In Memoriam
Following on from Skeptic Barista‘s tenacious questioning of the GCC over the lack of evidence for the chiropractic subluxation, and my obituary of it, the GCC have announced that it is no more than ‘an historical concept’ to be consigned to the rubbish bin of a bygone, pre-scientific, evidence-free history.
The final nail in the coffin for the subluxation is their guidance (cached) for chiropractors, issued today:
GUIDANCE ON CLAIMS MADE FOR THE CHIROPRACTIC VERTEBRAL SUBLUXATION COMPLEX
The chiropractic vertebral subluxation complex is an historical concept but it remains a theoretical model. It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.Chiropractors are reminded that
- they must make sure their own beliefs and values do not prejudice the patients’ care (GCC Code of Practice section A3)
- they must provide evidence based care, which is clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners, including the individual chiropractor her/himself (GCC Standard of Proficiency section A2.3 and the glossary)
- any advertised claims for chiropractic care must be based only on best research of the highest standard (GCC Guidance on Advertising issued March 2010)
Bogus
This is interesting because of their statement about beliefs. They clearly see a chiropractor’s belief in subluxations as unfounded and irrelevant and indeed possibly prejudicial to the best interests of their customers.
However, it’s not so much a ‘theoretical model’ of anything: it’s never been any more than an hypotheses and one that has never had any evidence base. It was a notion that the quack D D Palmer invented to ‘explain’ to the unsuspecting why he was charging them money to crack their backs. As I’ve said before, there has never been any good evidence for either the subluxation nor its supposed effects on nerves.
The way they’ve phrased their second sentence is also interesting:
It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.
It seems to me that this was carefully written so that it included all conditions — anything at all that might be considered a ‘health concern’ is covered whether that is some actual condition such as back pain, or some more esoteric chiropractic condition like ‘feeding problems’. This should prevent them claiming that anything at all is caused by the mythical subluxation and stop them blinding their customers with sciency-sounding words.
All change again
This is a good time to be a web designer. Just think of all those websites that will need to be changed — again — to remove yet more misleading claims.
Of course, it might not be that simple. As Blue Wode has pointed out, there are a plethora of terms used by chiropractors instead of the bogus S word. The GCC’s guidance doesn’t say anything about any of these, and I suspect that some website changes may amount to no more than substituting a few new words. The GCC will need to keep on its toes if they really want to protect the public from misleading claims.
Applying appropriate care
The second bullet point in the guidance cites part of clause A2.3 of the GCC’s Standard of Proficiency. Although in the same document as the Code of Practice, it’s not really been relevant to my complaints, so I’ve not mentioned it before.
However, in full, the clause is:
A2.3 Applying appropriate care
Chiropractors must be knowledgeable about the underlying theories of the care they provide and be competent to apply that form of care in practice. Chiropractors’ provision of care must be evidence-based and appropriate to the patient’s health and health needs. The patient must have consented to the form of care. Chiropractors must care for patients in a way that minimises risk to that patient.
With the ‘theory’ of subluxations finally declared a mere historical artefact, what ‘underlying theories’ of chiropractic are left?
How are they going to explain to a customer why they think a good back crack will make any difference to their cervicogenic dizziness, their migraines or their chronic back pain?
How are they going to explain to a customer that they need to keep coming back for ‘wellness’ or ‘maintenance’ care to stop those nasty subluxations from causing you future health problems?
How indeed.
Spirit
So whilst this new guidance by the GCC is a welcome step in the direction of evidence-based chiropractic (whatever that is), they may find some abiding by the letter of the guidance but not the spirit. Not dissimilar to the lip-service many have paid to the ASA guidance they are mandated to abide by.
Inspired by the atheist bus campaign and this bus advert that Skeptic Barista happened across:
144 Responses to “In Memoriam”
@skeptic barista,
please don’t be so condescending and remember that chiropractors are real doctors. You might not feel that way but they are doctors of chiropractic like medical doctors are doctors of medicine. they deserve that title, worked hard for it and I would appreciate that you respect that fact.
