The random thoughts of a sceptical activist

Where the evidence leads

Google Alerts is a very useful tool for skeptics. It sends you an email whenever the word or phrase you’ve asked for crops up in their searches of news, blogs or other websites. They are excellent for keeping tabs on what’s going on by helping you track new stories and hits.

Naturally, I have one set up for the General Chiropractic Council (GCC), just to see where they crop up on web sites and in the news.

A few days ago, I received a Google Alert about a page that had been recently updated, although the mention of the GCC was from some time ago. It linked to a decision by the Press Complaints Commission (PCC) about complaints made by the GCC against the Daily Telegraph, the Daily Mail and the Guardian about articles published on 9 November 2007.

According to the GCC, the articles said:

  • Chiropractors ‘are waste [sic] of money’, Daily Telegraph, Rebecca Smith
  • Chiropractors ‘are a waste of time’, Daily Mail, Jenny Hope
  • ‘Chiropractors may be no use in treating back pain, study says’, The Guardian, Alok Jha

Nothing new there, then.

In a statement (cached) published by the GCC the same day the article was published, GCC Chairman, Peter Dixon said:

The GCC is appalled by a number of reports in today’s press that ‘chiropractic is a waste of time and money’. This wildly inaccurate assertion is based on a small research study looking at acute low back pain only and involving GPs and physiotherapists. The purpose of the study was not to measure the effectiveness of chiropractors.

The press reports defy logic because neither the research study, nor the Lancet’s press release, mentioned chiropractic or concluded that ‘chiropractic was a waste of time and money’. It is sad to see a piece of research misrepresented in this way.

He goes on to say, with no hint of irony:

Chiropractors provide an evidence-based approach based on European-wide guidelines compiled by multidisciplinary teams of experts who reviewed all relevant research.

The main treatments of chiropractic have consistently been shown in reviews to be more effective than the treatments to which they have been compared. Chiropractic intervention is safe, effective and cost-effective in reducing referral to secondary care.

And the GCC’s Annual Report 2007, page 22, says about the case:

The accurate reporting of research outcomes by the media is essential to the public interest.

Quite.

Complaint

The full letter of complaint the GCC sent to the PCC can be read here (cached). Unfortunately, the various annexes mentioned — eight in total — are not included.

The GCC complained that the articles were:

…inaccurate, misleading and distorted reporting of the purpose and outcome of a research study

They went on to say:

The GCC is concerned that such reporting is irresponsible and does not serve the public interest. It misleads readers, may prevent members of the public from seeking the help of appropriately qualified, experienced and regulated health professionals, and ultimately undermines the public’s trust in the accuracy and utility of scientific research.

It is likely that such reporting has also undermined the reputation of the chiropractic profession and may have a direct impact on chiropractors’ practices; all chiropractors, apart from a handful, are in private practice. It may also prejudice any chance of increasing public access to chiropractic on the basis of need through NHS funding.

Ah. Reputation. Money. NHS funding.

More complaints

But they weren’t the only ones concerned by the articles.

Dr Damien O’Dwyer (a chiropractor who doesn’t appear to be a registered with the GMC as a medical practitioner) complained about the Daily Mail and the Guardian and the British Chiropractic Association also complained, apparently. I say apparently because the GCC Newsletter of March 2008 (cached), which tells their side of the story, states that the BCA had also complained to the PCC, but I can find no mention of their complaint on the PCC website or on the BCA’s own website.

The Hancock study

But what got the GCC, the BCA and a chiropractor so incensed with these three articles that they felt the need to complain to the PCC and demand the record be set straight?

The articles were about a new study by the University of Sydney, published in The Lancet:

Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial, M.J. Hancock et al, (Lancet 2007; 370:1638-43)

According to the GCC’s complaint:

The research study did not conclude that chiropractors are a waste of time and money, or of no use in treating back pain, as reported. Chiropractors were not mentioned in the research study at all. The purpose of the study was not to measure the effectiveness, or otherwise, of chiropractors or a single manipulative technique used by chiropractors, physiotherapists, osteopaths and others. [Their emphasis]

The GCC told their members (19):

The articles gave an inaccurate, misleading and distorted view of research published in the Lancet…

Although it doesn’t look like the BCA complained to the PCC, they did issue a press statement (cached) about the articles. Tony Metcalfe, the then President of the BCA said emphatically:

No direct comparison can be made from the results of the aforementioned study and the treatment offered by BCA chiropractors for a number of reasons:

  • The study did not address chiropractic only spinal mobilisation carried out by physiotherapists. The majority of participants had low-velocity mobilisation techniques and only 5% experienced high velocity techniques. Chiropractic manipulation is based predominantly on high velocity techniques, so the results are therefore not comparable with chiropractic treatment
  • There is no indication to suggest that the physiotherapists are specialist manipulative practitioners as BCA chiropractors are – the results could well have been different had chiropractors been involved with this study rather than physiotherapists
  • The level of training and education is not comparable. The British Chiropractic Association only accepts graduates who have undergone a minimum of a four year full-time internationally-accredited degree course at an internationally-recognised college of chiropractic education

At least the GCC and the BCA were in agreement about the fact that the study by Hancock et al. clearly had nothing whatsoever to do with chiropractic, chiropractic subluxations or chiropractic manipulations so it was therefore wrong to conclude from it that chiropractic was a waste of time or money.

Restitution

To make amends for this heinous misrepresentation of the truth, the GCC demanded:

In the GCC’s view, the best outcome to our complaint would be

  • Corrections and clarifications printed in a prominent position in each paper
  • The PCC publishing a specific good practice guideline for journalists on reporting research outcomes, or endorsing and circulating the SIRC guidelines mentioned above
  • The PCC upholding the GCC’s complaint and its judgement published in a prominent position in each paper

The end result of the complaints was that all three papers published corrections, acknowledging that the study was not about chiropractic and that there were wrong to say the horrible things they did about chiropractors.

I’m glad that’s clear.

But wait a minute…

Remember the GCC’s Bronfort Report?

As a result of my complaints — and presumably because they didn’t already know what the evidence base was — Bronfort and four other chiropractors were commissioned by the GCC to look at the totality of evidence for chiropractic and they gathered an impressive 322 references. One of these was a certain study by Hancock et al., cited as reference 37 in the Bronfort Reportthe very same study that the GCC complained about.

What did Bronfort have to say about it?

Hancock et al [37] found spinal mobilization in addition to medical care was no more effective than medical care alone at reducing the number of days until full recovery for acute LBP. This study had a low risk of bias.

And, in summary:

Moderate evidence that adding spinal mobilization to medical care does not improve outcomes for acute LBP in adults [37].

Assessing all the studies that Bronfort found, they concluded there was moderate positive evidence for acute lower back pain (LBP) from spinal manipulation/mobilisation.

But why was the Hancock et al. study (which has nothing to do with chiropractic, remember) ever considered by Bronfort? The GCC has made it abundantly clear that Hancock et al. has nothing whatsoever to do with chiropractic. Even if Bronfort was not aware of this at the time, you’d have thought someone at the GCC would have read it and noticed this irrelevant Hancock study and either asked Bronfort to remove it or issue an amendment to it.

Neither has happened.

Where the evidence leads…

So, with the GCC having rejected the Hancock et al. study as having nothing to do with chiropractic, where does that leave Bronfort? What happens if you take the Hancock study out of the Bronfort report? Well, removing Hancock et al. makes the remaining evidence look more positive in favour of chiropractic being effective for acute LBP.

I’ll go where the evidence leads and if that leads to show that chiropractic is effective for some conditions, then so be it. That’s what the evidence says. (But there is still the massive problem of the complete lack of a plausible mechanism of action, of course — something essential for Science-Based Medicine).

However, if the Hancock study is to be removed from Bronfort because it had nothing to do with chiropractic manipulation, then we must also remove all the other papers that Bronfort cited that were not explicitly to do with chiropractic and chiropractic manipulation. That’s the only sensible things to do — you can’t cherry pick, after all, can you? Reject one study because it has nothing to do with chiropractic and you must reject all others.

That includes the ones that were for osteopathic manipulation as well as those just described as ‘manipulation’ After all, as any chiro will tell you, a chiropractic adjustment is not an osteopathic adjustment and is not just any old spinal adjustment.

Definitions

Before looking further at Bronfort, it’s worth considering some definitions and how chiropractors try to define what they do: to be taken seriously, chiropractors would need to properly and fully define what they mean by chiropractic manipulation. If they don’t, they are no different to witches casting spells.

Chiropractors want to be unique. They want to be seen to be unique. They need to be unique. Many want chiropractic to be seen as something completely different to other ‘healthcare professions’. Their USP is chiropractic manipulations: high velocity low amplitude manipulations if you will. According to the BCA, even Physiotherapists only perform using low velocity techniques: it’s the speed of the manipulation that is critical, apparently.

Take away the chiropractic manipulation then they are no longer those unique manual practitioners they so desperately crave to be. Of course, part of the marketing is to give their spinal manipulations a special, unique name: chiropractic adjustments. It is the ‘specific yet gentle chiropractic adjustments’ that create the differential with other professions.

But defining what chiropractic is seems somewhat elusive — even to chiropractors. There have been many attempts by chiropractors to explain their ‘art’ to non-chiropractors, but these always turn out to be circular (and therefore explaining nothing) or end up relying on some variation of a hypothesis of the vertebral subluxation complex (VSC). Attempts to explain the VSC as anything tangible are, of course, thwarted by the complete lack of evidential proof of its existence. Attempts to explain further flounder in a sea of self-referential gobbledegook.

The GCC have been very cagey about exactly what chiropractic is and isn’t. They changed their guidance on the VSC a few months ago and modified it after pressure from chiropractors. The pressure group (the AUKC) had another meeting with the GCC earlier this week and it remains to be seen what further concessions they have managed to squeeze out of the GCC after their Council meeting yesterday.

In their October newsletter (cached), the AUKC say:

It was also agreed at this meeting [with the GCC on 17 August 2010] that the term Subluxation would again be included in the “Frequently Asked Questions” (FAQs) – A definition will be discussed and agreed at the next Communications Advisory Group meeting on 10th December 2010

Why does it take so long for chiropractors to agree on a definition? Perhaps they are just having trouble dumbing it down enough for us non-chiropractors?

Manipulated

But this is not just a UK problem. A recent study by Jann Bellamy (Legislative alchemy: the US state chiropractic practice acts) found 50 different definitions of chiropractic in the 50 US States: in 21 States, there was direct reference to a subluxation or similar; 23 States talked about ‘malpositioned vertebrae’ that interfere with nerve ‘flow’, with the final six simply referring to what is taught at a chiropractic training establishment (but who all teach as if the VSC was real).

Bellamy has this to say about spinal manipulation:

As with the word ‘subluxation’, the term ‘spinal manipulation’ is a source of confusion. Spinal manipulation is a form of manual therapy practised by chiropractors, physical therapists, osteopaths and medical doctors specialising in physiatry. Many different techniques are used in spinal manipulation, but in general it includes the application of varying amounts of force to the spine so that the selected joint is moved beyond its restricted range of movement.21 To physical therapists and medical doctors, the exclusive purpose of spinal manipulation is to reduce pain, increase joint range of motion, and address other physical manifestations of joint impairment.21,22 Osteopaths use the term more broadly, but also employ spinal manipulation for these purposes, as do chiropractors.21 However, there is one important distinction: chiropractors also believe spinal manipulation can be used to reduce the chiropractic subluxation thereby restoring ‘neural integrity.’23 Most chiropractors prefer the term ‘adjustment’ to ‘manipulation’ to distinguish this distinctive feature from other forms of spinal manipulation, but both appear in the literature and are used interchangeably.

To my mind, this simply smacks of chiropractors struggling to find and hang on to their USP — the one that allows them to appear to be a unique ‘primary healthcare profession‘. They may do other things as well (and some are no doubt of benefit to their customers — massage and being a listening ear to their woes, for example), but their USP is the chiropractic manipulation, made so by chiropractors themselves.

Acute Lower Back Pain

Back to Bronfort.

For non-specific LBP, Bronfort looked at five systematic reviews, covering some 70 RCTs. Bronfort found that:

…spinal manipulation was superior to sham intervention and similar in effect to other commonly used efficacious therapies such as usual care, exercise, or back school.

Which is what we knew already: it’s no better than other interventions.

In the evidence summary, Bronfort lists the evidence for acute LBP:

  • Moderate quality evidence that spinal manipulation/mobilization is an effective treatment option for acute LBP in adults [18,24].
  • Moderate evidence that adding spinal mobilization to medical care does not improve outcomes for acute LBP in adults [37].

The last one is the Hancock study, leaving just references 18 and 24:

Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. (Full text)

Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. (Full text)

The first does talk about chiropractic and it covered 69 studies in 12 systematic reviews, but few of the studies were specifically concerned chiropractic manipulation and it also included the discredited UK BEAM trial.

The second was written with the help of Alan Breen, currently a member of the GCC Council and Professor of Musculoskeletal Health at the Anglo-European College of Chiropractic, and another chiropractor from Denmark.

