A Beginner’s Guide to Chiropractic
[BPSDB] What is chiropractic anyway? The Wiki page on Chiropractic is OK and gives details of the history, philosophy, regulation and effectiveness (or otherwise) of chiropractic. Highlights include these gems: “Although vaccination is one of the most cost-effective forms of prevention against infectious disease, it remains controversial within the chiropractic community. Most chiropractic writings on vaccination focus on its negative aspects, claiming that it is hazardous or ineffective. Evidence-based chiropractors have embraced vaccination, but a minority of the profession rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that diseases cannot be affected by vaccines” [This strikes me as being both dogmatic and dangerously wrong. Some chiropractors are against vaccination because it goes against original chiropractic philosophy? That sounds quite similar to the homeopathy religion if you ask me – if it’s in the Organon, it must be true. And being opposed to the prevention of dangerous diseases because you believe all disease stems from spinal problems is nothing if not dangerously wrong];
“Straight chiropractors adhere to the philosophical principles set forth by D. D. and B. J. Palmer, and retain metaphysical definitions and vitalistic qualities” [Metaphysical and vitalistic? Hang on – vitalism is the belief in a magic ‘vital force’, that life cannot be explained by chemistry and physics but that another mysterious force is at work. It’s a bit Star Wars isn’t it? Anyway, I like Crick on vitalism – “When facts come in the door, vitalism flies out of the window”. And ‘metaphysical’ seems to have come to mean Esoteric these days – “knowledge which is only available to a narrow circle of “enlightened” people”. Like the Akashic records or those magic crystal skulls, special knowledge that only shamen may ‘access’];
The Wikipedia page also contains some links on the evidence for chiropractic. I have to say, it doesn’t look good. I looked at some Cochrane reviews in a previous post and I’ll reproduce that section here, as it has links to the reviews: This review of 33 trials did not favour manipulation or mobilisation done alone or in combination with various other physical medicine agents. It was unclear if manipulation and mobilisation performed in combination were beneficial, but when compared to one another, neither was superior. [For mechanical neck disorders]
There was weak evidence to support the use of hypnosis, psychotherapy, acupuncture and chiropractic but it was provided in each case by single small trials, some of dubious methodological rigour. Robust randomised trials are required with efficacy, cost-effectiveness and adverse effects carefully monitored.
[For nocturnal enuresis in children. It says there was ‘weak evidence to support the use of chiropractic’ and this was the absolute best I could find on Cochrane for Chiropractic – doesn’t exactly fill you with confidence does it?]
Apart from the Cochrane reviews, there are also some reviews on Pubmed. I had a look at the first five papers that came up on a search of reviews and meta-analyses. A recent paper, Chiropractic treatment of upper extremity conditions: a systematic review, concluded that:
There is a small amount of chiropractic research into upper limb conditions that is comprised mostly of case studies (level 4 evidence) and a small number of higher-level publications (level 1-3 evidence). Most treatments are multimodal in nature, which address both spinal and peripheral structures, with joint and soft tissue methods. There is a need for future research to be directed at higher-level evidence, in particular, randomized controlled trials for the chiropractic treatment of upper limb conditions. [PMID: 18328941]
Another review, The use of expertise-based randomized controlled trials to assess spinal manipulation and acupuncture for low back pain: a systematic review, had the following in the results and conclusions sections:
Of 12 eligible trials, none made use of an expertise-based randomized trial design […] Investigators designing acupuncture or spinal manipulation trials in which 2 or more active therapies are compared should consider expertise-based randomization to increase the validity and feasibility of their efforts. [PMID:18404113]
Of the other three papers in the first five, none were reviewing the efficacy of chiropractic but were instead looking at guidelines for use of diagnostic imaging and which outcome assessments were used in chiropractic [J Manipulative Physiol Ther. 2008 Jun; 31(5):355-75. PMID: 18558278, J Manipulative Physiol Ther. 2008 Jan;31(1):33-88. PMID: 18308153, and J Manipulative Physiol Ther. 2008 Jan;31(1):2-32. Review. PMID: 18308152]. The sixth paper was Edzard Ernst’s review Chiropractic: a critical evaluation. He runs through the same topics as the Wikipedia page: the history; the concepts; chiropractic practice and research; and he also looks at the efficacy, safety, and cost of chiropractic. [PMID: 18280103] The abstract includes this:
Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today. Currently, there are two types of chiropractors: those religiously adhering to the gospel of its founding fathers and those open to change. The core concepts of chiropractic, subluxation and spinal manipulation, are not based on sound science. Back and neck pain are the domains of chiropractic but many chiropractors treat conditions other than musculoskeletal problems. With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition. Manipulation is associated with frequent mild adverse effects and with serious complications of unknown incidence. Its cost-effectiveness has not been demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.