In regards to non-mentioning of sublux-concept in the AN Other’s chapter: “what’s in a name?…” I used another term like “dysfunctional mechanism” to replace the term. I think it has been reiterated numerous time now that “subluxation” is not a particularly good term. The point you’re making here is widely besides the point and if you’re going to pin your arguement on a tired point of discussion as case in point I will be saddned. Here you have it: osteopaths remove subluxations, they just call it something else and they “believe” they exist in different ways. Same principle tho. You can do a lot better than that.
Stefaan
@ Skeptic Barista
Are you saying no one should do manual therapies then?
You seem to agree with me that RCT are important but in musculoskeletal care, how can an RCT be done for a complaint such as low back pain that can have multiple causes on presentation. Thats why so many different manual therapies have had RCT done for low back pain and they all come out the same as each other (equally effective)
@stefaan Vossen
You say “chiropractors are real doctors”, but you have a vested interest in saying that. A conflict of interests, if you will.
Now I have no problem whatseover with people being ‘car doctors’, ‘garage door doctors’, ‘shower doctors, ‘etc, but I do personally have a big problem with chiropractors calling themselves doctor. And that is becuase they work in the area of health. Calling oneself a doctor in a health setting affects how they are perceived on a number of dimensions.
I’m not alone in this feeling: As far as I am aware, the UK trading standards also feel that chiropractors are not really doctors! One of the funniest headlines I’ve read in a long while was the one you can read here: http://www.telegraph.co.uk/news/uknews/1332118/Advertising-watchdog-cuts-chiropractor-down-to-size.html
So what is a real doctor? My feeling is that it’s absolutely only someone with a doctoral degree (PhD or D.Phil) awarded by a proper university, or a person with a medical degree such as MbChB. For heavens sake, man, you’re a chiropractor! Why not just call yourself that. If what you do is worthwhile, surely you don’t need to inflate your status with the title doctor.
This discussion could clearly run for ever, I’m going simply going to refer to the research I quoted to the GCC.
This is from Chiropractic & Osteopathy a peer-reviewed online journal that aims to provide chiropractors, osteopaths and related health professionals with clinically relevant, evidence-based information.
(You’ll notice it talks about CLINICAL RELEVANCE – something you are all very keen on)
=========================
http://www.chiroandosteo.com/content/17/1/13
An epidemiological examination of the subluxation construct using Hill’s criteria of causation
Conclusion:
Hill’s criteria are the most commonly used epidemiologic model for suggesting a causal link for any diagnostic or treatment approach.
There is a significant lack of evidence in the literature to fulfill Hill’s criteria of causation with regards to the chiropractic subluxation.
No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention.
Regardless of popular appeal this leaves the subluxation construct in the realm of unsupported speculation.
This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability.
=========================
(You’ll also notice the report concludes that subluxations have no valid CLINICAL application)
You see even when viewed from the point of clinical practice – subluxations fail!
@Andrew Gilbey
Thank god what you think is really ever only going to be what you think. Chiropractors are highly skilled, highly trained, MA-degree graduates from UK Universities with specialist education in the healthcare field (I can’t even begin to explain you my disagreement to the inclusion of others into the UK’s definition of the chiropractic profession…) These people are respected by GP’s, consultants and patients.
The ASA is right to make sure that there cannot be any abuse of trust or implication of medical philosophy. Why a chiropractor would want to do that is quite frankly beyond me, but I would have to look into the history of this non-sense. I suspect it has something to do with the inclusion of some who would see benefit in making out that they are medical doctors. Funny that there is a reported history of a GP calling themselves “chiropractor” (not followed up by the GCC (lol)
Doctor Stefaan Vossen, Chiropractor
@skeptic barista
the argument set in your reference falls apart as soon as you include a need for analysis of polycausality (which is so obvious it hurts). Therefore its (and those of other pieces of research done so far in this field) conclusions are invalid. The best and most accurate thing you can say is “there is no research available”.
Sorry Ernst and co.