Before looking at that study further, it’s worth repeating what Breen said about evidence in 2009:

To portray only part of the relevant information in a critique is itself pseudoscience, yet strong ontological commitment to only part of the knowledge base seems often to be the stance taken to contest the scientific basis of Chiropractic. Rather like psychiatry, debates about musculoskeletal practice need to go beyond positivist science and recognize that we have entered a more democratic and inclusive, post-normal age.

For a thorough analysis of this, see AP Gaylard’s blog post: In praise of chiropractic?

The European guidelines:

…also aim to inform the general public, patients with low back pain, health care providers (for example, general practitioners, physiotherapists, chiropractors, manual therapists, occupational physicians, orthopaedic surgeons, rheumatologists, rehabilitation physicians, neurologists, anaesthesiologists and other health care providers dealing with patients suffering from acute nonspecific low back pain)…

It tells us who might treat acute LBP:

Treatment for acute low back pain

Various health care providers may be involved in the treatment of acute low back pain in primary care. Although there may be some variations between European countries, general practitioners, physiotherapists, manual therapists,  chiropractors, exercise therapists…

However, that’s the last ever mention of chiropractic.

The guidelines gives recommendations for: Information and reassurance; Bed rest; Advice to stay active; Exercise therapy; Analgesia (paracetamol, nsaids, muscle relaxants); Epidural steroids, before finally getting round to ‘Spinal manipulation’.

The authors found six systematic reviews and one Cochrane review. They concluded that spinal manipulation, compared to placebo/sham, provided only short-term benefits, with no long-term benefits. Compared to other treatments:

Spinal manipulative treatment had no statistically or clinically significant advantage on pain and functional status over general practitioner care, analgesics, physical therapy, exercises, or back school.

But again, this is spinal manipulation, not chiropractic manipulation.

Double standards

Chiropractors can’t have it both ways: chiropractors can’t claim to be unique amongst the manual therapists because of their techniques, yet claim any evidence for their particular ‘art’ from the studies that were not about chiropractic manipulations. The GCC has made this perfectly clear.

So, the GCC can’t maintain that Hancock is irrelevant because it’s not about chiropractic manipulations, yet allow their prized Bronfort Report off the hook when it cites trials mainly not about chiropractic.

Once all those non-chiropractic manipulations have been removed from the Bronfort Report, what’s left?

Not a jot.

141 Responses to Where the evidence leads

  • > Once all those non-chiropractic manipulations have been removed
    * from the Bronfort Report, what’s left?

    Now that is the *really* important question…

  • Excellent work, Zeno.

    It’s interesting that you should mention the GCC’s Professor Alan Breen, and link to A P Gaylard’s blog post taking a close look at the validity of his assertions, because there seems to be a pattern in Professor Breen’s apparent failure to produce robust evidence in support of his claims. The following is the last paragraph of the authors’ reply to the responses to a 2006 systematic review of systematic reviews of spinal manipulation (Ernst E, Canter PH. A systematic review of systematic reviews of spinal manipulation. J R Soc Med2006; 99:192 -6):

    Quote
    “Several comments note that our conclusions are not in line with current guidelines. We also make this point in our article and suggest `… that these guideline be reconsidered in the light of the best available data’.1 Surely this is sensible? Yet Breen et al. categorically state `… there is enough evidence about manipulation in the back pain area’, providing no reference in support of this statement. One could therefore be forgiven for concluding that it is more the result of wishful thinking than of critical evaluation.”

    http://jrsm.rsmjournals.com/cgi/content/full/99/6/279

    Considering that Professor Breen is a very senior academic who holds responsible positions at the Anglo European College of Chiropractic (UK) and the University of Stavanger (Norway), one wonders what hope there is for the students whose educations he’ll be overseeing.

  • Zeno -a brilliant analysis. It shows how chiropractors are wriggling wildly as their the whole basis of their subject vanishes in to thin air. It might have taken a lot longer to sort this out without the help of the BCA’s lawsuit. No wonder they are desperate.

  • A great post, Zeno.

    I have always savored the irony that chiros claim to have unique skills, and then refer to manipulation done by others as proof of chiro efficacy. Then, they turn a blind eye to the evidence that they are responsible for most of the damage done by neck manipulation http://www.ptjournal.org/cgi/content/full/79/1/50 Bilateral vertebral artery dissection, followed by stroke, is chiropractics’ only unique contribution to “health.”

    If one merely looks at the Figures in Bronfort, it is possible to exclude 27 (32%) of the 85 treatments as not being done by chiropractors (mostly masseurs, osteopaths, and physical therapists). Then, when one looks at the treatments listed simply as manipulation, many more are eliminated as not being chiro (once again, osteos and PTs). Some that are chiro are found ineffective; and that is pretty harsh since the three negative studies of effectiveness of chiro for bed wetting (nocturnal enuresis) are reported as “Inconclusive, Favorable”!?

    Joe

  • This is a fantastic post. This deserves to go further: you should write to the GCC pointing out (in the first instance) the discrepancy in their handling of Hancock et al … and by extension the question of how they decided on which studies to include in the Bronfort.

    They’ll probably say something silly and weasel out of it. But it would be interesting to see what happens.

  • I notice that the Alliance for UK Chiropractors’ October 2010 newsletter states the following:

    On 17th August we met with the GCC council and presented a dossier on the Vertebral Subluxation Complex. After reviewing this document and discussions that followed at this meeting the GCC agreed that they would delete the phrase “…or health concerns” in the VSC guidance and provide an explanation why it had done so.

    http://tinyurl.com/36y3qwm

    However, I can’t seem to find the aforementioned explanation in the GCC’s new VSC guidance:
    http://tinyurl.com/3xvznvj

    Interestingly, Skeptic Barista looked at the same issue here http://tinyurl.com/355chd6 and here http://tinyurl.com/2uevgp7 and couldn’t track down a satisfactory explanation either.

    Perhaps it’s still to be published.

  • Very clever work, Zeno

  • Blue Wode: Oh dear. But not as silly as this from the end of the Newsletter:

    “Petition for a responsible approach to advertising. There are limitations of RCT’s, and good cohort studies should be acceptable evidence. A submission was made to the CAP Copy Team at the Advertising Standards Agency in April 2010 for a further 28 conditions not included in the Bronfort Report to be reviewed and accepted. We are still waiting for this documentation to be reviewed and assessed.”

  • @ Neuroskeptic

    Perhaps worst of all is that the Alliance of UK Chiropractors’ (AUKC) has apparently…

    …signed up to the ICA [International Chiropractors Association] best practices document that states best practice on x-ray is to x-ray every new patient – contravening IRMR guidelines.

    http://www.chiropracticlive.com/?p=688&cpage=1#comment-3099

    If that’s true, then it is scandalous, especially in view of the fact that in a recent meeting with the GCC’s Chief Executive, Margaret Coats, the Health and Safety Executive’s specialist inspectors explained that during visits to some x-ray units in UK chiropractic practices, concerns had been identified such as:

    lack of understanding of the role of the HSE and the powers of its inspectors

    poor standards of training in radiation protection

    failure to designate radiation-controlled areas

    poor quality assurance of x-ray equipment

    See page 2 here:
    http://www.gcc-uk.org/files/page_file/GCCNews28_WEBversion_March10.pdf

  • It seems a bit quiet around here, if I may say so. Are the usual detractors stunned into silence, do you think, or are they too busy shouting abuse at you in their comfy wee echo chamber?

  • We are all agreed that manipulation can be gentle (low velocity) or strong (high velocity).

    It doesn’t matter a fig whether its carried out by a GP, osteopath, physiotherapist or chiropractor.

    It’s either done appropriately and safely OR inappropriately and dangerously.

    At the risk of stating the obvious, whether it needs to be done at all depends on the outcome of clinical trials.

    A clinical trial aimed at comparing low velocity manipulation with high velocity manipulation (and hopefully a control group) might be worth considering (if one hasn’t already been done).

    However, the ‘chiropractic factor’ is irrelevant. It doesn’t matter what they call manipulation or why they do it – it is at the end of the day manipulation, either done appropriately and safely OR inappropriately and dangerously

  • @ malucachu

    Please note that “low velocity” manipulation does not equate to “gentle”, and that “high velocity” manipulation does not equate to “strong”.

    One of the arch principles of the chiropractic adjustment is that it may be high velocity, but that it is not necessarily forceful and is deliberately low amplitude. This is one of the many misconceptions surrounding chiropractic, that the speed of the adjustment suggests a violent and deep manipulation.

    The truth is, in fact, very much the reverse. A well-delivered chiropractic adjustment is fast, low-force and stays well within the anatomical limits of joint movement.

    It is the speed that makes it so effective and the low force/shallow depth that makes it safe.

    The appropriateness is then a matter of clinical judgement.

  • @David

    “The appropriateness is then a matter of clinical judgement.”

    Based upon good evidence, one would hope!

  • David said:

    A well-delivered chiropractic adjustment is fast, low-force and stays well within the anatomical limits of joint movement.

    It is the speed that makes it so effective and the low force/shallow depth that makes it safe.

    What is the difference between a force applied to a vertebra at high speed and one applied at low speed?

  • Zeno,

    I’m not going to get into the whole physiology of the adjustment, but essentially the higher speed allows for the use of less force. It also has a different effect on the nerve receptors in the musculo-tendinous structures associated with the joint, altering the bias between stimulation of the muscle spindle fibres and the golgi tendon organs.

  • David said:

    …the higher speed allows for the use of less force.

    Do high and low speed adjustments move a vertebra by the same distance?

  • Zeno,

    As I say, I’m not going to get into a long debate over this but, there are a couple of important points to bear in mind.

    The postion of a vertebra after an adjustment is the same as it was before. The intention is not to alter position but to alter function.

    The amount of movement that a joint undergoes during a manipulation is variable upon many factors, but mostly the depth of the thrust, not the speed.

  • So, a force is applied to one or more vertebrae: you say their final positions are the same as their initial positions. You say that the distance moved is not related to the speed of the force applied, so what’s the reason for the speed? Is faster better? If so, why?

  • We’ll assume all patients give informed consent before any procedures are undertaken.

    That said, low velocity/high amplitude techniques are generally repetitive and allow the patient to say stop at any time. With high velocity/low amplitude manipulation the patient forfeits this control.

    That doesn’t make the latter technique inappropriate, but is worth taking into account.

    But as I said earlier, call it a chiropractic adjustment if you will, but a high velocity/low amplitude manipulation is simply a manipulation which can be carried out by a variety of clinicians, not just chiropractors.

  • @zeno

    I believe it is to do with muscle resistance. With high velocity/low amplitude manipulation you over come local muscle resistance, thus having a better effect on joint movement.

    Again this does not imply inappropriateness per se.

    All manipulation techniques (low or high velocity) are a major ‘no-no’ for patients with osteoporosis or rheumatoid arthritis as well as other diseases that affect the integrity of joint structures.

    However, the danger with high velocity neck manipulation is that to overcome muscle resistance the neck is pushed into a position that can kink the basilar-vertebral arteries in healthy individuals. Damage to these can can cause stroke or death.

  • malucachu wrote:

    “…as I said earlier, call it a chiropractic adjustment if you will, but a high velocity/low amplitude manipulation is simply a manipulation which can be carried out by a variety of clinicians, not just chiropractors.”

    That appears to be true. Indeed, the Hancock study, which Zeno’s post so comprehensively informs us above was damned by the GCC and the BCA, made the following comment:

    The spinal manipulative therapy given in this trial included a range of low-velocity mobilisation and high velocity manipulation techniques done by physiotherapists with postgraduate training in manipulative therapy. A systematic review of spinal manipulation concluded that there is no evidence that high-velocity spinal manipulation is more effective than low-velocity spinal mobilisation, or that the profession of the manipulator affects the effectiveness of treatment. [20]

    http://www.acatoday.org/pdf/Lancet_Acute_Back_Pain_Nov.07.pdf

    Ref. [20] van Tulder MW, Scholten RJ, Koes BW, Deyo RA. Nonsteroidal anti-infl ammatory drugs for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000; 25: 2501–13.
    http://www.ncbi.nlm.nih.gov/pubmed/10796356

  • @Blue Wode

    Chiropractors might argue that the techniques described in the study were less effective because they were carried out by physiotherapists and not chiropractors. The argument will be over length of training (4 years as opposed to 3), under-graduate emphasis on manipulation skills, etc.

    I would counter argue that the three year course physiotherapists undertake is more grounded in orthodox medicine. We also have student placements where we actually see patients with a wide range of conditions in a variety of clinical settings as opposed to simply learning the theory.

    Manipulation is also taught separately in physiotherapy at post-graduate level. In my case this was a year.

  • malucachu wrote:

    Chiropractors might argue that the techniques described in the study were less effective because they were carried out by physiotherapists and not chiropractors. The argument will be over length of training (4 years as opposed to 3), under-graduate emphasis on manipulation skills, etc.
    I would counter argue that the three year course physiotherapists undertake is more grounded in orthodox medicine.

    Indeed. And that alone would suggest that physiotherapists will be far more judicial in their use of manipulation than chiropractors. In other words, many chiropractors will use the ‘bait and switch’ tactic to recruit unwitting patients before proceeding to apply an assortment of manipulations (‘adjustments’) unethically – i.e. based on vitalistic principles. See here:
    http://www.dcscience.net/?p=1516

  • I suppose if you are a hammer, everything you see will be a nail. That’s the big limitation with chiropractic as opposed to physiotherapy or osteopathy (the latter being more diverse than chiropractic).

