
  8. Followers feeling they are never able to be “good enough”
  9. A belief that the leader is right at all times
  10. A belief that the leader is the exclusive means of knowing “truth” or giving validation

Bearing in mind that not all of the 10 criteria need to be fulfilled, I ask you: is chiropractic a cult?

 

 

Of all the many forms of so-called alternative medicine (SCAM), Reiki is perhaps the one that has the least plausibility. It assumes that a Reiki healer can send healing energy into the body of a patient which, in turn, stimulates the self-healing ability of the body and thus cures illness. Neither the source of the energy, its nature, or its effects have ever been convincingly demonstrated. These facts, however, do not stop enthusiasts to conduct clinical trials of Reiki.

The aim of this randomised clinical trial was to investigate the effect of the application of Reiki on fatigue and sleep quality in people with MS. A total of 60 people (control group = 30, intervention group = 30) participated in this study. Personal Information Form, Piper Fatigue Scale (PFS) and Pittsburg Sleep Quality Index (PSQI) were used as endpoints.

It was found that the PFS and PSQI total and subcomponent scores of the intervention group decreased after Reiki compared to the control group and this was statistically significant (p<0.05). The study showed that Reiki was significantly effective in improving fatigue and sleep quality in people with MS.

The authors concluded that, as Reiki is a simple, inexpensive and accessible method, it was suggested that its use in the management of MS should be encouraged and maintained in nursing practice.

In the introduction, the authors state this:

Reiki is a non-invasive, low-cost, easy-to-apply practice with no side effects and no negative effects on the existing treatment, and prevents acute and chronic conditions. It is frequently preferred in rehabilitation centres, emergency care units, nursing homes, elderly care centres, paediatrics, psychiatry, obstetrics and gynaecology clinics. Reiki can be applied by trained practitioners such as health professionals who have received first level reiki training in hospitals and clinics, caregivers or patients themselves. Reiki can be administered from with the patient or remotely when the patient and practitioner are in separate locations. Both types of Reiki are based on the premise of a universal source of healing energy that the Reiki practitioner can channel through intention.

For me, this begs the questions:

  • If all of this were true, why do we need a study?
  • If anyone believes such BS, are they the ideal people to conduct a study of Reiki?

Anyway, we should ask why this study generated a positive result. The most plausible explanation is that, as the study was not blind, the Reiki healers managed to maximise patient expectation. This, in turn, has generated a placebo respose which affected the subjective outcome measures. In other words, Reiki has no specific effect but patients tend to improve because of non-specific effects.

This study tested the efficacy and safety of individualized homeopathic medicines (IHMs) in treating hemorrhoids compared with placebo. The double-blind, randomized (1:1), two parallel arms, placebo-controlled trial was conducted at the surgery outpatient department of the State National Homoeopathic Medical College and Hospital, Lucknow, Uttar Pradesh, India.

Patients were 140 women and men, aged between 18 and 65 years, with a diagnosis of primary hemorrhoids grades I-III for at least 3 months. Excluded were the patients with grade IV hemorrhoids, anal fissure, and fistula, hypertrophic anal papillae, inflammatory bowel disease, coagulation disorders, rectal malignancies, obstructed portal circulation, patients requiring immediate surgical intervention, and vulnerable samples.

Patients were randomized to Group 1 (n = 70; IHMs plus concomitant care; verum) and Group 2 (n = 70; placebos plus concomitant care; control). Primary-the anorectal symptom severity and quality-of-life (ARSSQoL) questionnaire, and secondary-the EuroQol 5-dimensions 5-levels (EQ-5D-5L) questionnaire and EQ visual analogue scale (VAS); all of them were measured at baseline, and every month, up to 3 months.

Out of the 140 randomized patients, 122 were protocol compliant. Intention-to-treat sample (n = 140) was analyzed. The level of significance was set at p < 0.05 two tailed. Statistically significant between-group differences were elicited in the ARSSQoL total (Mann-Whitney U [MWU]: 1227.0, p < 0.001) and EQ-5D-5L VAS (MWU: 1228.0, p = 0.001) favoring homeopathy against placebos. Sulfur was the most frequently prescribed medicine. No harm or serious adverse events were reported from either of the groups.