OK, so far it looks like the evidence for chiropractic is, at best, pretty weak. No benefits, then. What about costs? £20 for an examination and £32 for treatment for an adult – that’s £52 I’ve just saved by not booking an appointment, but I think it’s a total of Eighty Four Pounds at this practice. Here, prices range from £40-60, but… “the initial consultation may be offered free of charge. (If so it may not include a full examination in which case there may be a charge for the examination)” – so the free consultation is only free because you then have to have a paid-for examination if you are still interested in chiropractic treatment. There doesn’t seem to be any point to me in trying chiropractic and I can think of, ooh, around eight four reasons not to – they all have a lovely engraving of the Queen on one side and they are called pound coins. But at least it’s not harmful, right? Well, uh – maybe it is. Because some chiropractors like to claim that diseases all originate from the spine [remember – original chiropractic philosophy traces diseases to causes in the spine and states that diseases cannot be affected by vaccines], patients may be led to believe chiropractic can help whatever condition they have – and fail to seek proper medical attention from an appropriate source. There are also risks in spinal manipulation, which you would hope practitioners and patients would both be fully aware of – but this hasn’t prevented harm coming to some people who have tried chiropractic. Cases relating to both these potential risks are documented on whatstheharm.net. So… chiropractic is useless, costly and potentially dangerous.
More links: Quacksafe search, Improbable Science, HolfordWatch, Dr* T’s blog, an older Dr* post, Bad Science has a couple of posts that refer to chiropractic – one including this little gem from 2004: “the World Chiropractic Alliance’s ‘guidelines for straight chiropractic’ leave little room for discussion: a practitioner’s clinical assessment is ‘inviolable’ and their judgment is ‘the final authority'”. Here’s a link to a PDF of a response to some legal threats from Chiropractors. Which has been picked up on by twonilblankblank. More links to coverage of the legal shenanigans can be found in my earlier post here: more legal chill. Edit: Coracle has also now posted a response to the daffy legal threats – Weak minded, superstitious and ignorant. There’s more on this from Norbury as well. The Quackometer blog has a more holistic post on Chiropractors here.
BPSDB [Heh – I hope I’ve spelt it correctly this time]
Stuff And Nonsense 
Chiropractors resort to legal intimidation said,
August 8, 2008 at 10:48 pm
[…] A beginners guide to chiropractic, on the same […]
David Colquhoun said,
August 8, 2008 at 10:53 pm
A very nice summary. Something of a storm seems to be brewing for the chiropractors as a result of their attempt to suppress the opinions expressed in my original editorial.
Professor Frizelle’s Instant Classic: Let’s hear your evidence not your legal muscle « Holford Watch: Patrick Holford, nutritionism and bad science said,
August 9, 2008 at 2:00 am
[…] Streisand subluxation jdc offers: More Legal Chill – from Spine Cracking Chiropractors and offers A Beginner’s Guide to Chiropractic 20__ joins the news circle: New Zealand Chiropractors Association/Murray from Flight of The […]
dvnutrix said,
August 9, 2008 at 2:41 am
Doesn’t that sound extraordinarily like the Doctrine of Papal Infallibility? [/mutters]
I’m also going to toss in Dr Mark Crislip’s analysis of a paper on chiropractic and stroke. Plus Dr Harriet Hall on the sad case of Sandra Nette who is now living in locked-in syndrome following chiropractic treatment that went badly awry.