    That said, osteopaths and physiotherapists have come up with some bizarre theories of their own on many occasions. Many of their treatment techniques (manipulation or otherwise) have brand names – nearly always named after the inventor – and which are not always orthodox.

    Indeed many physiotherapists and osteopaths practice TCM acupuncture.

    Physiotherapy and osteopathy works best when basic science is respected.

  • @ malucachu

    I find some of your comments quite interesting. I’m always interested to learn about the training, skills and methods of other healthcare professionals, but I try not to make judgements without having all the relevant information to hand.

    I’m afraid that your statements about chiropractic are ill-informed, both in respect of the training and practice. The training that students receive, certainly at AECC and WIOC, is entirely appropriate for the management of the patients that they will see in practice and the final year is spent mostly in the clinical situation.

    You give the impression that the only tool available to chiropractors is manipulation. That is far from the case; there are no tools available to the physiotherapist that are not available to the chiropractor.

    It is true that the high velocity/low amplitude thrust is not the preserve of chiropractors. However, it is chiropractors who have traditionally put it to best effect and it is this success that has led some members of other professions to adopt it.

    I would have to disagree with you on a couple of points regarding the HVLA manipulation. Firstly, you have stated that it “overcomes” the muscle resistence. This is not true. The principle behind the HVLA is that it AVOIDS the muscle resistence and it is largely this that allows for the use of less force.

    You make a point about the patient “forfeiting” control. If I am adjusting a patient, I take the affected joint to its end range of movement to ensure that it is comfortable. Provided that it is comfortable in that position, the adjustment will also be comfortable. The patient has control throughout.

    As has been argued ad nauseam, there is no evidence that a high velocity manipulation carries any greater risk for the vertebro-basilar arteries than a low-velocity one. Your statement is opinion only.

    You have also stated that “All manipulation techniques (low or high velocity) are a major ‘no-no’ for patients with osteoporosis or rheumatoid arthritis…”

    This is not true either. They are important matters to consider when choosing what techniques to use and when, but they are not absolute contraindications. But it does rather depend on the level of skill and understanding possessed by the practitioner. I have many patients with osteoporosis and several with rheumatiod arthritis. They can still be safely and successfuly treated.

    Of course, one should remember that chiropractors are very aware of the features in a patient’s history and medical status that need to be taken into account before deciding what is the most approriate treatment to offer. This is why the minimum of four years training is necessary, and what makes chiropractic a safe and effective option for virtually all patients.

  • I would just like to remind readers that a thorough evaluation of the scientific evidence for ‘chiropractic’ in 2008 concluded the following…

    This treatment carries the risk of stroke or death if spinal manipulation is applied to the neck. Elsewhere on the spine, chiropractic therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions, chiropractic therapy is ineffective except that it might act as a placebo.

    Ref. p.285 ‘Trick or Treatment? Alternative Medicine on Trial’, by Simon Singh and Edzard Ernst.

    However, it would appear that that evaluation was somewhat generous in its findings as it was conducted before Zeno’s excellent investigative work which resulted in his blog post above – and which, let’s not forget, leaves the reader with the following sobering conclusion:

    Chiropractors can’t have it both ways: chiropractors can’t claim to be unique amongst the manual therapists because of their techniques, yet claim any evidence for their particular ‘art’ from the studies that were not about chiropractic manipulations. The GCC has made this perfectly clear.

    So, the GCC can’t maintain that Hancock is irrelevant because it’s not about chiropractic manipulations, yet allow their prized Bronfort Report off the hook when it cites trials mainly not about chiropractic.

    Once all those non-chiropractic manipulations have been removed from the Bronfort Report, what’s left?

    Not a jot.

    David, do you agree with Zeno’s conclusion?

  • @Zeno

    You ask, “Do high and low speed adjustments move a vertebra by the same distance?” My guess would be that the high velocity thump is carried out with a small, err, thumping device, and the low velocity thump is with a large thumping device. Thus the energy of the thump remains constant. So the thing being thumped moves the same distance irrespective of whether it’s low or high velocity?

    @david

    You say that, “The postion of a vertebra after an adjustment is the same as it was before. The intention is not to alter position but to alter function.” So does that mean a chiropractor would not be able to tell from an x-ray whether or not a patient has been treated by a chiropractor? OR had a lengthy course of treatment? And is function detectable from static x-ray?

  • “I’m afraid that your statements about chiropractic are ill-informed, both in respect of the training and practice. The training that students receive, certainly at AECC and WIOC, is entirely appropriate for the management of the patients that they will see in practice and the final year is spent mostly in the clinical situation”.

    I don’t buy that.

    “You give the impression that the only tool available to chiropractors is manipulation. That is far from the case; there are no tools available to the physiotherapist that are not available to the chiropractor.”

    Yes, OK. That said, manipulation is a component big of chiropractic.

    “It is true that the high velocity/low amplitude thrust is not the preserve of chiropractors. However, it is chiropractors who have traditionally put it to best effect and it is this success that has led some members of other professions to adopt it.”

    Prove it.

    “I would have to disagree with you on a couple of points regarding the HVLA manipulation. Firstly, you have stated that it “overcomes” the muscle resistence. This is not true. The principle behind the HVLA is that it AVOIDS the muscle resistence and it is largely this that allows for the use of less force.”

    Fair point. I accept this.

    “You make a point about the patient “forfeiting” control. If I am adjusting a patient, I take the affected joint to its end range of movement to ensure that it is comfortable. Provided that it is comfortable in that position, the adjustment will also be comfortable. The patient has control throughout.”

    You are missing my point.

    “As has been argued ad nauseam, there is no evidence that a high velocity manipulation carries any greater risk for the vertebro-basilar arteries than a low-velocity one. Your statement is opinion only.”

    No. It is backed up by studies.

    “You have also stated that “All manipulation techniques (low or high velocity) are a major ‘no-no’ for patients with osteoporosis or rheumatoid arthritis…” This is not true either. They are important matters to consider when choosing what techniques to use and when, but they are not absolute contraindications. But it does rather depend on the level of skill and understanding possessed by the practitioner. I have many patients with osteoporosis and several with rheumatiod arthritis. They can still be safely and successfuly treated.”

    This statement worries me.

    “Of course, one should remember that chiropractors are very aware of the features in a patient’s history and medical status that need to be taken into account before deciding what is the most approriate treatment to offer. This is why the minimum of four years training is necessary, and what makes chiropractic a safe and effective option for virtually all patients”

    So you have a monopoly on this?

  • Hello,

    I think the interesting point about the current blog entry is that three newspapers take a study that is done by physiotherapists using manipulation/mobilisation and come up with the headlines they did. It would seem more logical to say that mobilisation/manipulation done by physio, osteo or chiro “is a waste of money”
    Having said that i think the BCA made a poor choice by arguing that the technique is key to the results of the study and to chiropractic. All Manual therapists should use a variety of techniques because each patient is different.

  • A N Other wrote:

    I think the interesting point about the current blog entry is that three newspapers take a study that is done by physiotherapists using manipulation/mobilisation and come up with the headlines they did.

    Perhaps that’s because the journalists appreciated that most manipulation is carried out by chiropractors:

    Spinal manipulation or adjustment is a manual treatment where a vertebral joint is passively moved between the normal range of motion and the limits of its normal integrity, though a universally accepted definition does not seem to exist. It is occasionally used by osteopaths, physiotherapists and physicians, and it is the hallmark treatment of chiropractors. Practically all chiropractors use spinal manipulation regularly to treat low back and other musculoskeletal pain. It often involves a high velocity thrust…

    http://jrsm.rsmjournals.com/cgi/content/full/100/7/330

  • @ Blue Wode

    But the study was mobilisation and manipulation, which is done by all manual therapists.

  • A N Other wrote:

    But the study was mobilisation and manipulation, which is done by all manual therapists

    …which is *occasionally* used by osteopaths, physiotherapists and physicians, but is the hallmark treatment of chiropractors.

    Hallmark = distinctive feature.

  • @ Blue Wode

    Management of Nonspecific Low Back Pain by Physiotherapists in Britain and Ireland: A Descriptive Questionnaire of Current Clinical Practice
    Foster, Nadine E. BSc(Hons), DPhil, MCSP*; Thompson, Kate A. MSc†; Baxter, G. David TD, BSc(Hons), DPhil, MCSP‡; Allen, James M. BSc, PhD, CBiol, FIBiol‡

    “Analysis of the results indicated the overall popularity of the Maitland mobilization and McKenzie approaches among physiotherapists”

  • @ A N Other

    The title of the Hancock study (the subject of Zeno’s post):

    Assessment of diclofenac or spinal manipulative therapy, or
    both, in addition to recommended first-line treatment for
    acute low back pain: a randomised controlled trial

    And once again…

    Spinal manipulation or adjustment is a manual treatment where a vertebral joint is passively moved between the normal range of motion and the limits of its normal integrity, though a universally accepted definition does not seem to exist. It is occasionally used by osteopaths, physiotherapists and physicians, and it is the hallmark treatment of chiropractors. Practically all chiropractors use spinal manipulation regularly to treat low back and other musculoskeletal pain. It often involves a high velocity thrust…

    http://jrsm.rsmjournals.com/cgi/content/full/100/7/330

    BTW, based on the GCC and BCA’s assertions about the Hancock study, presumably if the study’s findings had been wholly in favour of spinal manipulation, both organisaitons would have had to dismiss it on the basis that it wasn’t measuring the effectiveness of chiropractors. Is that correct?

  • @ Blue Wode

    The type of spinal manipulative therapy included mobilisation and manipulation. Hence, representative of all manual therapists ie physios, osteo and chiros. So even if the title of the study says manipulative, the techniques used in the study included mobilisation and manipulation. Once again this study represents technique used by all professions and in the case of mobilisation used by all professions to be commonly associated with them. Therefore the headlines by the papers were poor due to the fact that the techniques used are common to a wide variety of professions. In essence it is lazy journalism that lead to the headlines.

    In response to your second comment, the GCC were stating “The research study did not conclude that chiropractors are a waste of time and money, or of no use in treating back pain, as reported. Chiropractors were not mentioned in the research study at all. The purpose of the study was not to measure the effectiveness, or otherwise, of chiropractors or a single manipulative technique used by chiropractors, physiotherapists, osteopaths and others”. So if the study was in favour of the techniques used the GCC would be able to accept it because it could be a technique done by chiropractors.
    However the BCA made the flaw, as i stated before, that they tried to distance themselves from the study by defining chiropractic as high velocity techniques (minimally used in this study). So, if the study was in favour, they would have to dismiss it because of the limitation they imposed on themselves

  • A N Other wrote:

    …the headlines by the papers were poor due to the fact that the techniques used are common to a wide variety of professions.

    That might be, however the techniques are *far more* common to chiropractic so there was a lot of truth in the headlines. In essence, the journalists put two and two together and correctly came up with four.

    A N Other wrote:

    …if the study was in favour of the techniques used the GCC would be able to accept it because it could be a technique done by chiropractors.

    Yes, it *could* be a technique done by chiropractors, but the GCC seems to be wrong in thinking that it is. One only has to look at the claim made by the BCA (the respectable face of the UK chiropractic profession representing more than 50% of UK chiropractors):

    No direct comparison can be made from the results of the aforementioned study and the treatment offered by BCA chiropractors for a number of reasons:

    • The study did not address chiropractic only spinal mobilisation carried out by physiotherapists. The majority of participants had low-velocity mobilisation techniques and only 5% experienced high velocity techniques. Chiropractic manipulation is based predominantly on high velocity techniques, sothe results are therefore not comparable with chiropractic treatment.

    http://tinyurl.com/38nrk2w

    As for the remainder of UK chiropractors, the vast majority of them, as we already know, base their practices on outdated principles.

    So, not matter which way chiropractors try to twist it, the media reporting of the Hancock study was correct due to the journalists’ understanding of the *amount* of spinal manipulative therapy used by chiropractors. Further, now that chiropractors have made it abundantly clear that the study had nothing to do with chiropractic, it renders much of the Bronfort Report’s content obsolete.

  • Related to my comment about the BCA above, I think readers should be made aware that the chiropractor, David, who is contributing to the comments here, recently made the following assertion about chiropractic on Skeptic Barista’s blog:

    It should be remembered that a manipulation is a “chiropractic manipulation”, or more properly a “chiropractic adjustment”, only when it is performed by a fully qualified chiropractor. Otherwise it is only a manipulation and should not be confused with chiropractic.

    http://tinyurl.com/3ywmjzk

  • One more point.