The authors concluded that IHMs demonstrated superior results over placebo in the short-term treatment of hemorrhoids of grades I-III. The findings are promising, but need to be substantiated by further phase 3 trials.

Yes, I know: it is not easy to keep a straight face when reading such a paper. And the task is not made easier when considering the affiliations of its authors:

  • 1East Bishnupur State Homoeopathic Dispensary, Chandi Daulatabad Block Primary Health Centre, Under Department of Health & Family Welfare, Government of West Bengal, India, South 24 Parganas, India.
  • 2Department of Organon of Medicine and Homoeopathic Philosophy, State National Homoeopathic Medical College and Hospital, Lucknow, India.
  • 3Department of AYUSH, Government of Uttar Pradesh, Lucknow, India.
  • 4State National Homoeopathic Medical College and Hospital, Lucknow, India.
  • 5Department of Materia Medica, State National Homoeopathic Medical College and Hospital, Lucknow, India.
  • 6Department of Pathology & Microbiology, D. N. De Homoeopathic Medical College & Hospital, Government of West Bengal, Kolkata, India.
  • 7Department of Pathology & Microbiology, Mahesh Bhattacharyya Homoeopathic Medical College & Hospital, Government of West Bengal, Howrah, India.
  • 8Department of Repertory, D. N. De Homoeopathic Medical College and Hospital, Kolkata, India.

Let’s nevertheless ask three serious questions:

  1. According to classical homeopathy, for a cure, one needs a remedy that, when given to a healthy volunteer, causes the symptom one wants to treat. So, does sulfur etc.cause the symptoms of hemorrhoids?
  2. According to classical homeopathy, the remedy is supposed to cure the condition, not alleviate the symptoms. Is that what the results show?
  3. Is it plausible that homeopathy can have any effects on hemorrhoids?

I am confident that the answers are: no, no and no.

And this leads me to ask my final question: do we believe these findings?

I let you answer this one!

In a recent comment, our resident chiro, ‘Dr.’ Dale Thompson (alias ‘DC’), in an attempt to provide a rationale for the approach, provided a link to a definition of MAINTENANCE CARE:

Maintenance care is care given to people with chronic illnesses to maintain or slow a decline in their health or function. For example, exercise and physical therapy can minimize abnormal or painful positioning of the joints and may prevent or delay curvature of the spine in a person with muscular dystrophy.

Let’s for the moment ignore that this definition is not necessarily related to CHIROPRACTIC maintenance care and assume it describes the approach adequately. In this case, chiropractic maintenance care would be:

care given to people with chronic illnesses to maintain or slow a decline in their health or function.

That sounds almost reasonable and is very different from what I recently implied it is, namely sly scare mongering of greedy chiros to fleece vulnerable individuals.

So, who is closer to the truth, Dale or Edzard?

How is chiropractic maintenance care employed in ‘real life’?

One way of finding out might be to look at social media and see how chiropractic maintenance care is being promoted or written about. Here are the texts of recent Tweets that I found on 23/6 informing us on this issue:

  • Chiropractic care encompasses three main phases:  1. Acute / Intensive Care  2. Healing / Corrective Care  3. Wellness / Maintenance Care
  • Maintenance is key! Once you’ve completed your care plan, routine chiropractic visits can help keep you feeling your best. Think of it as preventative maintenance for your body; you deserve it!
  • Chiropractic maintenance care now encompasses all sorts of patients; no matter their history, symptoms or reasons for seeking a chiropractor
  • Chiropractic care goes beyond back pain relief!  It’s all about proactive health maintenance, not just reactive illness treatment. Discover the pathway to a healthier, more balanced life
  • Understanding the proper documentation and coding of maintenance care in your office will help you sleep better at night knowing you are doing this correctly.
  • Staying well with chiropractic has never been easier! Researchers have discovered that people who receive maintenance chiropractic care have better long term outcomes and may even be able to prevent future episodes of back pain. Interested in learning more? Give us a call today.
  • Researchers have discovered that people who receive maintenance chiropractic care have better long term outcomes and may even be able to prevent future episodes of back pain. Interested in learning more? Give us a call today!
  • Many patients willingly choose to keep getting regular, maintenance Chiropractic care. Just like going to the dentist periodically, spinal hygiene and chiropractic adjustments are part of a healthy lifestyle.
  • Consider your body as a biological machine, just like a car needing maintenance. Chiropractic care at The Joint provides essential upkeep, not just alleviating existing pain but also preventing future discomfort.
  • We advocate regular maintenance Chiropractic care to keep your spine and posture in as great shape as possible. If you have not been to the clinic for a while, why not call our reception team
  • When you finally get that special car you always wanted; you don’t want to trust just anybody for care & maintenance. The same is true with your healthcare.
  • Around 22 million Americans turn to chiropractic care each year for pain relief, holistic healing, and preventive maintenance!  Experience natural, non-invasive solutions that keep you feeling your best. Discover the benefits today!
  • We believe in the beauty of regular maintenance care. Nurture your well-being & witness the transformative difference in your life
  • Chiropractic and Maintenance Care “Do I need to keep coming back for treatment to prevent this from happening again?” This method of chiropractic care is known as Maintenance care.
  • If you are wanting to improve your overall quality of life. Maintenance care is very important
  • Chiropractic “discharge” plans are always something else. “Patient has no pain or complaints and is released from regular chiropractic care. She is recommended to return 4x/mo for maintenance care“. I’m not sure there is a profession that I think less of.

I ought to stress that most of these Tweets were accompanied by pictures of patients receiving spinal manipulations.

Who then is correct, Dale or Edzard?

I let you decide.

An article in ‘METRO’  caught my eye – not least because it quotes me. Here are a few edited excerpts:

Peter Stott lost his first wife to cancer in 1998. Her death, he believes, was due to geopathic stress (GS) – harmful energies that originate from the Earth. ‘I found out that the house where we had lived had a serious GS problem,’ he says. The discovery prompted him to become a professional ‘dowser’, devoting his life to finding and managing geopathic stress.

But what exactly is this mysterious force erupting from the surface of the Earth – and can it really harm people?Geopathic stress is said to cause discomfort and health issues for certain individuals. These energies, also called ‘harmful Earth rays’ by believers, can be detrimental, beneficial or neutral according to those who think they are ‘in the know’.

Peter Stott
Peter Stott is a professional dowser

The word ‘geopathic’ is derived from the Greek words ‘Geo’ meaning the Earth and ‘pathos’, meaning disease or suffering – hence the term pathogens, the medical terms for bugs that make us ill.

Dowsing, practitioners say, is a method used to detect the presence of various subtle Earth energies and assess their nature and quality. They argue that some of these energies can be linked to geomagnetic anomalies caused by flowing underground water, dry faults and fissures, subterranean cavities, or mineral and crystal deposits.

Dowsing is carried out by a dowser, practitioners who try to find the source of these energies using special tools, such as pendulums, rods, and bobbers – essentially sexed-up tree branches. The person holds the tool, waiting for it to move or react, which they take as a sign that they’ve found what they’re looking for. The odd practice can allegedly also be used to identify leaks, stress fractures, environmental pollutants, electromagnetic fields, nutritional deficiencies, black spots, and, rather oddly, sexing pigeons.

Peter claims that a skilled dowser effectively advises on the optimal placement of buildings and structures to mitigate the impact of geopathic stress, and often possesses the ability to reduce or eliminate it through the use of various methods. He emphasises the fact that GS ‘does not affect everybody in the same way. Cancer has been described as “a disease of location”,’ he says. ‘And if there is a family history of cancer – as there was in my late wife’s case – a person can be more susceptible to GS being a contributing factor in succumbing to the disease.’ Peter believes that GS impacts our immune system, depleting its resources and hindering its ability to function optimally. By eliminating GS from our surroundings, we allow our immune system to operate more efficiently, he contends. Our susceptibility to GS varies, he says, with some experiencing mild symptoms like sleep disturbances and fatigue, while others may face more severe health issues such as arthritis, multiple sclerosis and cancer.

17th Century dowsing illustration
Dowsing has been around for millennia (Picture: Getty)

In 2017, rather incredibly, a report revealed that 10 out of 12 water companies in the UK were employing the practice of water dowsing to identify and locate leaks. Even more incredibly, last year, it emerged that Thames Water and Severn Trent Water were still using this form of ‘witchcraft’ for leak detection, despite scientific research indicating its lack of efficacy.