David R said,
August 11, 2008 at 6:30 am
Having just read about this use of the legal system by chiropractors to silience free speech it strikes me as similar to the aggressive tactics used by the church of scientology, which could be coincidence however it should be noted that the church of scientology court chiropractors and even have special “assists” (a range of scientology “treatments”) designed for chiropractors to use. Intel has also logged a number of chiropractors associated with the church of scientology; a “church” known to have an affinity for cash cows.
I was also unaware of the woo-ist background of chiropractors, I just thought they “did backs” and that was it; I’ve even had my “back done” (spine popped) a couple of times and it did feel better for it. I wasn’t aware of this all illnesses stemming from the spine dogma; maybe that’s because that’s where all the body thetans attach themselves, L Ron Hubbard was something of a guru so he’d know.
Lee said,
August 11, 2008 at 8:46 pm
I ama newby to this posting stuff so excuse my IT skills in my reply. The use of the title doctor is written into the Chiropractors act. By Law UK Chiropactors are able to call themselves doctor. The original meaning of the word means teacher. Yes Chiropractors teach the public about chiropractic paradigms. Where is the research that states the perception of doctor means medically trained and only medically trained?? Chiropractic established itself as a non medical (model) profession. The Doctor of Chiropractic Degree is held as an equivalency degree throughout the world, accredited in over 80 countries worldwide by the CCEI. A Quango put together by the Chiropractic profession to regulate the educational standards of the profession, paid for and run by the profession. The CCEI is not just made up of Chiropractors!
Legal muscle complaints aught to be directed to the precedent case for the modern day Chiropractic profession; the Wilk Trials. This was a case brought against the American Medical Association by the American Chiropractic Association. This was a long drawn out effort from the Chiropractic profession collecting unfounded defamatory evidence from the AMA to the ACA. Over 20 years of evidence was presented and the AMA were found guilty and lost against the ACA. A david and goliath case. In California, often the beginning of things complementary their law does not allow a medic to decide if a person needs Chiropractic as they are not qualified. Much as Prof Colquhoun is not qualified to judge an acupuncturist, a lawyer, a Chiropractor, a surveyor or an Osteopath in his latest New Zealand Medical Journal Article.
The introduction above on this page is not a qualified statement of Chiropractic. As a learned Physio posted on Colquhouns dcimprobable science page on the same issue he can only speak for physiotherapy.
Please get over the crack, vertebral alignment and pinched nerves this is an oversimplification. In much of medicine and Chiropractic didactic education is used to inform the patient. Oversimplifications are often not 100% accurate. This is down to the individual Chiropractor to point out to their patients. The term subluxation was not fostered by my British University, that I received Government funding to become educated in Chiropractic.
The studies included in the Cochrane database are not an unbiased presentation of the Chiropractic profession. Mostly due to the selection criteria. Much as in ‘Best Evidence’ produced by the BMJ, in their coverage of manipulation. More recently in Best Evidence and Practice of Rheumatology Journal we have a reasoned presentation of Chiropractic (not bodywork) literature by a Chiropractic Researcher.
It is coming into the arena of health care that the randomised controlled trial is not a panacea of a methodology to measure all things in the world related to the human being. We simply do not know how to control for all factors when measuring the human being, we probably don’t know all factors. Thus we have the emergence of talking therapies and body work therapies in research. This is where you will find more evidence. Qualitative research rules the roost when not all variables are known or can be controlled for. Admittedly if we know the number of unknown variables then maths can answer the question, but we do not even know the number of unknown variables. The RCT is not a valid measure of the human being. It is a valid measure of a drug and a symptom. Complementary medicine works with people and lifestyles.
The validity of the degree of Chiropractic is not valid according to Colquhoun as it is quacks teaching quacks! In my education my anatomy was taught at a medical school by surgeons, my nutrition was taught by dieticians, my pharmacology was taught by a pharmacologist, my behavioural science was taught by a behavioural scientist, our differential diagnosis was taught by medic / chiropractor mix, our radiography was taught at a medical school by radiographers, our radiology was taught by a medical radiologist and a chiropractic radiologist, I could go on but frankly I think my point has been made.