    With regard to the Hancock study, the GCC wrote:

    The GCC is concerned that such reporting is irresponsible and does not serve the public interest…[it] ultimately undermines the public’s trust in the accuracy and utility of scientific research.

    http://www.freezepage.com/1290012762YQHNINKPOG

    One wonders how the GCC is going to manage to accurately report information about the chiropractic ‘subluxation’ when it is re-published on its FAQs page following a meeting with its Communications Advisory Group on 10th December 2010. For example, here’s what Skeptic Barista recently had to say on the subject:

    This post is an update on my earlier discussions with the General Chiropractic Council on the subject of the evidence to support various claims surrounding the Chiropractic Vertebral Subluxation Complex (VSC)…This resulted in the GCC issuing some guidance to its members. To say this new guidance was unpopular with chiropractors would be something of an understatement…An organisation calling itself the Alliance of UK Chiropractors (AUKC) was formed and they proceeded to put pressure on the GCC to reinstate their beloved subluxation…Eventually the GCC gave way and issued an amendment to their guidance…The GCC’s original statement was that there was no evidence to support subluxation claims, yet after this meeting they changed the guidance. If they are going to allow subluxations to be linked to health concerns, then surely they must now have some evidence…on 27 Aug I wrote to the GCC asking if they could explain the reasoning behind changing the guidance and asked if they now had any evidence. My personal view was that these changes had more to do with chiropractic politics than actual evidence…

    http://tinyurl.com/2uevgp7

  • @ Blue Wode,

    The headlines give a biased skew to the evidence because mobilisation is a common technique to all the professions, so to single out one from this study is poor journalism ie mis-representing the evidence that is out there in journals ie a majority of physio use mobilisation and the same for osteopaths.

  • @ A N Other

    I disagree, but who’s correct about the media reporting of the Hancock study is really irrelevant now that it is on record that at least half of all UK chiropractors won’t accept study results unless they *specifically* involve techniques used by chiropractors – and the vast majority of the remainder of UK chiropractors, as we know, cannot be taken seriously whilst their heads are stuck firmly in the vitalistic sand.

  • I think it comes back to the definition ‘manipulation’.

    I have always used the word as an umbrella term for any passive manual technique, be it a ‘low velocity mobilisation’ or a ‘high velocity manipulation’.

    I think is fair to say that physiotherapists tend to favour low velocity mobilisation, whilst chiropractors favour high velocity manipulations. However neither technique is the preserve of any one particular progression, even if each generally tends to favour one technique over another.

    The quote above:

    It should be remembered that a manipulation is a “chiropractic manipulation”, or more properly a “chiropractic adjustment”, only when it is performed by a fully qualified chiropractor. Otherwise it is only a manipulation and should not be confused with chiropractic.

    is quite frankly nonsense to me.

    In some US states chiropractors have sought legislation to bar physiotherapists from practising high velocity manipulations using the argument above.

  • RE: above. That should say profession not progression.

  • @ Blue Wode,

    It is on record that a representative of an organisation the represents more or less than half of chiropractors won’t accept the study unless they specifically involve techniques used by chiropractors. That is different to half of all chiropractors won’t accept study results unless they *specifically* involve techniques used by chiropractors. The only way you can find that out is by surveying the whole profession on whether the Hancock et al study uses techniques used by chiropractors.
    As i previously stated it was a flaw for that representative to make the statement that he did because he undermines himself and the profession which he represents.
    Also it is important how the media reports the Hancock et al study, because it can lead to mis-information, which is something the Bad Science Blog complains about ie poor interpretation of scientific studies

    Finally i am interested in what you understand as vitalistic, please elaborate.

  • Andrew Gilbey said:

    @david

    You say that, “The postion of a vertebra after an adjustment is the same as it was before. The intention is not to alter position but to alter function.” So does that mean a chiropractor would not be able to tell from an x-ray whether or not a patient has been treated by a chiropractor? OR had a lengthy course of treatment? And is function detectable from static x-ray?

    Popcorn Smiley

  • @ Andrew Gilbey

    You say that, “The postion of a vertebra after an adjustment is the same as it was before. The intention is not to alter position but to alter function.” So does that mean a chiropractor would not be able to tell from an x-ray whether or not a patient has been treated by a chiropractor? OR had a lengthy course of treatment? And is function detectable from static x-ray?

    No is the answer to all the questions

  • A lumbar x-rays is 120 x the radiation dose of a chest x-ray. It should only be used to exclude trauma (fractures) or in patients at hugh risk of space occupying lesions, infection, cancer and /or seronegative/seropositive arthropathies.

    To use x-rays to look for chiropractic subluxations is like using a torch for looking for fairies at the bottom of the garden, only far more dangerous.

    To be fair, many chiropractors dismiss the subluxation theory.

  • A N Other wrote:

    It is on record that a representative of an organisation the represents more or less than half of chiropractors won’t accept the study unless they specifically involve techniques used by chiropractors. That is different to half of all chiropractors won’t accept study results unless they *specifically* involve techniques used by chiropractors. The only way you can find that out is by surveying the whole profession on whether the Hancock et al study uses techniques used by chiropractors.

    As i previously stated it was a flaw for that representative to make the statement that he did because he undermines himself and the profession which he represents.

    Sorry, not buying that. If it was a flaw/mistake, where has it been publicly rectified? Pages 6 and 7 of the GCC’s March 2008 newsletter certainly don’t even hint at it being a flaw:
    http://www.gcc-uk.org/files/page_file/WEBSITE_GCCNews23.pdf

    A N Other wrote:

    Also it is important how the media reports the Hancock et al study, because it can lead to mis-information, which is something the Bad Science Blog complains about ie poor interpretation of scientific studies

    Indeed. So perhaps the media’s targeting of chiropractors was a reflection of their journalists’ view that since so much of chiropractic is mired in quackery, what’s the point in anyone going to see a chiropractor when the evidence for spinal manipulative therapy administered by (apparently more trustworthy) physiotherapists is so dire.

    A N Other wrote:

    Finally i am interested in what you understand as vitalistic, please elaborate.

    The concept that the functions of an organism are due to a “vital principle” or “life force” distinct from the physical forces explainable by the laws of physics and chemistry. Chiropractors refer to that force as “Innate Intelligence”. For readers who may be unaware, it is a concept that is, apparently, fundamental to the Alliance of UK Chiropractors’ vision:

    VISION

    To create a vitalistic, Chiropractic model of health and well-being for families in the UK by providing the distinct elements offered by Chiropractic as a healthcare profession predicated upon its philosophy, science and art.

    http://www.chiropracticlive.com/?p=842

  • malucachu wrote:

    To be fair, many chiropractors dismiss the subluxation theory

    Not it the UK, they don’t:

    Data collection was achieved via a descriptive oneshot
    questionnaire sent to a randomly selected sample of GCC registered chiropractors within the UK….Traditional chiropractic beliefs (chiropractic philosophy) were deemed important by 76% of the respondents and 63% considered subluxation to be central to chiropractic intervention.

    http://tinyurl.com/599vfs

  • @Blue Wode

    Quote: ….when the evidence for spinal manipulative therapy administered by (apparently more trustworthy) physiotherapists is so dire.

    Again, chiropractors might argue that physios are not as skilled in any type of manipulation/mobilisations compared with chiros.

    But then maybe manipulations/mobilisations are simply not what they are cracked up to be (regardless who performs them).

  • @ Blue Wode

    It is a shame that the journalists come from a biased point of view.

    “what’s the point in anyone going to see a chiropractor when the evidence for spinal manipulative therapy administered by (apparently more trustworthy) physiotherapists is so dire”

    So from the above statement are you saying spinal manipulative therapy (Manipulation/mobilisation) performed by physiotherapist has poor evidence? If so, then physios (possibly a majority of them) are doing a technique that is not evidence based in your view.

    Any response from malucachu, who i think suggested he was a physiotherapist.

  • This is my last post on this.

    malucachu said:

    The quote above:

    “It should be remembered that a manipulation is a “chiropractic manipulation”, or more properly a “chiropractic adjustment”, only when it is performed by a fully qualified chiropractor. Otherwise it is only a manipulation and should not be confused with chiropractic.”
    is quite frankly nonsense to me.

    The point is that it is incorrect to refer to a manipulation as a “chiropractic manipulation” unless it is performed by a chiropractor. Otherwise, it should be referred to simply as a manipulation. If the technique is genuinely of the style that is used by chiropractors, then it might be described as a chiropractic “style” manipulation, but not as a chiropractic manipulation.

    It’s a bit like the difference between sparklimg wine and champagne. Champagne is a sparkling wine but not all sparkling wine is champagne and the term should be reserved for only the genuine article.

    It is, of course, an offence for a practitioner to describe what they offer as chiropractic without them being a chiropractor, in the same way that a doctor of chiropractic would be committing an offence if they were to be representing themselves as a medical doctor.

    Andrew Gilbey wrote:

    @david

    You say that, “The postion of a vertebra after an adjustment is the same as it was before. The intention is not to alter position but to alter function.” So does that mean a chiropractor would not be able to tell from an x-ray whether or not a patient has been treated by a chiropractor? OR had a lengthy course of treatment? And is function detectable from static x-ray?

    In response to the first question, yes, it does.
    In response to the second question: Probably, although it would rather depend on what the patient’s problems were. If there were “before and after” x-rays for comparison (for which there is no justifiacation), changes may well be visible but there is of course no way of telling from an x-ray what has caused those changes.
    In response to the third question: Yes, clues about function can be gained from x-rays and it can be a very useful tool in assessing joint function.

    I will consider Blue Wode’s points when Blue Wode gets round to telling us whether his/her previous misrepresentation of research evidence was intentional or unintentional. Given the apparent certainty of his/her assertions, I feel we are entitled to know what lies behind the erroneous ones that he/she makes.

  • malucachu wrote:

    Again, chiropractors might argue that physios are not as skilled in any type of manipulation/mobilisations compared with chiros.

    But then maybe manipulations/mobilisations are simply not what they are cracked up to be (regardless who performs them).

    I think your last comment may be what manual therapists are going to have to face up to eventually, especially if Professor Edzard Ernst’s evaluation of the 2004 United Kingdom back pain exercise and manipulation (UK BEAM) trial is anything to go by:

    “Three brief comments on the excellent BEAM Trial.

    My reading of the results is that the data are compatible with a non-specific effect caused by touch: exercise has a significantly positive effect on back pain which can be enhanced by touch. If this “devil’s advocate” view is correct, the effects have little to do with spinal manipulation per se.

    It would be relevant to know which of the three professional groups (chiropractors, osteopaths, physiotherapists) generated the largest effect size. This might significantly influence the referral pattern. A post-hoc analysis might answer this question.

    It is regrettable that the study only monitored serious adverse effects. There is compelling data to demonstrate that minor adverse effects occur in about 50% of patients after spinal manipulation. If that is the case, such adverse events might also influence GP’s referrals.”

    http://tinyurl.com/3ydmp6j

    Where spinal manipulative therapy is indicated as a last resort, then physiotherapists are probably the best bet to perform it, at least in the UK where most work within the NHS in salaried positions and are therefore far less likely to experience the…

    “excessive financial burden which may influence individual practice style and ethical behaviour following graduation”

    http://www.ecupresident.org/2010/09/what-will-it-take-to-gain-acceptance.html

    …something which many chiropractors are apparently faced with as they enter private practice and which appears to result in their patients (unwittingly) becoming ensnared by quackery.

  • A N Other wrote:

    you saying spinal manipulative therapy (Manipulation/mobilisation) performed by physiotherapist has poor evidence? If so, then physios (possibly a majority of them) are doing a technique that is not evidence based in your view.

    I suspect that may well turn out to be the case. See the answer I gave to malucachu above.

  • David wrote:

    I will consider Blue Wode’s points when Blue Wode gets round to telling us whether his/her previous misrepresentation of research evidence was intentional or unintentional. Given the apparent certainty of his/her assertions, I feel we are entitled to know what lies behind the erroneous ones that he/she makes.

    As you are prefectly well aware, that was addressed in post #61 here (and further embellished in the comments before and after it):
    http://skepticbarista.wordpress.com/2010/10/24/subluxations-who-said-what/comment-page-2/#comment-891

  • @ Blue Wode,

    It is a shame that Prof. Ernst seems to be out of touch with a chochrane review in relation to exercise for low back pain:

    Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group.

    van Tulder M, Malmivaara A, Esmail R, Koes B.

    The conclusion was “the evidence summarized in this systematic review does not indicate that specific exercises are effective for the treatment of acute low back pain. Exercises may be helpful for patients with chronic low back pain to increase return to normal daily activities and work.”

    This seems to be equivalent to mobilisation / manipulation. So his “devils advocate” is poor.

    In relation to adverse events the same study noted this:

    “A small number of studies reported on the presence or absence of
    adverse events (16 studies, 26%). Twelve studies reported mild
    negative reactions to the exercise program, such as increased lowback pain and muscle soreness, in a minority of patients. Due to limitations of reporting, it was not possible to assess the treatment benefit to harm ratio.”

    As i explained before to you on another blog there is research for each of these techniques (exercise, manipulation and mobilisation etc.) but they have to be applied to the right sort of patient groups that exist within non-specific low back pain.

  • A N Other wrote:

    …there is research for each of these techniques (exercise, manipulation and mobilisation etc.) but they have to be applied to the right sort of patient groups that exist within non-specific low back pain.