Stefaan
Quote by David Colquhoun:
“A. Gilbey finds that the abuse of the title doctor is widespread and that chiropractors are the main culprits. An amazing 82% of 146 chiropractics used the title Doctor, andL most of them used the title to imply falsely that they were registered medical practitioners.”
I ask of @ Andrew Gilbey, how does one know that chiropractors use the title to falsely imply that they were registered medical practitioners? Or is the feeling such that it is “thought” to be such as it infers, in one’s own view greater importance?
Doctor Stefaan Vossen, Chiropractor
Stefaan Vossen
Whilst checking up on a few chiropractor websites, I found this information on the Yost Family Chirorpactic centre’s website: One in Four Parents Link Autism to Vaccines. The actual study appears to have been a survey, but on Yost’s website I feel it is being used in the context of vaccines cause autism! (Not least becuase BArbara Loe Fisher gets a mention.) Given the recent news regarding Wakefield,this really is quite staggering. Yost, by the way, has some amazing videos of herself at work on YOUTUBE (search for the username of drheatheryost) (http://www.yostfamilychiropractic.com/templates20/article/1987.html)
@stefaan
I love your line: “Thank god what you think is really ever only going to be what you think.”
@ Andrew Gilbey,
somewhere, someone said something which you feel it is being used in the context of….? Man you’re good at this stuff. Is that how the New Zealand research was done?
I would love to know how the conclusion in regards to “chiropractors using teh title Dr. to imply medical status” came about, really I would LOVE to know. Or was it a BOGUS claim based not on evidence but prejudice and derogation?
(giggle in clenched fist)
Kind regards,
Stefaan Vossen
Doctor of Chiropractic
This is only the beginning
I think you’re being deliberately obtuse, Stefaan. As you well know, the title ‘Doctor’ is commonly understood to mean one of two things: either that the title holder has a PhD or that s/he has qualified as a doctor of medicine. It is completely understandable that Joe Public should believe anyone claiming to be able to treat medical conditions and who uses the title of ‘doctor’ is a doctor of medicine. Other highly trained professionals like nurses, midwives, physiotherapists and dieticians don’t seem to feel the need to pretend they are anything other than what they are but (some)chiropractors do and I note that those who do make a huge issue out of it and use the title at every opportunity – something even real doctors don’t do. What possible reason can there be for you to call yourself ‘doctor’ other than that you wish to give the impression that you are qualified doctors of medicine?
This isn’t a ‘bogus claim based on prejudice’ but a reasonable assumption based on the evidence available to us. What you don’t seem to realise is that by pretending to be something you are not, you are shooting yourself in the foot and making it easier to dismiss you as dishonest quacks.
@skepticat
Thank you for recognising my obtusiveness is deliberate.
Stefaan Vossen
@Skepticat
Thanks for that excellent explanation!
I recently carried out a little experiment (double-blind, although we only claimed single-blind) looking at CAM practitioners use of the title doctor (Gilbey & Perezgonzalez, 2010). It seems that potential clients are significantly swayed by the title of doctor: chiropractors using the title of ‘Dr’ were perceived as more expert, more scientific, and more likely to help than chiropractors using just their given and surnames. They were also perceived as more expensive.
In New Zealand, there is a report known as the Royal Commission into Chiropractic (1979). It makes interesting reading for any sceptics! It’s very often cherry-picked by chiropractics – perhaps because it concludes that chiropractic probably does little or no harm. One part chiropractors almost entirely overlook is the recommendation that chiropractors should not use the title of doctor.
@stefaan Vossen is there any reasonable quality research to support the existence and clinical relevance of your “dysfunctional mechanism” ? If it lacks research behind it, how does it differ from being a personal re-interpretation of subluxation ?
@Skepticat, I don’t think chiropractor so much want to pretend to be medical practitioners as to claim equal status with them in the patient’s mind. That’s consistent with Stefaan’s request for respect and with Andrew Gilbey’s observation that ” chiropractors using the title of ‘Dr’ were perceived as more expert, more scientific, and more likely to help than chiropractors using just their given and surnames.” In the U.S. they seem to often claim the role of a “primary care practitioner” too.