The Chiropractic profession has never had central funding in the UK and this is probably why it has taken almost 100 years to compile research that has come out of the wages of Chiropractors, taking that money away from their families as they believe the results will show Chiropractic as effective. The Medical Research Council part funded the Meade Trial with a two year follow up 93-95 -demonstrating that Chiropractic care is superior to hospital outpatient management with greater satisfaction. Let us remember that GP’s refer to hospitals and are thus positioned implicitly in the medical framework as superior. The only thing that could be picked at was the lack of public environment treatment given: i.e. private care has better outcomes than public care! Another decade went past until the profession was able to answer this criticism. Again without central funding from government the profession organised the multicentre BEAM trial published in the BMJ. This demonstrated that Chiropractic was better than GP advice / education, physiotherapy outpatient management and cheaper than all interventions including exercise and with greater satisfaction.
The 84 reasons above (in JDC’s introduction to Chiropractic) are not well reasoned. The largest cost comparison study has been carried out by a Californian based health insurance provider. Policy holders were given a choice to have a Chiropractor as their gatekeeper or to have a medic. those that opted to have a chiropractor saved the insurance company millions because Chiropractic is low tech. Chiropractors ordered less imaging, fewer tests, consultations are cheaper and a non existent pharmacy bill in comparison to the medical gatekeepers. If you know where to look the cost effectiveness of Chiropractic is millions cheaper than the medical model with exactly the same diagnostic codes and outcomes.
The low tech nature of Chiropractic means that much of the information and research done is not in the high tech arena as yet. Yes old fashioned library work needs to be done to find the research you want. No matter how good your search of the internet you will not find all the information that is held within Chiropractic schools. One thing is clear and that is that Chiropractic has chosen to be tested – first government was New Zealand and they concluded that Chiropractors were not quacks, in the UK we have set up our own regulatory body through our own means. We are currently trying to gain Royal Assent for the college of Chiropractors through the repeated lobbying of Lords and Ladies. In the US There is the FCER; set up to investigate such things as Stroke and manipulation.
The past president of the FCER being not a chiropractor but a clinical chemist from Harvard and a learned man who holds an LLD degree explained to me the rate of spontaneous stroke in the population is higher than the spontaneous rate of stroke in the chiropractic patient population. Thus it is safer to walk into a chiropractors office than it is to walk into your GP’s office. It is as safe to turn your own head than to be adjusted by a Chiropractor. The notion that the body would have such a weak point in the neck due to the route of the vertebral artery passing through the lateral mass foramina of the upper 5 cervical vertebrae and in particular at the atlas where the route of the artery is tortuous – surely random chance will dictate that some people’s arteries are not as patent as others and are prone to dissection spontaneously and yes that includes the posterior inferior cerebella artery that locks you in. Such as in the NettevsStiles trial ongoing in Alberta, Canada. As I am a Darwinian – the strongest trait will be passed on and not the turnover rate of soil by worms! – the vertebral artery is able to withstand physiological forces applied. Having the stats explained to me by a doctor of law and PhD in clinical chemistry from Harvard, I was able to apply some logic from my readings of Darwin and from my teachings at University where I was taught fluid mechanics by a mathematician and biomechanics from a PhD (in the hysteresis of human tissues) human anatomist. In the PhD thesis my biomechanics teacher explained how she learnt the force required to damage the vertebral artery in a longitudinal stretch. By damage I mean enough force to tear the intima of the artery. Well couple this knowledge with the recordings of another tutor of mine in Chiropractic Technique who has been recording forces applied during adjustive thrusts and I could easily see that the vertebral artery needs a force 9x the strength of the strongest recorded adjustment by a Chiropractor to tear the intima of one vertebral artery wall. Obviously to have a double tear the force is greater still. There are numerous case studies of patients dropping dead from a spontaneous stroke in the Chiropractic office before the Chiropractor laid their hands anywhere near them!