But water companies aren’t the only ones turning to dowsers for help. Peter believes that ‘it is also possible to carry a token or amulet on your person that has been imbued with the powers of protection by someone who is proficient in [dowsing]’. ‘This can protect you from GS and other detrimental energies wherever you go anywhere throughout the world,’ he claims. ‘Other protection techniques can also offer a degree of protection.’

However, Dr Edzard Ernst, a man who has dedicated years of his life to examining questionable, science-based claims, won’t be enlisting the services of a GS specialist or house healer anytime soon. ‘Geopathic stress cannot cause health problems for the simple reason that it does not exist,’ says the retired physician. ‘It is a sly invention of quacks who exploit gullible consumers. The methods to diagnose GS are as bogus as the ones that allegedly treat it. But the quacks don’t mind – as long as the consumer pays.’

Peter fully acknowledges ‘that dowsing and this work in general is not a catch-all solution for every ailment or every person’s situation’. ‘However, often we are approached by people who are “at the end of their tether” due to their exasperation of experiencing events or circumstances in their lives that are not well catered for in the mainstream wellbeing sector,’ he says. ‘I can only speak personally, I cannot speak for the possibly tens of thousands of dowsers around the world. If our work can help ease a person’s experience of life then that is a good enough reason to continue to help where I can’. He adds that ‘we are never going to change the minds of people like Dr Edzard Ernst’, someone ‘who seems to focus exclusively on debunking anything for which there is not a scientific explanation’. Moreover, science, he notes, ‘is moving on with research done into quantum physics and the theory that everything in the universe is connected and is also accessible to everyone’.

_________________________

Oh, dear Peter!

Perhaps you should learn the difference between critical evaluation and debunking (this ‘debunker’ has shown more forms of so-called alternative medicine (SCAM) to be worthy of integrating into the NHS than anyone else).

Perhaps you should read up about the difference between evidence and belief?

And perhaps the chapter on dowsing in my book could help you in this endeavour:

Dowsing is a common but unproven method for divining water and other materials. In alternative medicine, it is sometimes used as a technique for diagnosing diseases or the causes of health problems.

      1. Dowsers employ a motor automatism, amplified through a pendulum, divining rod or similar device. The effect is that the device seemingly provides an independent, visible reaction, while the dowser is, in fact, its true cause.
      2. Dowsing is used by some homeopaths as an aid to prescribe the optimal remedy and as a tool for identify a miasm or toxin load.
      3. The assumptions upon which dowsing is based lack plausibility.
      4. Dowsing has not often been submitted to clinical trials.
      5. All rigorous attempts to test water dowsing have failed, and it is no longer considered a viable method for this purpose.
      6. The only randomized double-blind trial that has tested whether homeopaths are able to distinguish between a homeopathic remedy and placebo by dowsing failed to show that it is a valid method. Its authors (well-known homeopaths) drew the following conclusion: “These results, wholly negative, add to doubts whether dowsing in this context can yield objective information.”[1]
      7. If dowsing is employed for differentiating between truly effective treatments (rather than homeopathic remedies), the risk of false choices would be intolerably high, and serious harm would inevitably be the result.

[1] McCarney et al. (2002).

 

We have recently heard much about spinal manipulations for kids. It might therefore be relevant to learn about an international taskforce of clinician-scientists formed by specialty groups of World Physiotherapy – International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) – to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions.

A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes).

Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.

1. It is not recommended to perform:

• Spinal manipulation and mobilisation on infants.

• Cervical and lumbar spine manipulation on children.

•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.

2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:

• Spinal mobilisation and manipulation on adolescents;

• Spinal mobilisation on children; or

• Thoracic manipulation on children for neck-back pain only.

3. No high certainty evidence to recommend these interventions was available.

Reports of mild to severe harms exist; however, risk rates could not be determined.

It was concluded that specific directives to guide physiotherapists’ clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.

Whether one agrees with these directions or not (and I am not sure I fully do), I have always thought that people who, despite the largely lacking or flimsy evidence for spinal manipulations, insist on having manual therapy should consult a physiotherapist, rather than a chiropractor or osteopath.

Why?