@Andrew Gilbey
“it seems that potential clients are significantly swayed…”
“Chiropractors using the title doctor were perceived to be more expert and more scientific…”
Seriously? It took a piece of “research” (“experiment” = a survey?) for you to figure that out?
Out of 100 people asked what they expect to see when they are told to expect a “dog”, people are signiifcantly swayed into expecting to see an animal with 4 legs…possibly furry with a serious expectation of a tail…
Come on Andrew, how you come to conclude from any of this work that chiropractors are using the title to falsly imply medical status is beyond me.
You imply and refer so much to this nonsense that you seem to believe your own bovine doodoo.
I know what I do when it comes to spinal biomechanics, I get results for my patients (oh, delivery of predicted best self-reported outcome by the way: 98% of the time, or is that too unbelievably high a statistic for you?) and 90% of my new patients are referred to me by existing patients. My patients are chronic pain sufferers and the average cost of delivering results is £288.
If anything I am too cheap, come to think of it, but I am a bit of a socialist at heart so I want to make my prices affordable.
What exactely is your beef? Coz’ it sure as hell ain’t science! (or cricket)
Stefaan Vossen
Chiropractor, Human Being and Master of my Universe (yes I am being funny now and challenging your self-serving prophecies in relation to this mental mantra you and some of your compadres/madres seem to have that chiropractors are creepy, esoterical quacks-admittedly my wife has pointed out that something is only funny when it makes people laugh, so I will leave that to the readership).
@davidp
is that a serious question? Or are you being as ridiculous as me (at times)?
Cr Stefaan,
It’s funny you should say that “chiropractors are creepy”. When my children are messing about at night, I tell them the chiropractor will come out from underneath their beds and crack their spines for them! It sure scares them to sleep! I bet you do the same with your kids, but use ‘GP’ for ‘bogey-man and say he’s going to prick them with a vaccine’?
More seriously, you say, “I know what I do when it comes to spinal biomechanics, I get results for my patients”. What makes you so sure that isn’t simple placebo?
So basically, the “skeptics” cry foul of a profession which in the UK by and large looks after chronic back pain which more often than not has been looked at by GP’s and physiotherapists, is not ellegible for surgery and is causing lots of time off work and human suffering. They “critique” the subluxation concept whilst not actually understanding it and rather deride it for its historical origins. They say it is potentially dangerous whilst not making an accurate assessment of risks and benefits and discarding the evidence that is available (Breen report, amongst others). They say it might all be down to the placebo effect, and because a very complex and expensive clinical trial which would put this ridiculous debate to bed has not beend done yet they feel chiropractors have no place in the healthcare market (lack of evidence). Despite the fact that they are highly trained and on topics of relevance to the arena they function in score significantly better than most practitioners they shouldn’t be allowed to call themselves “Dr.”, a courtousy title they have earned and deserve, just so no-one is confused whether they are medical doctors or not… Really? I refer you back to an earlier post about being misguided: This is only about one thing for me: the patient.
Stefaan Vossen
@stefaan
You say that, “This is only about one thing for me: the patient”
Then I suggest you stop using the title of doctor, as clearly that is about you.
@AndrewGilbey
I hope you’re NOT a doctor! Please look up the definition in your choice of dictionary
and tell us what the word means.
@Andrew Gilbey,
1) I would love you to answer the questions I have put before you some time ago now in regards to how you cam to the conclusion that doctors of chiropractic use the title doctor to imply medical “status”
2) would you also like me to stop wearing ties because god forbid they might imply status too (albeit sartorial in nature) or charge a fee for my work? That’s about me too…
3) your argumentation is so weak and sollipsistic that even you must see that you are very much clutching at straws. I think you are only doing so by virtue of having failed to identify your real beef. Maybe you think that the provision of care for the patients I treat and help in the UK is adequate and think chiropractors redundant? Just so you know: it’s not the case. Far from it.
4) can you please elucidate the thinking behind your position that a chiropractor should not use the title doctor “because it is not abut the patient but about them”? I think you will find that this is true for any academic or professional title, so I find it difficult to take your position seriously.