‘Disease from the spine dogma’ mentioned by David R actually stems from Pennsylvania Medical School. A medical pathologist by the name of Windsor working for a decade dissecting thousands of cadaver specimens and animals he noted the correlation between minor curvatures of the spine and the cause of death in their natural deaths. He found a 99% correlation in all humans and animals between the spine and their cause of natural death. The other 1% were within one vertebral level of the enervation of the organ that caused their death. Then antibiotics were discovered and funding was withdrawn. In a Japanese medical school in the last two years a study was completed that demonstrated adjustments of the upper four thoracic segments normalised abnormal ‘pre-pathological’ readings on ECG (heart). One old and one recent example from medical schools across the globe of the dogma of, disease originates in the spine, is a ‘non-pharmacological’ medicine discovery and not unique to Chiropractic.
There ends my rant about my profession and when considering the human body it is noteworthy to return to the writings of JBS Haldane ‘on being the right size’ and take from his brilliant mathematics that the human body is how it is through years of random variations that have lead to a body that works and not one that doesn’t and not one that needs to be filled with Pharmaceutical products on an ongoing basis because it can’t heal. Correctly prescribed medication is a leading cause of death. Perhpaps my friends there is much to learn for us all…
jdc325 said,
August 12, 2008 at 11:15 am
Hi Lee,
Thanks for taking the time to post a response to my piece.
“In California, often the beginning of things complementary their law does not allow a medic to decide if a person needs Chiropractic as they are not qualified. Much as Prof Colquhoun is not qualified to judge an acupuncturist, a lawyer, a Chiropractor, a surveyor or an Osteopath in his latest New Zealand Medical Journal Article.”
Are you seriously suggesting that no-one can have an opinion on anything unless they are a professional in that field? You don’t need to be an acupuncturist to be aware that meridians have no basis in reality – neither do you need to be an acupuncturist to know that ‘real’ acupuncture only works as well as sham acupuncture. You can stick the needles in willy-nilly and get just as good a result as a trained acupuncturist who believes in meridians.
“The RCT is not a valid measure of the human being. It is a valid measure of a drug and a symptom. Complementary medicine works with people and lifestyles.”
RCTs measure whether a treatment works – it is not true that they can only measure ‘a drug and a symptom’. If a complementary treatment works (i.e., has a significant beneficial effect) then that will show up in an appropriately designed RCT. To suggest otherwise is disingenuous.
“The validity of the degree of Chiropractic is not valid according to Colquhoun as it is quacks teaching quacks! In my education my anatomy was taught at a medical school by surgeons, my nutrition was taught by dieticians, my pharmacology was taught by a pharmacologist, my behavioural science was taught by a behavioural scientist, our differential diagnosis was taught by medic / chiropractor mix, our radiography was taught at a medical school by radiographers, our radiology was taught by a medical radiologist and a chiropractic radiologist, I could go on but frankly I think my point has been made.”
While it is certainly appropriate to learn about nutrition from dieticians and pharmacology from a pharmacologist, the parts of a degree in chiropractic that are based on unevidenced hypotheses are not worth teaching. With regards quacks teaching quacks: the most important thing here is what is being taught – not how many qualifications the teacher has; it doesn’t matter how highly qualified in quackery a person is – they will always be a quackademic rather than an academic. The difference between an unqualified homeopath and someone who has a degree in homeopathy, for example, is simply that one person has learnt their untruths at an otherwise respectable institution.
“A medical pathologist by the name of Windsor working for a decade dissecting thousands of cadaver specimens and animals he noted the correlation between minor curvatures of the spine and the cause of death in their natural deaths. He found a 99% correlation in all humans and animals between the spine and their cause of natural death. The other 1% were within one vertebral level of the enervation of the organ that caused their death.”
This sounds intriguing. Unfortunately, I have been unable to find any reference to anyone by the name of Windsor having anything to do with Pennsylvania Medical School – or spines, or chiropractic or anything vaguely relevant. If you have any references to this Windsor, please feel free to post a relevant link and I will take a look at it.
Kind regards,
jdc.
Jonah said,
August 12, 2008 at 5:14 pm
I have had problems with my back and spine for years – I had one accident as a child that involved falling on my head (concussion and neck injury), another playing sports that injured my lower back.
When I went to M.D.s, I was usually prescribed muscle relaxants and pain pills. When I went to chiropractors, I got a variety of treatments including adjustments, some sort of electric massage (ems?), myofascial treatments, exercises, and posture education. I have had better results from chiropractic, and would rather treat the problem without the heavy drugs.