    And before chiropractors are allowed anywhere near patients in such instances, they should be made to sort out this major problem first:

    The risk of mild to moderate adverse effects is undisputed even by chiropractors: about 50% (!) of all patients suffer from such adverse effect after spinal manipulations. These effects (mostly local or referred pain) are usually gone after 1-2 days but, considering the very moderate benefit, they might already be enough to tilt the risk-benefit balance in the wrong direction.
    In addition, several hundred (I estimate 700) cases are on record of dramatic complications after spinal manipulation. Most frequently they are because of vertebral arterial dissection. Considering these adverse events, the risk-benefit balance would almost certainly fail to be positive. It is true, however, that the evidence as to a causal relationship is not entirely uniform. Yet applying the cautionary principle, one ought to err on the safe side and view these complications at least as possibly caused by spinal manipulations.
    So why were these risks not considered more seriously? The guideline gives the following reason: ‘The review focused on evidence relevant to the treatment of low back pain, hence cervical manipulation was outside our inclusion criteria’. It is true that serious complications occur mostly (not exclusively) after upper spinal manipulation. So the guideline authors felt that they could be excluded. This assumes that a patient with lower back pain will not receive manipulations of the upper spine. This is clearly not always the case.
    Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them. And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.”

    Ref: Ernst, E. Spinal manipulation for the early management of persistent non-specific low back pain: A critique of the recent NICE guidelines. Int J Clin Prac, Vol 63, No10, Oct 2009, pp.1419-1420.

  • @ Blue Wode

    What about the rest of my post?

  • @ A N Other

    OK, then. Discount spinal manipulation/mobilisation, NSAIDs, and/or exercise, and what are you left with?

    The Hancock study:

    Australian researchers found that neither spinal manipulation or the drug diclofenac hastened recovery of acute low-back pain patients who had been properly counseled by their primary physician and prescribed paracetamol for pain relief. The study involved 240 patients who received either (a) diclofenac plus spinal manipulation, (b) diclofenac and sham spinal manipulation, (c) spinal manipulation and a placebo pill, or (d) sham manipulation plus a placebo pill. About half recovered within two weeks and nearly all recovered within three months.
    [Hancock MJ and others. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomized controlled trial. Lancet 370:1638-1643, 2007]

    Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID). Paracetamol is a pain-reliever marketed in the United States as acetominophen or Tylenol. An accompanying editorial noted:

    • Systematic reviews had concluded that NSAIDS and spinal manipulation were more effective than placebos. However, the patients in the reviewed studies did not have optimum first-line care, and the apparent benefit was not large.

    • Advice to remain active and prescription of paracetamol will be sufficient for most patients with acute low back pain. [Koes BW. Evidence-based management of acute low back pain. Lancet 370:1595-1596, 2007]

    Not much room for any type of manual therapy, is there?

  • @ Blue Wode,

    Well there is room for manual therapy, but you will have to look for the research. As i explained to you before this topic is much more complex that you have tried to portray. The identification of sub-groups within non speciifc low back pain has begun and research has been published. These show that for certain “types” of low back pain will respond best to particular types of treatment.
    So the advice of the study you quoted is limited to treating a symptom (back pain) and trying to limit deconditioning by advising the patient to remain active, as well as limiting psycho-social factors . It is not addressing the underlying cause, but should be viewed as part of a process.

    It is a shame that you have gone from supporting manual therapies (physio) to now saying that “Not much room for any type of manual therapy”.

  • A. N. Other wrote:

    The identification of sub-groups within non speciifc low back pain has begun and research has been published. These show that for certain “types” of low back pain will respond best to particular types of treatment.

    Until the scientific data are in, I will remain unimpressed by manual therapists who charge their patients fees *as if* good evidence already exists – especially where the current risk/benefit profile of their treatment indicates that it is not recommendable (e.g. most aspects of chiropractic).

  • @ Blue wode,

    That scientific data is already in. You need to find it. Also the risk / benefit profile would change because if the form of treatment is appropriate, the patient responds quicker, with less risk.

  • A N Other wrote:

    That scientific data is already in. You need to find it. Also the risk / benefit profile would change because if the form of treatment is appropriate, the patient responds quicker, with less risk.

    I would remind you that in the case of chiropractic (the topic of this thread}, the scientific data don’t seem to have changed since 2008. A quick reminder:

    This treatment carries the risk of stroke or death if spinal manipulation is applied to the neck. Elsewhere on the spine, chiropractic therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions, chiropractic therapy is ineffective except that it might act as a placebo.

    Ref. p.285 ‘Trick or Treatment? Alternative Medicine on Trial’, by Simon Singh and Edzard Ernst.

    Indeed, until chiropractors clean up their act, which doesn’t look like being any time soon due to the appearance of the Alliance of UK Chiropractors (AUKC), I can’t see chiropractic being recommendable for back pain due to the safety issue I highlighted in Edzard Ernst’s recent critique of the NICE guidelines for low back pain.

  • A N Other said:

    That scientific data is already in. You need to find it.

    Have they been published?

  • @ Zeno

    Yes

    @ Blue wode

    As i have previously discussed with you certain aspects of chiropractic do need to change. However, within manual therapies there is more than you seem to or want to understand. Chiropractic as a profession can be narrow minded and stubborn and doesn’t want to change, but there are chiropractor who are open and reflective. This is the same for osteos and physios.

    Please read around more on manual therapies and you will find that there is more to it, as we previously discussed on another blog.

  • A N Other said:

    @ Zeno

    Yes

    Since you have simply said that there is evidence, but have neither supplied it nor even given its title or where it’s published, we have no choice but to doubt its existence. Since it’s you who are making claims about it, the onus rests with you to supply it. The only alternative is for us to take your word for it. I’m sure you’ll understand if I choose no to.

  • @ Zeno,

    Thanks for the reply. What has made you doubt me. i have supplied evidence previously. I was hoping that you would like to learn more about manual therapies and see that it is not all black and white. Neuromusculoskeletal complaints such as low back pain is a complex area and there is lots of research being produced. Maybe you should read that passage i tried to post on here by Karel Lewit from the book Rehabilitation of the spine, as it explains that maybe medicine needs to relook at this area (neuromusculoskeletal) from a different position.

  • A N Other

    Do you or do you not have the published evidence to back up the claims you made? If you have it, please provide a link to it or its published title.

  • @ Zeno

    Are you going to read the article by Karel Lewit?

  • A N Other

    No robust peer reviewed scientific evidence, then?

  • @ Zeno

    Yes, robust peer reviewed scientific evidence, but i want you to learn something new, maybe see something from a different point of view.

  • A N Other

    You made claims — please back them up with evidence.

  • @ Zeno

    Are you going to read the article by Karel Lewit? it is interesting

  • A N Other

    Is that your robust peer reviewed scientific evidence?

  • Spine (Phila Pa 1976). 2006 Mar 15;31(6):623-31.
    Identifying subgroups of patients with acute/subacute “nonspecific” low back pain: results of a randomized clinical trial.

    Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE.

    Hope you do read the article by Lewit, it may help you understand the issues around manual therapies better.

  • Although it has its faults, the methodology is an interesting way of investigating ways of opening the ‘black box’ of acute LBP — but what do you think of the different treatments used and, since this is now over four years old, has any further research been done into the classification subgroup algorithm as it recommended?

  • @ Zeno

    Every study has its faults. There is further research, but it does take time.

    BMC Musculoskelet Disord. 2010 Mar 26;11(1):58.
    The cost-effectiveness of a treatment-based classification system for low back pain: design of a randomised controlled trial and economic evaluation.

    Apeldoorn AT, Ostelo RW, van Helvoirt H, Fritz JM, de Vet HC, van Tulder MW.

    Are you going to read the article by Karel Lewit?

  • malucachu here.

    I had put my name original down which is a bit unusual, so I have asked Zeno to change it to malucachu, in case anyone was wondering where ‘he’ came from home.

  • Well done a n other, Blue wode consider yourself spanked.

  • Bet he/she’d rather be spanked than corrected (or adjusted) ;-)

  • A N Other wrote:

    The identification of sub-groups within non speciifc low back pain has begun and research has been published. These show that for certain “types” of low back pain will respond best to particular types of treatment.

    So the advice of the study you quoted is limited to treating a symptom (back pain) and trying to limit deconditioning by advising the patient to remain active, as well as limiting psycho-social factors. It is not addressing the underlying cause, but should be viewed as part of a process.

    It is a shame that you have gone from supporting manual therapies (physio) to now saying that “Not much room for any type of manual therapy”.

    A N, you may be interested to learn that the latest issue of the British Medical Journal has published a paper that’s closely related to this very topic. It seems to suggest that coping strategies are far more important than addressing any perceived underlying causes:

    Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial. BMJ 2010; 341:c6414
    http://www.bmj.com/content/341/bmj.c6414.full

    What is already known on this topic

    • The economic burden of low back pain is huge and primarily related to costs of productivity losses
    A small group of patients with severe, chronic low back pain generate most of the costs
    • Cost effective interventions are lacking for this selected group with chronic back pain

    What this study adds

    • An integrated care programme substantially reduced sick leave for a small but relevant group of patients with chronic low back pain
    • The programme has large potential to significantly reduce the societal costs of low back pain in this group of patients
    • Integrated care was more cost effective than usual care for return to work and quality adjusted life years

    Patients allocated to integrated care were referred to a clinical occupational physician who was responsible for the coordination of the care and for communication with the other healthcare professionals in the team. The intervention consisted of a workplace intervention protocol and a graded activity protocol. The workplace intervention protocol, based on participatory ergonomics, was a stepwise process involving the participant and supervisor and aimed to formulate a consensus based plan for adaptations at work to facilitate return to work.12 13 14 Graded activity was a time contingent programme based on cognitive behavioural principles.15 16 17 The integrated care team consisted of a medical specialist, occupational therapist, physiotherapist, and clinical occupational physician. The primary aim of integrated care was to restore occupational functioning and to achieve lasting return to work for patients in their own job or similar work.

    Conclusions

    The costs of an integrated care programme for patients sick listed because of chronic low back pain were lower than for usual care. From a societal perspective after 12 months integrated care was more cost effective than usual care. This applied to a selected group of patients with chronic specific and (non-)specific low back pain, all of whom were judged appropriate for this kind of psychosocial treatment.

    Note that spinal manipulation by any professional, chiropractors included (the topic of Zeno’s blog post), isn’t mentioned – and even it were, it would still leave chiropractors with the following problem:

    If a chiropractor limited his practice to musculoskeletal conditions such as simple backaches, if he were able to determine which patients are appropriate for him to treat, if he consulted and referred to medical doctors when he couldn’t handle a problem, if he were not overly vigorous in his manipulations, if he minimized the use of x-rays, and if he encouraged the use of proven public health measures, his patients would be relatively safe. But he might not be able to earn a living.

    Ref: Stephen Barrett, MD, (Quackwatch), p.175 of the ‘Spine Salesmen’ chapter of the book, The Health Robbers: A Close Look At Quackery In America

  • “If a chiropractor limited his practice to musculoskeletal conditions such as simple backaches, if he were able to determine which patients are appropriate for him to treat, if he consulted and referred to medical doctors when he couldn’t handle a problem, if he were not overly vigorous in his manipulations, if he minimized the use of x-rays, and if he encouraged the use of proven public health measures, his patients would be relatively safe. But he might not be able to earn a living.”

    As I have said on many occasions, I only see people with back/neck pain. I always refer back to their GP if I have even a slight worry, I can and do refer for MRI. I don’t take x rays. I do advise continuing or starting physio sessions. I don’t mind pain killers and anti inflamms, if used conservatively. I have been doing this for 20 years. I’m not a millionaire but I do make a living. i’m not an usual chiropractor, there are loads just like me. So again we see an ignorant quote from somebody that doesn’t actually know what they are talking about.

  • fed up wrote:

    I only see people with back/neck pain.

    I always refer back to their GP if I have even a slight worry

    I can and do refer for MRI.

    I don’t take x rays.

    I do advise continuing or starting physio sessions.

    I don’t mind pain killers and anti inflamms, if used conservatively.

    I have been doing this for 20 years.

    I’m not a millionaire but I do make a living.

    i’m not an usual chiropractor, there are loads just like me.

    So why are the majority of chiropractors in the UK up in arms over their scope of practice, and voting – almost unanimously – that they have no confidence in their regulator?

  • “It seems to suggest that coping strategies are far more important than addressing any perceived underlying causes:”
    “Note that spinal manipulation by any professional, chiropractors included (the topic of Zeno’s blog post), isn’t mentioned”
    As usual you have put your usual spin on things. The reason manipulation isn’t mentioned is because “comparing integrated care with usual care for patients” and ” Patients who visited an outpatient clinic of the five participating hospitals because of low back pain were approached.” Obviously manipulations is not the USUAL CARE. “10 physiotherapy practices, one occupational health service, one occupational therapy practice” is the usual care.

    The majority of chiros have no confidence in the GCC because as a regulator it is infected. It has been from the start. We voted no confidence long before you decided to join in. It has nothing to do with scope of practice etc and you know that from reading chirolive. It has everything to do with our own regulator being anti chiropractic, gregg price, and our regulator being vindictive in prosecuting it’s members for having cat hair in the treatment room or prosecuting you for not haveing a complaints procedure(even though the GCC didn’t have one at the time), or dragging you through the mud because a disgruntled ex wife or girlfriend decides to complain. regulation is fine, crap regulators make it un workable.

  • fedup wrote:

    The reason manipulation isn’t mentioned is because “comparing integrated care with usual care for patients” and ” Patients who visited an outpatient clinic of the five participating hospitals because of low back pain were approached.” Obviously manipulations is not the USUAL CARE. “10 physiotherapy practices, one occupational health service, one occupational therapy practice” is the usual care.