Kind regards,
Stefaan Vossen
This is only the beginning
@Stefaan
Any progress on your research yet? Do you have a proposal? Even an outline might be interesting.
@IainD
will post a link to my blog, so we can have a bit of a topic-specific discussion. Link published here tomorrow or Thursday.
Stefaan
@Stefaan, it was a serious question, but carefully re-reading your comments I think I had mis-interpreted you, and by “dysfunctional mechanism” you just mean that there is some component of the body or behaviour causing the problem. I am coming to think this is the case.
On Tuesday 25 May 2010 at 10:00 you referred to “any systematic dysfunction in any arena of the healthcare spectrum which is causing a challenge to the ability to cope”
On Saturday 29 May 2010 at 14:04 you said, in discussing diagnosis, “What is the systematic dysfunction? … Is it biomechanical, is it chemical/nutritional, or is it psycho-emotional? ”
On the other hand, your language is somewhere in the postmodern / poetic / symbolic realm. Whe you use them it seems
“subluxation” = “underlying cause, of any kind”
“Chiropractor” = something special, perhaps ‘true healer?’- “I strive with humility to become, whilst knowing I will never be, a Chiropractor”
You also said Sunday 30 May 2010 at 17:35 “is there someone out there who would be able to come up with a nice short term meaning “source of dysfunctional mechanism”? It has to be applicable to biomechanical, chemico-nutritional and psycho-emotional mechanisms.” I think the term is “underlying cause.”
Giving it a special name like “subluxation” creates a misleading apparent grouping a disparate set of causes. You have already recognised that the causes can be biomechanical, chemical/nutritional, or psycho-emotional (presumable not an exhaustive list) and restricted modern chiropractors to addressing a subset of biomechanical causes. Incorrectly grouped names cause errors in thinking by researchers, practioners and the public/patients.
I wonder what the GCC would have to say about this series subluxation-based lectures about to be held in the UK:
http://www.chiropracticlectures.com/speakers.html
@ Blue Wode
“I wonder what the GCC would have to say about this series subluxation-based lectures about to be held in the UK:”
Why don’t you ask them?
@david
I think they may be a litte busy at the moment! PLease refer to Zeno’s next post
Official: Chiropractic built on sand.
http://www.pulsetoday.co.uk/story.asp?sectioncode=20&storycode=4126259&c=1
(Free registration)
Folks, it has been interesting reading this discussion. Some proponents of chiropractic have been extremely eloquent and I will never be able to match them on that front however eloquence does not imply in the smallest sense rationalism. As an example consider the world’s religions, there are many, many religions, every single one is promoted by extremely eloquent adherents, and every one (more or less anyway) claims to be the only true religion, all the others being bogus religions.
Since they are often, usually or always contradictory, nearly all of them, all of them except one, or exactly all of them are misguided, bogus and wrong.
Until the Singh episode I had no clue what a chiropractic or indeed chiropractic might be. I did not even know of the exact word “chiropractic”, using instead chiropractor/chiropractise (although I had never needed to try to spell them). “Chiropractic” smarts of ostentatiously mangled grammar to me.
Now, it is my honest opinion that it is a trade that cares much more for appearance than for facts, that worries about “reputation” rather than evidence, that is concerned with exotic, confusing, undefined words more than for customer’s (including children’s) health, that cares for the confusing use of titles and not a jot about reliable evidence. It is now thoroughly discredited subsequent to recent events in the Courts and the exposure of dodgy advertising and other claims and apparent misuse of titles by hundreds and hundreds of such traders. Del-boy looks like some kind of saint in comparison.
It seems that the whole concept was dreamed up by a snake oil salesman over 100 years ago. After reading a little about the history of this now scurrilous trade, I have wondered if perhaps he was a bit hard up and couldn’t afford to stock up with snake oil, bottles, labels and stoppers. He therefore invented oil-less, bottle-less, stopper-less, label-less, snake-less snake oil. No more tedious sessions over the cauldron, plugging the bottles, licking the labels, loading the wagon.