I’ve been to 4 chiropractors over the past 2 decades. The second one I saw I would describe as a nut – he wanted me to get adjustments for everything … if I felt a cold coming on, etc. etc. I didn’t stay a patient of his long. But the other 3 were very much back and neck oriented. If something is clearly musculoskeletal, I would rather go to a chiropractor than a regular M.D.
jdc325 said,
August 13, 2008 at 11:56 am
Hello again Jonah,
Having defended supernatural religion and Apple Cider Vinegar, I’m not surprised that you are now speaking up for chiropractic.
Cheers,
jdc
Jonah said,
August 13, 2008 at 12:50 pm
http://www.ncbi.nlm.nih.gov/pubmed/18564952
“A comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatient clinic.”
At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group (decrease in disability by 5.9) than for the pain-clinic group (0.36) (95% CI 2.0 points to 9.0 points; p = 0.004). Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group (p = 0.023). Conclusions: This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a subpopulation of patients with CLBP.
jdc325 said,
August 13, 2008 at 1:28 pm
Jonah – I’m at a loss as to why you have linked to a single study published in JACM on chiropractic for low back pain, when there is a link in my post to a Cochrane review of chiro for low back pain. You are using a single study (weaker evidence) to refute a systematic review (stronger evidence). This is a little like trying to beat a straight flush with a high card in poker. I suppose it is at least better than your previous post, which relied simply on anecdote. Once again, “there is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.”
PS – interesting that you cite a study from JACM, the journal that some have re-named the “Journal of Alchemy and Compleat Magick”. AltMed journals have been criticised because of their standards of peer-review. Dr Aust has more here and here on the problems with AltMed journals.
Lee said,
August 13, 2008 at 2:14 pm
Being new to blogging I love the debate. I like that you have challenged my ideas and comments. Thank you for making my experience with blogging good.
Acupuncture in the Vivkers Trial was shown to be better than placebo. It was the first placebo controlled trial in Acupuncture and it showed that acupuncture made a difference over and above placebo.
I prefer meaning medicine than placebo. E.G why does an injection get better results than a pill – even if the doseage is equal? Why do some health care professionals get better results than others? Is your answer to the above the same? Probably not! placebo to please has been over and wrongly utilised by the lay press.
Henry Windsor original reference is from The Medical Times 1928 – probably not e available.
Chiropractic education in the UK is far from Chiropractic ‘Philosophy’. Let us not forget the centre of the soul described by Galen held true for 1000 years as found in the human brain. This was of course not true as he had found the centre of the soul in an animal dissection and presumed it was in the human. Inconsistancies are made when a profession is young and Chiropractic is a young profession. Whenever we have been asked to step up to the board we have and are continuing to regulate and to exist without central funding. In the UK we are doing well, considering there are under 3000 of us serving a population of over 50 million. Throw in the quack stuff if you must; it is water off…..!
Incidently a trial comparing Chiropractic with the Vickers trial I think by Giles et al, demonstrated Chiropractic to be more effective than acupuncture for acute low back pain. Is this a differing strength of placebo / meaning?!!
Research from the Osteopathic and the Chiropractic literature show that visiting a Chiropractor or an Osteopath reduces the frequency and the duration of colds. In reply to Jonah’s comment about going in for colds. From the medical literature we can see that regular visits with a rheumatologist lessens the severity of Arthritis (RA). Surely then regular visits with the Rheumatologist should not be allowed as it is unfounded and simple quackery?!! Lets not be too caught up on the incorrect associations and simplified cause and effect.
To consider the effects telegraph poles have on heart disease – where there are more telegraph poles there is more heart disease, does this mean that heart disease is caused by telegraph poles?
I will return with more about why the RCT is not the best measure for CAM interventions….
jonathanhearsey said,
August 13, 2008 at 3:03 pm
@ Jonah
You quote a study of 30 patients – in my opinion, that is NOT a study, it’s a luncheon party!
@JDC
“there is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.”