    My point was that if spinal manipulation had any true value as an intervention, then you’d think that it would have been included in the study’s *integrated* care package. It was, after all, trying to determine what was the most effective approach for patients with severe, chronic low back pain – the sub-group of back pain sufferers that is the most difficult and expensive to treat.

    fedup wrote:

    We voted no confidence long before you decided to join in. It has nothing to do with scope of practice etc

    Nonsense. The Alliance for UK Chiropractors (AUKC), which apparently represents *at least* 50% of the chiropractor population of the UK, seems desperate for the GCC to restore the old, lucrative, quackery-based chiropractic practices:

    On 17th August we met with the GCC council and presented a dossier on the Vertebral Subluxation Complex. After reviewing this document and discussions that followed at this meeting the GCC agreed that they would delete the phrase “…or health concerns” in the VSC guidance and provide an explanation why it had done so…It was also agreed at this meeting that the term Subluxation would again be included in the Frequently Asked Questions (FAQs) – A definition will be discussed and agreed at the next Communications Advisory Group meeting on 10th December 2010…We surveyed the AUKC membership and over half of our members took the time to complete this online survey; the results are as follows:

    • 88.2% felt that chiropractic should remain drug-free and that chiropractors should not pursue prescribing rights,
    • 82.9% felt that the Vertebral Subluxation was NOT an historical concept
    • 95.4% thought that Philosophy should be taught in the Chiropractic Colleges
    • 90.5% had found that in their experience Chiropractic was effective for conditions outside those mentioned in the Bronfort Report
    • 83.9% answered NO to the question “Do you have confidence in the GCC to regulate the profession?

    http://tinyurl.com/36y3qwm

    If that isn’t about scope of practice, then I don’t know what is.

    fedup wrote:

    It has everything to do with our own regulator being anti chiropractic, gregg price, and our regulator being vindictive in prosecuting it’s members for having cat hair in the treatment room or prosecuting you for not haveing a complaints procedure(even though the GCC didn’t have one at the time), or dragging you through the mud because a disgruntled ex wife or girlfriend decides to complain. regulation is fine, crap regulators make it un workable.

    Here’s what you’re really looking at…

    You can use people from your own profession to regulate, and they’ll prove themselves incompetent. Or you can use people to regulate your industry properly – and they’ll destroy it.

    http://adventuresinnonsense.blogspot.com/2010/11/chiropractic-trade-organisations-launch.html

  • No it was looking at it’s USUAL care for low back pain. If the USUAL care doesn’t involve manipulations then why do you presume it would have been included?

    “Nonsense.” WTF? are you trying to tell me you know more about how the chiro profession views the GCC and why we have no confidence in it? Did you attend a meeting 2003 about de railing the GCC? Did you speak to all the chiros in your area and listen to their negative views about the GCC around the same time?
    the lack of confidence has NOTHING to do with scope of practice, i promise you that.

    I read Mr perrys quote when he posted it and didn’t agree with it then. The 2 biggest problems past and present with the GCC are Gregg price and Margaret Coates. Neither are chiropractors, though price did descibe himself as one on an anti chiro web site. maybe the incompetent bit has some merit. But nobody will destroy the chiropractic profession I’m afraid.

  • fed up wrote:

    No it was looking at it’s USUAL care for low back pain. If the USUAL care doesn’t involve manipulations then why do you presume it would have been included?

    Because chiropractors are always pushing the idea that they provide a “package of care”, and the integrated care team in the study consisted of a medical specialist, occupational therapist, physiotherapist, and clinical occupational physician – but no sign of a chiropractor who might have been able to advise on ergonomics, lifestyle changes, or even to suggest manipulation. What’s more, as you pointed out, the usual care was “10 physiotherapy practices, one occupational health service, one occupational therapy practice” which suggests that chiropractic manipulation isn’t a consideration for this sub-group of patients.

    That all indicates that chiropractic isn’t effective for long term back pain – and, as we already know, it isn’t any better than a couple of paracetamol for short term back pain, and for everything else it is no better than placebo.

    fed up wrote:

    the lack of confidence has NOTHING to do with scope of practice, i promise you that.

    I don’t believe that for one minute and I suspect that if you were honest with yourself you wouldn’t either.

    fed up wrote:

    I read Mr perrys quote when he posted it and didn’t agree with it then. The 2 biggest problems past and present with the GCC are Gregg price and Margaret Coates. Neither are chiropractors

    So are you saying that chiropractors want to put the foxes in sole charge of the henhouse? If that’s correct, then I reckon that Simon Perry was spot on with this observation:

    The GCC was set up by chiropractors in order to protect their profession, rather than by members of the public seeking protection from them.

    http://adventuresinnonsense.blogspot.com/2010/11/chiropractic-trade-organisations-launch.html

  • “which suggests that chiropractic manipulation isn’t a consideration for this sub-group of patients.”

    That is a total assumption and you have no evidence to back that statement up. It suggests that, like the UK, their usual treatment consists of physio and like the UK nearly all NHS based physios don’t manipulate. Thats all. Chiro wasn’t considered because this was the basis of the study.
    “Interventions Integrated care consisted of a workplace intervention based on participatory ergonomics, with involvement of a supervisor, and a graded activity programme based on cognitive behavioural principles. Usual care was provided by general practitioners and occupational physicians according to Dutch guidelines.”

    don’t try and make it something it isn’t.

    as for the no confidence, if I put a vote to the chiro profession with these questions we would get a similar outcome.

    Do you like margaret coates?
    Should she be kicked off the GCC?
    Should Gregg Price have been prosecuted?
    Should the GCC have bought massive offices in central London?
    Do you think the GCC handles complaints fairly?
    Has the GCC EVER promoted the profession? as was it’s initial remit.
    Do you trust the GCC to regulate the profession honestly?
    Do you have confidence in the GCC?

    The question you are using are new questions based on an old distrust and dislike and no confidence in the GCC.

    Again you squirm like a snake.

    “You can use people from your own profession to regulate, and they’ll prove themselves incompetent. Or you can use people to regulate your industry properly – and they’ll destroy it”

    How can this be right if we ARE NOT using people from our own profession to regulate in the first place? Don’t quote then run.

    “The GCC was set up by chiropractors in order to protect their profession, rather than by members of the public seeking protection from them.”

    This is laughable. The GCC was set up by chiropractors to protect the profession which in turn protects the public. The reason why members of the public didn’t set up the GCC for protection from chiropractors is the exact reason why you will never destroy chiropractic. It’s the public who vote with ther feet and benefit from what we do. The day you can actual understand that we are not con men out to swindle big bucks from people, but therapists that the vast majority of the PUBLIC that come to see us WANt to come and see us. They know if it benefits them and often they have been through the USUAL treatment protocols and that hasn’t worked.
    Can you name one regulated profession that the regulator was founded by the public? Give us an example that the GCC should have followed.

  • That studys outcomes were also measured by sick leaves. So days off work were the factors considered. was it days off work for back pain only? hang over maybe? Flu?

    “Firstly, the primary outcome was assessed accurately by collecting sick leave data every month from patients and by checking these data with the sick leave data of registration systems of the occupational health services.”

  • fed up, it’s completely understandable why you’re thrashing about over this.

    In other words, it’s now becoming totally transparent that the statutory regulation of chiropractic was premature – i.e. when one examines the robust scientific data that are now in for chiropractic, it raises the question, why does it exist at all?

    Once again, I would remind readers that treating acute back pain has been shown, fairly consistently, to be chiropractors’ main meal ticket:

    This treatment carries the risk of stroke or death if spinal manipulation is applied to the neck. Elsewhere on the spine, chiropractic therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions, chiropractic therapy is ineffective except that it might act as a placebo.

    Ref. p.285 Trick or Treatment? Alternative Medicine on Trial, by Simon Singh and Edzard Ernst.

    However, as we have learned previously in the comments here, until chiropractors clean up their act, which doesn’t look like being any time soon due to the appearance of the subluxation-based Alliance of UK Chiropractors (AUKC), it would appear that chiropractic spinal manipulation cannot be a recommendable treatment for back pain due to the safety issue highlighted in Edzard Ernst’s recent critique of the NICE guidelines for low back pain:

    Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them. And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.”

    Ref: Ernst, E. Spinal manipulation for the early management of persistent non-specific low back pain: A critique of the recent NICE guidelines. Int J Clin Prac, Vol 63, No10, Oct 2009, pp.1419-1420.

    And let’s not forget the findings of the Hancock study which was published around the same time as Trick or Treatment, and which, as a consequence, may not have been considered in the authors’ thorough evaluation of all the evidence for chiropractic:

    Australian researchers found that neither spinal manipulation or the drug diclofenac hastened recovery of acute low-back pain patients who had been properly counseled by their primary physician and prescribed paracetamol for pain relief. The study involved 240 patients who received either (a) diclofenac plus spinal manipulation, (b) diclofenac and sham spinal manipulation, (c) spinal manipulation and a placebo pill, or (d) sham manipulation plus a placebo pill. About half recovered within two weeks and nearly all recovered within three months.

    [Hancock MJ and others. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomized controlled trial. Lancet 370:1638-1643, 2007]

    Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID). Paracetamol is a pain-reliever marketed in the United States as acetominophen or Tylenol. An accompanying editorial noted:

    • Systematic reviews had concluded that NSAIDS and spinal manipulation were more effective than placebos. However, the patients in the reviewed studies did not have optimum first-line care, and the apparent benefit was not large.

    • Advice to remain active and prescription of paracetamol will be sufficient for most patients with acute low back pain.

    [Koes BW. Evidence-based management of acute low back pain. Lancet 370:1595-1596, 2007]

    http://www.ncahf.org/digest07/07-47.html

  • Now can you use a quote from anybody that is not totally biased.
    “Prof EE and Stephen Barrett, M.D., and cosponsored by NCAHF and Quackwatch”

    If you use anything done by EE you are as equally biased and equally ignorant of your subject. IMO.

  • fed up wrote:

    If you use anything done by EE you are as equally biased and equally ignorant of your subject. IMO

    fed up, if you’re a chiropractor working in private practice, then the value of your opinion is questionable.

  • As opposed to any quote by a chiropractor, a chiropractic training organisation or a chiropractic trade or promotional body, who are, of course, utterly and completely neutral, independent and unbiased?

  • Do you not agree that if you only use quotes from 1 researcher with questionable constant negative outcomes, who usually cherry picks better than anybody, then you must have a biased opinion? Of course I’m biased, thats maybe because I actually know what I’m talking about. You can’t show me evidence that what I do doesn’t work in a RCT situation, because you don’t know what I do.
    Zeno: thats why research, for the majority of the time is pretty much about proving a point you want to prove. Do you agree all research gives reliable unbiased data? If not what sort of percentage do you think is unbiased? EE pretends to be unbiased but come on, we all can see he is as one sided as they come.
    Blue wode constantly changes tact. You show her views and quotes to be wrong or flawed, a n other did this very well, and she just moves on to something else. It’s not constructive. She does not bother to actual LEARN anything about the subject, but relies on blogs and research printed online. Maybe not a biggot but blinkered.
    As for my opinion I think far more people value you it than you may think. Again this is why you don’t really matter in the outcome of chiropractics future. You have no understanding of what a chiropractor does and you definately have no idea about what I do.

  • fed up wrote…

    If you use anything done by EE you are as equally biased and equally ignorant of your subject. IMO.

    …Zeno wrote:

    As opposed to any quote by a chiropractor, a chiropractic training organisation or a chiropractic trade or promotional body, who are, of course, utterly and completely neutral, independent and unbiased?

    Quite.

  • @ Blue Wode

    Thnak you for highlighting this new Study, I will read it soon. The specific subset of low back pain patients you refer to is the most problematic to treat (“chronic non-specific low back pain”). About 10% of all low back patients become chronic and they do account for 90% of the cost. So the highlighted study is important.

    However, a more important approach would be to prevent that 10% from becoming chronic (prevention better than cure). So the continued research into finding the underlying cause (please read Karel Lewits article), looking into the subgroups within the “non-specific” low back pain group and what type of treatments would be appropriate for each of these sub-groups are all vital. This means that manual therapists still have an important role using a variety of techniques (exercise, mobilisation/manipulation, soft tissure work, advice etc.)

  • @ blue wode

    Apologies i meant Thank you.

  • A N Other wrote:

    …a more important approach would be to prevent that 10% from becoming chronic (prevention better than cure). So the continued research into finding the underlying cause (please read Karel Lewits article), looking into the subgroups within the “non-specific” low back pain group and what type of treatments would be appropriate for each of these sub-groups are all vital. This means that manual therapists still have an important role using a variety of techniques (exercise, mobilisation/manipulation, soft tissure work, advice etc.)

    And until the data is in from that research, and chiropractors have cleaned up their act (especially the subluxation-based AUKC crowd), a responsible risk/benefit assessment of the evidence for ‘chiropractic’ is likely to continue to show that it is not a recommendable treatment.

  • ” a responsible risk/benefit assessment of the evidence for ‘chiropractic’”

    If you are suggesting EE’s risk/benefit assessment then it is not a responsible assessment but a biased atack.
    Chiropractic is safe, no matter how hard you try to imply that it isn’t.