Simply get the punters into the wagon and wave the tongue over them, an ostentatious wee rub on the back and poof! instant pecuniary relief without prior investment and of course instant pecuniary and perhaps other pains for the punter.
Charlatanics – is the word that springs first to my mind. (Please excuse the exotic mangled grammar, it seems strangely apposite:-)
Jim Smith
It has only just begun
[...] This post was mentioned on Twitter by . said: [...]
@ Jim Smith
It’s a terrible shame that you have come to the opinion you have about chiropractic. It just goes to show what a calamity the ill-judged decision to sue Simon Singh was.
The truth about chiropractic, as I have known it for the last quarter century, is that it is an honourable, caring profession helping a great many people to a better life.
If one was to form an opinion based on the information available on sites such as this, it is inevitable that you’re going to come to a negative conclusion. Don’t be swayed by the origins of the profession; if you were to judge “medicine” by its origins, you would believe that to be populated by barbaric, blood-letting charlatans.
I’m not going to defend every chiropractor out there, as I’m sorry to say that there are some whose philosophies and ideals are quite bizarre. However, don’t dismiss the whole profession as a result of that or you should probably dismiss the whole dental profession for the views of some on the dangers of amalgam fillings. See for example this character who holds strong views on amalgam http://dentalwellness4u.com/index.html There again he calls himself “Dr”, so presumably he must be a charlatan…………
Similarly, you would dismiss the whole medical profession for the views of some on homeopathy, for example this chap http://www.doctortwrobinson.com/homepage.html
Or, all veterinary surgeons because some hold that homeopathy can be effecetive, for example this lot: http://www.holisticvet.co.uk/
Quote: “Now, it is my honest opinion that it is a trade that cares much more for appearance than for facts, that worries about “reputation” rather than evidence, that is concerned with exotic, confusing, undefined words more than for customer’s (including children’s) health, that cares for the confusing use of titles and not a jot about reliable evidence. It is now thoroughly discredited subsequent to recent events in the Courts and the exposure of dodgy advertising and other claims and apparent misuse of titles by hundreds and hundreds of such traders. Del-boy looks like some kind of saint in comparison”
Honest or dishonest opinion is hardly relevant here, what is, is that it is founded on the same quicksand of the subluxation as-cause-of-all-disease interpretation… I am sorry but you really are barking up the wrong tree, but understandably so… seeing where you get your information from.
ps. the profession was not quite discredited in court action, the BCA’s attempt to sue Simon Singh for libel (rightly, in my opinion) was.
pps. chiropractors don’t misuse the title doctor, they are entitled to use it if they so wish
ppps. exotic confusing words are there to name exotic confusing things. these things being exotic is one thing, them being confusing yet another and a profession’s concern with them only expresses the fact that there seems to be (for whatever reason) some intrest in it. It may be that there is a kernel of truth to it and that they are finding it difficult to discern that kernel.
That surely can only be a good thing..
Stefaan Vossen
@ Jim Smith
Most chiropractors become chiropractors because of a personal healing experience or seeing someone else helped when conventional medicine didn’t. Do medical doctors choose their occupation
the same way or is because they’ll have tremendous status, make extremely good livings and have a
great career? No one becomes a chiropractor because they can’t wait to start dodging punches!
And chiropractic which literally means practical hands ,is a better descriptive name than osteopathy
( look up the definition of pathy and osteo). And ask Andrew Gilbey to tell you and us the definition of doctor.
@Stefaan,
“Honest or dishonest opinion is hardly relevant here…”
That statement was either stunningly stupid or stunningly arrogant! – The whole of your last post was nothing more than your opinion! Do you consider your opinion more relevant that that of others?
You offer your opinions on subluxations, whilst dismissing the opinion of some other chiropractos that that subluxations are a cause-all, cure-all condition.
Given your view that Opinions, honest or otherwise, are not relevant here, why should anybody accept your opinion as fact!
Perhaps they you would prefer to stick to proven facts, that is those supported by research evidence, although this is an area usually avoided by chiropractors!