Because, in my experience, physiotherapist:

  • display less cult-dependent behaviours,
  • do not follow the gospel of charlatans, like Palmer and Still,
  • do not believe in the fiction of subluxation,
  • are not so money-minded,
  • less prone to use un- or disproven methods, like applied kinesiology, homeopathy, cranial osteopathy, etc.,
  • unlikely to try to sell you useless dietary supplements,
  • tend to judge better their limits of professional competence,
  • are far less likely to try to persuade you of BS related to anti-vax, anti-drug, anti-science, anti-EBM, etc.

‘Chiropractic economics’ might be when chiropractors manipulate their bank accounts or tax returns, I thought. But, no, it is a publication! And a weird one at that – it even promotes the crazy idea of maintenance care:

The concept of chiropractic maintenance care has evolved significantly. Initially seen as a method for managing chronic pain, it now includes a broader range of patients and focuses on overall wellness. Modern maintenance care aims to keep patients healthy regardless of their symptoms or history, alleviating and preventing pain through regular, prolonged care. This approach is largely preventive, serving as both secondary and tertiary care.  Studies show chiropractic maintenance care often includes diverse treatments such as manual therapy, stress managementnutrition advice and more, with flexible intervals typically around three months. This evolution underscores the importance of evidence-based, individualized patient care. This article shares the evolution of chiropractic maintenance care, looks at what a modern maintenance care appointment can include and explores best practices for DC maintenance care in 2024. 

Knowledge of chiropractic maintenance care has evolved over the years. In the past, maintenance care in the chiropractic world was often viewed as a way to keep patients going; particularly those suffering from chronic conditions that needed routine care for pain management and prevention. In the last several years, chiropractic maintenance care has changed; no longer does it only involve pain prevention and management for those with chronic conditions. It now encompasses all sorts of patients; no matter their history, symptoms or reasons for seeking a DC…

An interview study of Danish chiropractic care showed maintenance care sessions included a range of treatment modalities, including manual treatment and ordinary examinations alongside multiple packages of holistic additions, like stress management, diet, weight loss, advice on ergonomics, exercise and more. In other anecdotal accounts, chiropractic maintenance care seemed to follow a more traditional guideline of lower back pain management and adjustment. The study hypothesized that maintenance care could also help patients from a knowledge perspective, stating, “DCs could obviously play an important role here as ‘back pain coaches,’ as the long-term relationship would ensure knowledge of the patient and trust towards the DC.” 

Researchers found that three-month intervals were the most common spacing of maintenance care treatments for patients. Most commonly, patients sought or scheduled chiropractic maintenance care over the course of one to three months.  

Chiropractic maintenance care has evolved past simply being a method of ongoing chronic pain management. Today’s patients want to achieve overall wellness, and regular trips to their DC can become a part of that if you work to transition patients into a wellness plan after their acute phase of care is over. 

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The author of this article seems to have forgotten two little details:

  1. Chiropractic maintenance care is not supported by sound evidence, particularly in relation to economics (even the above cited paper stated: “We found no studies of cost-effectiveness of Maintenance Care”).
  2. Chiropractic maintenance only serves one economic purpose: it boosts the chiropractors’ income.

Yes, easy to forget, particularly if your name is ‘Chiropractic Economics’.

And also easy to forget that maintenance care would, of course, require informed consent. How would that look like?

Chiro (C) to patient (P):

If you agree, we will start a program that we call maintenance care.

P: Can you explain?

C: It consists of regular sessions of spinal manipulations.

P: That’s all?

C: No, I will also give you advice on keeping fit and living healthily.

P: Why do I need that?

C: It’s a bit like servicing your car so that it works reliably when you need it.

P: Is it proven to work?

C: Yes, of course, there are tons of evidence to show that a healthy life style is good for you.

P: I know, but I don’t need a chiro for that – what I meant do the manipulations keep my body healthy even if I have no symptoms?

C: The evidence is not really great.

P: And the risks?

C: Well, yes, if I’m honest, spinal manipulations can cause harm.

P: So, to be clear: you ask me to agree to a program that has no proven benefit and might cause harm?

C: I would not put it like that.

P: And how much would it cost?

C: Not much; just a couple of hundred per year.

P: Thanks – but no thanks.

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