Nail on the head
@ Lee
You write well – you know your stuff. Don’t get drawn in – set up a study on manipulation in a way that is scientific. CAM’s NEVER fight fire with fire. We (yup – I’m an osteopath working for the NHS) ALWAYS defend ourselves with words where science is needed.
http://jonathanhearsey.com/?p=57
JH
jdc325 said,
August 13, 2008 at 3:59 pm
Hi Lee,
Thanks for dropping by again. I have one point I would like to discuss further – re your comments “Acupuncture in the Vivkers Trial was shown to be better than placebo. It was the first placebo controlled trial in Acupuncture and it showed that acupuncture made a difference over and above placebo.” and “I will return with more about why the RCT is not the best measure for CAM interventions….”
You start by referring to a placebo controlled trial showing acupuncture works and end by claiming RCTs don’t work for CAM.
Firstly, it wouldn’t be a huge surprise for me to find out that acupuncture had been shown to have some effect, as sticking pins in someone could plausibly elicit a physiological response (such as transmitter release).
Secondly, I’m surprised that you seem to claim that the RCT in acupuncture worked, but still claim that RCTs don’t work for CAM. It could be that I’ve misunderstood your comment, it could be that you don’t consider acupuncture to be CAM or it could be that familiar state of affairs in AltMed – scientific trials of treatments are to be embraced, but only when they have positive outcomes that we like.
Cheers,
jdc
jdc325 said,
August 13, 2008 at 4:00 pm
JH – thanks for dropping by. I see you are a regular on some of the other blogs I visit (I’m particularly a fan of Improbable Science and Bad Science).
Cheers, jdc
lee said,
August 14, 2008 at 7:40 am
The confusion between RCT’s and qualitative stuidies depends upon which model you are following. My aparent contradiction (thanks JDC!) saying no RCT for CAM and then citing Vickers as proof for Acupuncture. Times are changing and ideas are developing. I practice under the current model utilised in psychiatric medicine as I feel this is more applicable to CAM than the RCT. Yes Whittingham demonstrated a single blind cross over randomised placebo controlled trial for Chiropractic to gain his PhD, so I am not choosing the model that fits what is out there or taking the easy option because we Chiropractors can’t do it!!!.
Under the current model we as health care practitioners don’t want to know about populations, soley; what about me, you might ask – how is this research meaningful to me?!? For Qualitative research the individual is measured on their merits in each case. This means that as a Chiropractor / Osteopath / Physio / Psyc or other progressive and up to date health care researcher we are able to draw probable outcomes from population based studies, whilst being able to mesaure the individual, ‘live’. Thus avoiding the unreasonable and prohibitive costs involved in research. As enough individuals have been measured the power of the stats improves. The qualitative model continues to measure the practitioner with each and every patient. Not a snap shot like an RCT and without inclusion and /or exclusion criteria. Qualitative research allows the patient to decided what will be measured loosing the ineveitable bias that implicitly exists when a single or small group of people (scientists) decide upon the research design…
Qualitative studies are comparable to open ware software and the RCT comparable to a closed door development of software by a single company. Qualitative research is like having a fuel guage in your car that gives a current reading of fuel status and the RCT is like having a fuel guage that can only tell you fuel levels at pre specified times.
Thank you JH for commenting and I will look at your site this morning as I would like to learn more from you… anyway re your suggestion of a trial:
I have set up a trial, it is ongoing, it is qualitative and it has measured my performance over the last 3 years of practice, clearly demonstrating that I am effective at managing low back pain in the acute and sub acute phases and when I team up with my business partner, a psychotherapist, we are effective at managing chronic low back pain too. When I say effective I mean clinically effective according to the MYMOP score of the individual case. Each patient scores their own improvements. There is no hiding behind the (1 in 20) ‘random’ blips in results like in an RCT.
Rather than calling for a standardisation in chiropractic, it is up to the individual chiropractor to substantiate their effects once in practice….
I would prefer to have my day to day problems managed by a body worker and a brain worker as opposed to a drug worker. I would prefer to be managed by a drug worker when I have had a serious accident and my life is in threat.
lee said,
August 14, 2008 at 8:02 am
Sorry two more things in reply to JDC on Acupuncture
Suprised if acupuncture has an effect: The US Government comissioned research into Acupuncture to see if the points existed and could be measured as different to the surrounding areas. The conclusion was that most of the points could be measured as having different properties than the body parts around them. Performed by a physicist and carried out in the late 1950’s.