@Skeptic Barista
given the choice of the two, I’d rather it be “stunningly arrogant”. A little like your misquoting, or rather taking out of context of the quote;
1) it is simply not relevant whether it is honest or dishonest opinion, what on the other hand is relevant is that it is opinion fullstop, and not as you misread from my post that “opinion is irrelevant”.
2) as very clearly (in my opinion) explained within the syntax of my post, the opinion is ill-informed and ill-construed. This is further demonstrated by means of the entries at the end of that post.
3) opinion is a wonderful thing and there to be added to, subtracted from, strengthened and changed alltogether and rhetotic is a powerful way to do so.
4) I would love to stick to proven fact supported by research evidence, but there isn’t much of it. I already stated this to you in the past. The fact that something hasn’t been researched does however not mean that it is ineffectual, a fact you seem to struggle with. Maybe you should spend a day in clinical practice, medical or otherwise to find out for yourself the difficulties entailed in a world of knowledge interlaced with gut-instinct and lashings of experience. But then you probably think that medical practice is an exact science, which is where I would seriously encourage you to speak to a few GP’s about that topic. My dad is one, 38 years in practice, my mum is a nurse, 34 years in practice, and they have both told me that medicine is an art, rooted in knowledge, required for the reduction of unpredictability, predictability tested by science.
I just cannot help to feel like you are really missing the crux of this matter: clinical life (which is what most chiropractors are concerned with) is not the lab-version of reality you seem to be so fond of. I wish we could have tested models a bit better and a bit more by now. And no, in my opinion there is no science to back up that spinal subluxations cause colic and asthma, but then that is why I don’t claim to treat these things. The problem is that there isn’t even that much evidence to claim anything at all, so I don’t claim much, other than that which I have experience of that I can predictably change in the patient in front of me. They are quite happy to buy into my service on that basis and the insurance company which provided me with the money-back guarantee was happy to provide me with the policy to claim that after having looked at my results. In the meanwhile I am working on developing the science…
Kind regards,
Stefaan Vossen
This is only the beginning
@Stefaan said: “will post a link to my blog, so we can have a bit of a topic-specific discussion. Link published here tomorrow or Thursday.”
Any progress???
@davidp
thank you for revisiting the posts I made in order to answer your question. I appreciate that response. I also fully concur that there is something very confusing abuot grouping things together like that but I think there is some merit in conceptualising the principle.
Kind regards,
Stefaan Vossen
@iaind
some progress, unfortunately not enough. Talk soon
Stefaan
@Jim Smith
You say, “Some proponents of chiropractic have been extremely eloquent and I will never be able to match them on that front…”.
I disagree on both counts
@Jim Smith
I would agree with you: eloquence does indeed not imply rationalism
Stefaan
Imitation is the most sincere form of flattery
@Stefaan
I appreciate these things take time to polish – if you have a first draft, perhaps you could publish that?
Hi IainD:
the underlying premises of the study and its relevance to the practice of chiropractic care are the following:
1)dysfunctional mechanisms (the term used to replace an archaic and unhelpful “subluxation” exist in three general subgroups:
-emotional/psychological
-functional/structural
-chemical/nutritional/endocrine
2)when the potency and intensity of the dysfunctional mechanism exceeds the subsystem’s ability to cope destructive function results.
3)when destructive function occurs there is an increased likelihood of injury, inability to recover from injury or symptomatic display.
caveats:
-not all symptomatic displays are consequence of intrinsic destructive function, but can also be due to excessive external impact
-certain intrinsic dysfunctions are secondary or predisposed to genetic function or secondary or predisposed to by cultural conditioning
the general outline of the study is as follows:
chiropractors today do not practice the full remit of the chiropractic philosophy as proposed herein. Chiropractors today practice primarily in the functional/structural field and provide primarily treatment for spinal dysfunction.
The first step in the study is to ascertain whether or not there is any validity to the notion that removing the underlying/predisposing biomechanical dysfunctional mechanism is likely to result in recovery or reduction in likelihood to biomechanical injury.