  • “Australian researchers found that neither spinal manipulation or the drug diclofenac hastened recovery of acute low-back pain”

    “Use of diclofenac (Cataflam, Voltaren) is associated with 91% increase in the relative risk of a fatal heart attack or stroke in healthy adults, and the risk was greater at higher doses, Danish researchers reported”

    “An important study recently published in the journal Circulation: Cardiovascular Quality and Outcomes alerts us to a serious hazard associated with non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac (Voltaren®), rofecoxib (Vioxx®, now withdrawn), and even ibuprofen to a lesser degree.”

    “Most physicians readily acknowledge that NSAIDs are an important cause of gastrointestinal (GI) morbidity. This problem is largely a consequence of NSAIDs’ regular use by more than 60 million Americans (1) resulting in clinically significant upper GI events in 1–2% of users (2). Not widely appreciated, however, is that NSAIDs use also results in death. Few studies have estimated mortality resulting from GI complications of NSAIDs. Among the available reports, estimates attributable to NSAIDs have widely varied from 3,200 to higher than 16,500 deaths per yr in the United States (3,4).”

    And there is loads more, so Blue wode where do you stand on a GP prescibing diclofenac for acute low back pain? And don’t say it’s not connected to chiropractic as you brought up a study that has nothing to do with chiro or manipulation.

  • fedup wrote:

    ” a responsible risk/benefit assessment of the evidence for ‘chiropractic’”

    If you are suggesting EE’s risk/benefit assessment then it is not a responsible assessment but a biased atack.

    As opposed to an assessment by a chiropractor, a chiropractic training organisation or a chiropractic trade or promotional body, who are, of course, utterly and completely neutral, independent and unbiased? (H/T Zeno)

    fedup wrote:

    Chiropractic is safe, no matter how hard you try to imply that it isn’t.

    No, it’s not:
    http://www.ebm-first.com/chiropractic/risks.html

  • You will probably quote that german study, the facts of which you neatly ducked when it was shown the safest person to adjust your neck is a chiropractor. Has there ever been a case of a McT chiro causing vad? I think you will not find one. Has an activator neck adjustment caused a vad? You don’t actually know do you. Not every neck is manipulated and not evryneck is manipulated in the same way. If I was using a technique where there were no recorded cases of vad after, would you describe it as safe? or do you need to ask the prof?

    Don’t use a chiropractors study but equally don’t use a biased study by EE. Come up with something else if you can.

    Diclofenac? Your thoughts.

  • Fedup cited and wrote the following:

    “Most physicians readily acknowledge that NSAIDs are an important cause of gastrointestinal (GI) morbidity. This problem is largely a consequence of NSAIDs’ regular use by more than 60 million Americans (1) resulting in clinically significant upper GI events in 1–2% of users (2).”

    And there is loads more, so Blue wode where do you stand on a GP prescibing diclofenac for acute low back pain? And don’t say it’s not connected to chiropractic as you brought up a study that has nothing to do with chiro or manipulation.

    For a true comparison with chiropractic spinal manipulation one would have to take into account the following:

    No prospective randomized trial conclusively demonstrates that chiropractic management reduces the incidence of serious NSAID complications, such as fatal gastrointestinal bleeding.

    NSAIDs taken at recommended doses for a short time are generally very low-risk for appropriately selected patients — particularly the relatively young not on corticosteriods, anticoagulants, alcohol or tobacco and without a history of ulcers or severe comorbid illness.

    Many patients continue to take NSAIDs while undergoing spinal manipulation.

    Moreover, spinal manipulation can frequently cause an exacerbation of pain, which might cause some patients to increase or initiate NSAID therapy.
    [Ernst E. Prospective investigations into the safety of spinal manipulation. Journal of Pain and Symptom Management, 21(3): 238-242, March 2001]

    Herbal recommendations seem to be common among DCs; some remedies have actions similar to NSAIDs, while others directly affect bleeding per se. A recent set of reports by the North American Spine Society includes an 18-page reference chart listing approximately 70 herbs with their uses, potential side effects, and (known) potential interactions.

    While side effects of low-back manipulation appear to be very uncommon, some chiropractic back-pain patients also receive neck manipulation, which entails additional risks.

    Manipulation is much more expensive than NSAID treatment. So if both are equally effective, manipulation would be much less cost-effective.

    It’s worth reading the full commentary here:
    http://www.chirobase.org/18CND/03/03-03.html

    It’s also worth remembering that packets of NSAIDs contain patient information leaflets detailing risks. However, it is evident that not all chiropractors warn patients about the risks associated with their manipulative treatments.

    I would also venture that because the number of people taking NSAIDs is bound to be much higher than those receiving spinal adjustments, then NSAIDs are likely to be far safer.

    In addition to that, NSAIDs have been proven to work and their adverse effects are recorded and acknowledged. More here:

    It is, of course, important to present any risk-benefit assessment fairly and in the context of similar evaluations of alternative therapeutic options. One such option is drug therapy. The drugs in question—non-steroidal anti-inflammatory drugs (NSAIDs)—cause considerable problems, for example gastrointestinal and cardiovascular complications. Thus spinal manipulation could be preferable to drug therapy. But there are problems with this line of argument: the efficacy of NSAIDs is undoubted but that of spinal manipulation is not, and moreover, the adverse effects of NSAIDs are subject to post-marketing surveillance while those of spinal manipulation are not. Thus we are certain about the risks and benefits of the former and uncertain about those of the latter. Finally, it should be mentioned that other therapeutic options (e.g. exercise therapy or massage) have not been associated with significant risks at all.

    http://jrsm.rsmjournals.com/cgi/content/full/100/7/330

  • @ Blue wode

    I thought we discussed that the research is in for using certain sub-groups matched to a particular treatment, which in clude manual therapies.

  • @ A N Other

    As far as I’m concerned there’s no *good quality* research for anything about chiropractic that would change Simon Singh and Edzard Ernst’s 2008 assessment of it in their book, Trick or Treatment? Alternative Medicine on Trial . (And that’s before you factor in chiropractic’s unfavourable risk/benefit assessment.)

  • @ Blue Wode

    I am talking about manual therapies which include chiropractic, osteopathy, physiotherapy etc. All these professions use techniques which are common to each other. As i have said before aspects of chiropractic need to change, but if you read the article by Karel Lewit, you will see that there is more to manual therapy than what Ernst writes about ie treatment of the neck can help with low back pain.

    Also the is no panacea in the treatment of low back pain. It does require the use of multiple modalities which include mobilisation, exercise, meds etc as highlighted in the study you found for chronic back pain.

  • A N Other wrote:

    I am talking about manual therapies which include chiropractic, osteopathy, physiotherapy etc. All these professions use techniques which are common to each other. As i have said before aspects of chiropractic need to change

    If chiropractic needs to change then why is the Alliance of UK Chiropractors (AUKC) dragging *at least* half of the UK chiropractor population backwards with its demands that the GCC restore chiropractic’s quackery-based (vitalistic) practices?

    On 17th August we [the AUKC] met with the GCC council and presented a dossier on the Vertebral Subluxation Complex. After reviewing this document and discussions that followed at this meeting the GCC agreed that they would delete the phrase “…or health concerns” in the VSC guidance and provide an explanation why it had done so…It was also agreed at this meeting that the term Subluxation would again be included in the Frequently Asked Questions (FAQs) – A definition will be discussed and agreed at the next Communications Advisory Group meeting on 10th December 2010…We surveyed the AUKC membership and over half of our members took the time to complete this online survey; the results are as follows:

    • 88.2% felt that chiropractic should remain drug-free and that chiropractors should not pursue prescribing rights,
    • 82.9% felt that the Vertebral Subluxation was NOT an historical concept
    • 95.4% thought that Philosophy should be taught in the Chiropractic Colleges
    • 90.5% had found that in their experience Chiropractic was effective for conditions outside those mentioned in the Bronfort Report
    • 83.9% answered NO to the question “Do you have confidence in the GCC to regulate the profession?

    http://tinyurl.com/36y3qwm

    The AUKC’s publicly stated intention/mission is to “create a vitalistic chiropractic model of health”:
    http://www.chiropracticlive.com/?p=842

    Now note what Joseph Keating Jr, wrote in ‘The Meanings of Innate’, Journal of the Canadian Chiropractic Association, 46,1 (2002), p.10.

    “…we surely stick out like a sore thumb among professions which claim to be scientifically based by our unrelenting commitment to vitalism. So long as we propound the ‘one cause, one cure’ rhetoric of Innate, we should expect to be met by ridicule from the wider health science community. Chiropractors can’t have it both ways. Our theories cannot be both dogmatically held vitalistic constructs and be scientific at the same time.”

    So true.

  • @ Blue wode,

    If you read the Karel Lewit article, a lot of these themes are discussed.

  • @ A N Other

    As I have already said, I will wait for any new evidence for chiropractic to be published in quality medical journals. Until then, it’s interesting to note the words of the editor of the journal, Clinical Chiropractic:

    …the time is fast approaching when chiropractic will have to decide whether it is informed by 19th century metaphysics or by 21st century science. If it chooses wrongly, then it may not be possible for all the king’s horses and all the king’s men to effect a repair.

    Humpty Dumpty chiropractic
    http://www.fnks.org/fnks/sites/default/files/Humpty%20Dumpty%20chiropractic.pdf

    Those words would seem to apply to the 3,000 or so individuals and organisations who recently submitted comments on the proposed changes in the US Council on Chiropractic Education’s (CCE) educational standards for accredited institutions. Apparently the 3,000 submissions oppose the following:

    • A proposed accreditation category of “equivalent” to the DC degree
    • The removal of the “Purpose of Chiropractic Education Statement” from the current standards which eliminates a strong statement defining chiropractic as a drugless and non-surgical profession,
    • The elimination of “subluxation” language as a key clinical component of chiropractic education, and the deletion of the current clinical competencies which provide a strong focus on the adjustment and the detection and correction of the subluxation,
    • The proposed modification of the definition of “Chiropractic primary care physician”

    http://tinyurl.com/3×79wnr

    Another example of Humpty Dumpty chiropractic?

  • Readers might also be interested to know that a proposed new code of conduct in Australia has Antipodean chiropractors worried that it will restrict their current forms of advertising, curtail ‘wellness care’, discourage their recommendations that parents get their children checked regularly, and require them to be up to date on all vaccines:
    http://tinyurl.com/33zfyte

    In addition to that, a report released last month by the Swedish Agency for Higher Education on the education for chiropractors, has Swedish chiropractors deeply concerned. If the report’s recommendations go through, then Swedish chiropractic education, and the Swedish chiropractic profession as it stands today will be removed with the stroke of a pen and turned into a speciality of physiotherapy:
    http://www.ecupresident.org/2010/11/swedish-report-makes-chiropractors.html

  • …I might also add that the Barcelona College of Chiropractic, which has just been granted ECCE candidate status (which assures the quality of chiropractic undergraduate education and training), and which is a public university-affiliated college of chiropractic registered with the Catalan Government’s Justice Department via a non-profit foundation, is, apparently, not recognised by the Spanish Ministry of Education and Universities and is currently being investigated for misleading claims about its (false) university status:
    http://tinyurl.com/33svz2u

    As the editor of Clinical Chiropractic warned, it may not be possible for all the king’s horses and all the king’s men to effect a repair to the above.

  • @ Blue Wode,

    Thats is all very interesting too. But you should read the article by Karel Lewit and comeback with some feedback on that.

  • @ A N Other

    Agreed. It is all very interesting.

    Re Karel Lewit – I repeat, I will wait for any new evidence for chiropractic to be published in quality medical journals.

  • @ Blue wode

    Karel Lewit has nothing to do with chiropractic. He is a neurologist who has worked in rehabilitation for the last 40 years. The article he has written i think will help you understand manual therapies and musculoskeltal complaints better.

  • @ A N Other

    A few things about Karel Lewit:

    It’s interesting to note that he concludes that spinal asymmetry is the rule, not the exception, and that it is of dubious clinical significance. (Lewit K. Manipulative Therapy in Rehabilitation of the Locomotor System. Boston: Butterworths, 1985. p.45) That is a very significant assertion since it’s not what many chiropractors would have their customers believe.

    It’s also worth remembering that Lewit’s cervical manipulations do not involve the dangerous thrusting techniques used by some chiropractors. (Lewit K. Manipulative Therapy in Rehabilitation of the Locomotor System. Boston: Butterworths, 1985. p.351)

    With regard to the various procedures that chiropractors use to diagnose problems and evaluate their patients’ progress, apparently Lewit, and Craig Liebenson DC, (Lewit K, Liebenson C. Palpation – problems and implications. JMPT 16:586-590, 1993) concluded that

    “there is an urgent need for research in palpation, which could provide basic scientific credibility to manipulative techniques”

    and noted that

    “the historic as well as rational importance of palpation…is not sufficient to uphold its credibility in the managed care environment of the future. Research into the nature of palpation is needed to legitimize this crucial part of the chiropractic art”.

    In other words, they seem to be saying that chiropractic’s most fundamental procedure cannot withstand scientific scrutiny.

  • @ Blue wode,

    So are you going to read the article?