The first functional brain study to capture my imagination in acupuncture demonstrated when the traditional headache point down in the foot was needled there was a reliable and reproducible change in blood flow in the brain. When adjacent to the point was needled there was no such blood flow change.
One more on Chiropractic
Are you aware that a pilot study into the effects of ‘the chiropractic adjustment’ on the human spine has shown a plausible effect on the Ach pathway. We know something happens here, already…
Thank you for all who have taken the time to follow my comments.
jdc325 said,
August 14, 2008 at 9:54 am
Hi Lee,
Thanks for your comments. I’m afraid I found some of your points difficult to follow and I’d like to clarify a couple if you don’t mind.
“Qualitative research allows the patient to decided what will be measured loosing the ineveitable bias that implicitly exists when a single or small group of people (scientists) decide upon the research design…”
Are you trying to make the point that RCTs are less reliable than other methods of measurement? And are you arguing that the reason for this is that scientists introduce bias?
“When I say effective I mean clinically effective according to the MYMOP score of the individual case. Each patient scores their own improvements. There is no hiding behind the (1 in 20) ‘random’ blips in results like in an RCT.”
Are you making the argument here that self-assessment by patients is more accurate than an RCT? If so, please could you expand on this and tell me why you think self-assessment is more accurate? I would have thought that self-assessment would be fairly subjective.
I’m afraid I have a couple more points I would like to clarify on this issue: Are you telling me that the typical p-value used in RCTs of 0.05 means that one in twenty results is a fluke? I.e., that the p-value indicates the probability that a finding is a fluke?
Also – could it not be a potential problem with MYMOP that the patient will want to please the practitioner? How do you prevent or control for patients (whether consciously or unconsciously) trying to show their therapist in a favourable light when completing the follow-up?
“I would prefer to have my day to day problems managed by a body worker and a brain worker as opposed to a drug worker. I would prefer to be managed by a drug worker when I have had a serious accident and my life is in threat.”
Is ‘drug worker’ a term you apply to Medical Doctors?
I apologise for making so many requests of you, but I felt it would be better for you to make these point clear yourself rather than have me attempt to interpret the meaning for myself – I would likely have erred in doing so.
Once again – thank you for taking the time to comment.
jdc325 said,
August 14, 2008 at 10:11 am
Re: “The US Government comissioned research into Acupuncture [Performed by a physicist and carried out in the late 1950’s]” and “Are you aware that a pilot study…” – I don’t suppose you have a link to these pieces of research do you? In the absence of a weblink, a proper citation would suffice.
Thanks,
jdc.
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WellnessSteve said,
September 1, 2009 at 9:25 am
“Jonah – I’m at a loss as to why you have linked to a single study published in JACM on chiropractic for low back pain, when there is a link in my post to a Cochrane review of chiro for low back pain. You are using a single study (weaker evidence) to refute a systematic review (stronger evidence). This is a little like trying to beat a straight flush with a high card in poker.”
jdc325,
If you took the time to read each of the studies you posted, you’ll note that they were looking at “manipulative therapies” across various disciplines, not Chiropractic. Do you think it reasonable that a study about Chiropractors practicing THEIR profession might have better outcomes than studies which include professionals from other fields like MDs who picked up “manual manipulation” at a weekend seminar? Hardly representative of “chiro” as you claim.
In this regard Jonah is right to present a “high card”, for upon examining your “straight flush” we discover in your hand you have a cherry, emu, pine cone, kitty-cat and papaya. At least Jonah’s was a real card not an imposter. A lot of garbage data isn’t better than some good data. Once again a poor use of the scientific process. Go fish.
I also find it interesting that when you read these articles and actually find the word “Chiropractic” you find that there were positive results. Hmmm…
There goes that theory, jdc.
Cheers
jdc325 said,
September 1, 2009 at 2:02 pm
@WellnessSteve: please can you point me to the trials that looked at MDs using manipulative therapy having studied it at a weekend seminar?
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jace said,
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this stuff reminds me of scientology… another rather litigious group…
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