Due to the overwhelming interest and expertise in the back pain field held by most chiropractors in the UK, this first preliminary study will further narrow down to assessing the validity of this notion in the assessment of dysfunctional mechanisms pertinent to low back pain.
The study will prescribe assessment protocols for:
-gait dysfunction
-orthognathic malocclusion
-spinal dysfunction
The study is a prospective cohort study, where chiropractors using the protocol are compared to chiropractors who do not.
Further subdivision can be achieved by comparing results of patients who tested positive in one area but did not receive treatment in that area compared to patients who tested positive and did receive treatment.
Data acquisition tools and frequency are under discussion.
Assessment and treatment are provided by chiropractors in private setting. Podiatrist selected from a panel. Malocclusion will be managed by using soft dental splints. Chiropractors will use the manipulative technique of their choice, excluding traction techniques. Treatment protocols will be prescribed in three categories according to extent of tissue injury and tissue involved:
1)Muscular ++ Skeletal 0(or+)
2)Muscular ++ Skeletal ++
3)Muscular + (or ++) Skeletal + (or ++) Neurological +
Presence of neurological symptomatology requires identification of mechanism of injury (pathological/annular tear/discal bulge/discal hernia/IVF hernia). Only groups 2, 3 and 4 are eligible for the study, others must be referred for further evaluation).
This would then provide a number of criteria:
-class of injury (1, 2 or 3 as above)
-class of dysfunctional mechanism (gait, bite, spinal, gait-spinal, gait-bite, bite-spinal and gait-bite-spinal, totalling 7 subgroups)
-treated vs not treated
-reported progress
I hope it makes sense.
The real stumbling block is the control group and the placebo, but my thoughts on that are that it might be possible to cross-reference to other studies like the Mead study. It would also be possible to follow up with patients who were assessed and found to have any of the 7 classes of dysfunctional mechanisms but did not receive treatment and those who did not have any of the 7 classes of dysfunctional mechanisms and did not receive treatment.
there are lots of gaps within the text above as I am sure you will understand, but please do let me know your thoughts.
kind regards,
Stefaan
I thought you were going to publish it on your own blog?
G’day Stefaan,
Cohort comparison from different practices is a very weak study design because the populations are not comparable, and the equivalence of initial conditions and treatment results is unreliable.
To do the comparison reliably I think you need to:
- Have a common intake assessment of patients for suitability for treatment for orthognathic malocclusion or gait dysfunction
- The person doing the intake assessment must not prejudice the patients as to what treatment is appropriate.
- After assessing the patient, request that they enter the trial. If they agree they get randomly assigned to one of two treatments.
- Treatments to be provided by a different person from the person providing the intake assessment.
- Half the patients get treatment for the orthognathic malocclusion or podiatric treatment for gait dysfunction.
- The other half get the best ‘conventional’ spinal chiropractic treatment for their condition, in the opinion of the treating chiropractor.
- After a suitable time, the patients’ condition is assessed by a person who is not aware of the treatment given, and who takes care not to find out. Someone not committed to the new protocol is probably best for this, so they do not unconsciously look for the signs used in the initial diagnosis.
Important points this achieves are:
- Randomised treatment, blinded assessment
- Control group with a control treatment with similar size placebo-effect
- No significant difference in patient experience between groups (all groups experience a change of practitioner between assessment and treatment)
- Minimisation of unconscious prejudice effects
“Imitation is the most sincere form of flattery” or insult.
@Davidp
problem with some of the criteria required to improve the validity is that they are not feasible in a private setting and that almost all chiropractors work in a private setting and would loose income over taking time off to work on a trial. Another problem is that the patients will want to be treated at the best of current knowledge. I haven’t checked yet but am pretty sure there might be an ethics committee issue in this. I also think that even if the design is flawed in this way it will enhance or reduce the plausibility of the theory. Either way we will know a bit more and I am a firm believer that somewhere someone far smarter than me will be able to progress on from this. I think though that much value would lie in vast numbers. If this assessment protocol were to be held by a substantial number of chiropractors and held up for a number of years, it might overcome some of the concerns of population variability.
Kind regards
Stefaan