  • @ A N Other

    I have already answered you.

    I will wait for robust peer reviewed scientific evidence on chiropractic/manual therapies to be published in quality medical journals.

  • @ Blue Wode,

    I have shown you robust peer reviewed scientific evidence on chiropractic/manual therapies published in quality medical journals.

    This article (by Karel Lweit) is about broadening your horizons from the narrow position they are at now.

  • @ A N Other

    I am perfectly content with my horizons in regard to chiropractic/manual therapies, even if you are not. Indeed, I would venture that you are the one who is not facing up to the writing on the wall.

  • @ Blue Wode,

    So you are refusing to read an article by a world renowned rehabilitation specialist, who has worked in manual therapies for 40 years! Also have i not shown you research that supports my point of view?
    Are you then saying that there is no place for any manual therapies ie physiotherapy, chiropractic, osteopathy etc?

  • A N Other wrote:

    Are you then saying that there is no place for any manual therapies ie physiotherapy, chiropractic, osteopathy etc?

    Osteopathy is dubious beyond the treatment of low back pain, not least because there’s this to consider:
    http://www.nowinnofeeclaims.biz/why-do-uk-osteopathy-schools-have-such-shockingly-low-standards/

    Chiropractic for the treatment of low back pain (its only real evidence) cannot be recommended due to its unfavourable risk/benefit profile. Of course, that profile could be improved if the large vitalistic component of the profession saw sense and dropped their (income-friendly) cherished beliefs. However, even then, like osteopathy, there would still be cheaper and more convenient treatment options available to back pain sufferers.

    As for physiotherapy, as we know, it’s not nearly so mired in quackery, although with regard to low back pain, it possibly has little to offer in view of the Hancock study’s findings:

    Australian researchers found that neither spinal manipulation or the drug diclofenac hastened recovery of acute low-back pain patients who had been properly counseled by their primary physician and prescribed paracetamol for pain relief. The study involved 240 patients who received either (a) diclofenac plus spinal manipulation, (b) diclofenac and sham spinal manipulation, (c) spinal manipulation and a placebo pill, or (d) sham manipulation plus a placebo pill. About half recovered within two weeks and nearly all recovered within three months.

    [Hancock MJ and others. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomized controlled trial. Lancet 370:1638-1643, 2007]

    Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID). Paracetamol is a pain-reliever marketed in the United States as acetominophen or Tylenol. An accompanying editorial noted:

    • Systematic reviews had concluded that NSAIDS and spinal manipulation were more effective than placebos. However, the patients in the reviewed studies did not have optimum first-line care, and the apparent benefit was not large.

    • Advice to remain active and prescription of paracetamol will be sufficient for most patients with acute low back pain. [Koes BW. Evidence-based management of acute low back pain. Lancet 370:1595-1596, 2007]

    I would, however, remind you that most physiotherapists in the UK enjoy salaried employment within the NHS and therefore won’t have to resort to over-selling/deception in order to earn a living.

  • “Osteopathy is dubious beyond the treatment of low back pain, not least because there’s this to consider:
    http://www.nowinnofeeclaims.biz/why-do-uk-osteopathy-schools-have-such-shockingly-low-standards/

    Consider and dismiss out of hand i’m afraid. and frankly not quite up your usual standards .

    http://bit.ly/fxlYGO this thread on ukskeptics shows good evidence of the standards of training in uk osteopathic schools.

    I am studying for my MSc at the best medical school in the uk and the standards of teaching at my osteopathic school was at the same level as what I am doing now.

  • osteopathjw said:

    I am studying for my MSc at the best medical school in the uk

    Which one?

  • osteopathjw wrote:

    I am studying for my MSc at the best medical school in the uk and the standards of teaching at my osteopathic school was at the same level as what I am doing now.

    That may well be, however it’s interesting to note the following which is lifted from pages 130-135 of the ‘Bad Backs’ chapter of Rose Shapiro’s well-researched book, Suckers: How alternative medicine makes fools of us all:

    The UK’s 5,000 or so osteopaths, require no scientific medical training and so are more firmly established in the ‘alternative’ camp. Very few are MDs and many combine osteopathy with dubious practices such as naturopathy and cranial osteopathy. They are regulated by statute.

    Osteopathy and chiropractic were invented, or ‘discovered’ by a pair of determined and charismatic Americans in the late 19th century – Andrew Taylor Still and Daniel David Palmer. They both could be described as chancers and fantasists who had tried and failed to make their fortunes in a variety of jobs and get-rich-quick schemes. They saw themselves as visionaries and spiritual leaders and believed they had discovered a single cause and a single cure for all diseases.

    Andrew Still claimed he had been a battlefield surgeon, but no record of it exists. He found phrenology and mesmerism interesting and following the deaths of three of his children he became a magnetic healer. He went on to have a ”prophetic vision” which apparently revealed a truth to him that if bones could be manipulated back into alignment then the nerves would “properly conduct the fluids of life” and so-called diseases or effects would trouble the patient no longer. In the mid 1880s he coined the word ‘osteopathy’ and business was booming.

    However, I would concede that osteopathy today doesn’t seem to be quite so mired in quackery, and it is acknowledged that it has some limited use. The following is a summation of the evidence for it by Professor Edzard Ernst and Simon Singh:

    WHAT IS IT?
    A manual therapy which focuses on the musculoskeletal system to treat disease. Osteopaths use a range of techniques to mobilise soft tissues, bones and joints. Osteopathy and chiropractic therapy have much in common, but there are also important differences.

    Osteopaths tend to use gentler techniques and often employ massage-like treatments. They also place less emphasis on the spine than chiropractors, and they rarely move the vertebral joints beyond their physical range of motion, unlike chiropractors. Therefore osteopathic interventions are less likely to injure.

    In general they treat mainly musculoskeletal problems, but many also claim to treat other conditions such as asthma, ear infection and colic.

    DOES IT WORK?
    There is reasonably good evidence that the osteopathic approach is as effective as conventional treatments for back pain (if, however, you receive no significant benefit then be prepared to switch to physiotherapeutic exercises, which is backed by similar evidence and which is more cost- effective as it is often done in groups).

    There is no good evidence to support the use of osteopathy in non-musculoskeletal conditions.

    http://tinyurl.com/39o4ktz

  • @ Zeno university college london, actually looking at the league tables oxford cambridge and edinburgh are ranked higher. so I should qualify my statement as “one” of the best medical schools in the uk (UCL ranks higher for the clinical aspects I think as UCHL is an excellent hospital)…

    @ BlueWode “require no scientific medical training” the shapiro book again? i guess the anatomy physiology biochemistry etc I studied as an undergrad was non scientific… sorry but that shapiro quote is plain bollocks.

    Don’t have a massive problem with the singh/ernst quote as I don’t believe that there is any good evidence beyond the potentially biased anecdotal for non musculo-skeletal in osteopathy. Surprised you are not quoting the latest hatchet job by podolsky and ernst yet…

    While it might sound good and help to paint osteopaths in a bad light the shapiro quote is wrong. Nothing I have learnt at UCL is in anyway different to stuff learnt on my undergrad course, and if anything it has shown to me that much of what you chaps view as pukka medicine is equally badly evidence based and has a much much higher risk profile than manual therapy.

    obviously that doesn’t excuse the lack of evidence for osteopathy but the profession cannot generate this overnight.

    One could ask why should osteopaths be allowed to practice as if they did have *evidence* for what they do? a good question which could be asked of every musculo-skeletal practioner including Orthopaedic surgeons, physiotherapists etc and if put into practice would essentially shut down the Orthopaedic ward of every single hospital in the UK for anything other than fracture fixation… However I realise that this is not the topic of this thread…

    *evidence* meaning robust RCTs of course.

  • osteopathjw wrote:

    i guess the anatomy physiology biochemistry etc I studied as an undergrad was non scientific… sorry but that shapiro quote is plain bollocks.

    I suspect that what Rose Shapiro means by “require no scientific medical training” is that osteopaths don’t train as MDs first and then specialise in osteopathy.

    osteopathjw wrote:

    Surprised you are not quoting the latest hatchet job by podolsky and ernst yet…

    I’d forgotten about that, but since you mention it:

    Osteopathy for musculoskeletal pain patients: a systematic review of randomized controlled trials

    “Collectively, these data fail to produce compelling evidence for the effectiveness of osteopathy as a treatment of musculoskeletal pain.”

    http://www.ncbi.nlm.nih.gov/pubmed/21053038

    osteopathjw wote:

    One could ask why should osteopaths be allowed to practice as if they did have *evidence* for what they do?

    Probably because, along with physiotherapists, their interventions are not mired in blatant quackery as those of chiropractors are.

  • Blue Wode wrote:

    Probably because, along with physiotherapists, [osteopaths] interventions are not mired in blatant quackery as those of chiropractors are.

    What a load of rubbish.

    I have nothing against osteopaths, but if Zeno was to cast his net over their websites in the same way he did chiropractors’, he would find just as many claims that are every bit as contraversial.

    No, the mire around chiropractors is principally that being flung by Blue Wode and his/her associates.

  • David wrote:

    I have nothing against osteopaths, but if Zeno was to cast his net over their websites in the same way he did chiropractors’, he would find just as many claims that are every bit as controversial.

    I don’t think so. Indeed, Zeno’s actions appear to have had enormous impact:

    Ever since Simon Singh had a go at the Chiropractors our governing body has been nervous.l….The GOsC (General Osteopathic Council) has warned every osteopath to remove, from their websites and advertising material, all references to treatment of conditions that do not have a “medically” proven set of trial data to support the effectiveness of osteopathic treatment. The BOA (British Osteopathic Association), the nearest thing we have to a trade organisation has come out in support. They have told us that if the ASA (Advertising Standards Authority) receive a complaint about an osteopath who advertises treatment for a particular condition that lacks “medically” acceptable evidence, that osteopath will be suspended from the register while an enquiry is carried out. Bottom line = don’t claim to treat anything!

    More…
    http://www.tenterdenosteopath.co.uk/legal/osteopaths-told-to-be-careful/

  • I rest my case.

  • @Blue Wode
    you have still failed to answer my long-standing question of what a patient who has tried exercise, physiotherapy and pharmacopaeia is supposed to do? i.e. what is one who fails to fall in the behavioural bracket covered by the evidence to do?
    Stefaan

  • @Blue Wode
    ps could you also let us all know what “blatant quackery” chiropractic interventions are “mired in”?
    Stefaan

  • Stefaan Vossen wrote:

    you have still failed to answer my long-standing question of what a patient who has tried exercise, physiotherapy and pharmacopaeia is supposed to do? i.e. what is one who fails to fall in the behavioural bracket covered by the evidence to do?

    Learn coping strategies? After all, it’s likely that by that stage a patient’s pain can’t be relieved by any intervention. It certainly wouldn’t be responsible to recommend that they visit a chiropractor, mainly for the following reason:

    Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them. And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.
    Ref: Ernst, E. Spinal manipulation for the early management of persistent non-specific low back pain: A critique of the recent NICE guidelines. Int J Clin Prac, Vol 63, No10, Oct 2009, pp.1419-1420.

    As regards your other question, I’m not indulging you in a game of semantics when you know perfectly well what I mean.

  • And what would you answer to the patient who is happy to take the risks because they have heard that they can actually get better by seeing a chiropractor, rather than having to learn coping strategies?

  • ps, my patients have never heard of a subluxation, so Ernst’s observation are demonstrably untrue

  • pps if semantics is a no-go zone, can I just point out to the readers that Blue Wode is very adept at implying inferiority, and other pejorative commentary about chiropractic as a profession without ever actually making falsifiable statements… just so they know what kind of game he plays…
    Stefaan Vossen

  • ppps a little like Ernst really…

  • @Blue Wode

    When you say “learn coping strategies”, I think you hit the nail on the head. The expectation that there is a cure for every problem mankind suffers is unrealistic. A Deepak Chopraism, if you will. As we get older, our bodies do start to fail in annoying ways. It’s life. The idea is that you cope rather than dwell on it.

    @Stefaan

    I think Blue Wode was probably being polite when s/he said they don’t want to argue semantics with you. If anyone wants a clue as to why why, then click on http://www.elsewhere.org/pomo/ (you have to read then refresh and read again) ;-)

  • @Andrew Gilbey
    thanks for the link, I thought that was quite funny :)
    In regards to the “coping strategies” I think you’re wrong to intimate that there isn’t a cure for many chronic spinal complaints which have not been resolved with pharmaceutical and excerise-based treatment. My patients would say you’re wrong and my clinic stats would say that you’re wrong. Admittedly that may still mean that I hypnotise my patients and I readily admit as much to them (in the context of the discussion as to how much evidence there is for and against what I am planning to do with them.
    On the other hand this may be a classic case of “I can’t do it so therefore no-one can do it” on your behalf. But still the question remains: “And what would you answer to the patient who is happy to take the risks because they have heard that they can actually get better by seeing a chiropractor, rather than having to learn coping strategies?”
    Stefaan Vossen

  • @Blue Wode you have still failed to answer my long-standing question of what a patient who has tried exercise, physiotherapy and pharmacopaeia is supposed to do? i.e. what is one who fails to fall in the behavioural bracket covered by the evidence to do? Stefaan

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