> Once all those non-chiropractic manipulations have been removed * from the Bronfort Report, what’s left? Now that is the *really* important question… Reply
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. Reply
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. Reply
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 Reply
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. Reply
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. Reply
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.” Reply
@ 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 Reply
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? Reply
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 Reply
@ 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. Reply
@David “The appropriateness is then a matter of clinical judgement.” Based upon good evidence, one would hope! Reply
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? Reply
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. Reply
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? Reply
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. Reply
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? Reply
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. Reply
@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. Reply
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 Reply
@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. Reply
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 Reply
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. Reply
@ 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. Reply
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? Reply
@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? Reply
“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? Reply
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. Reply
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 Reply
@ Blue Wode But the study was mobilisation and manipulation, which is done by all manual therapists. Reply
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. Reply
@ 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” Reply
@ 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? Reply
@ 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 Reply
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. Reply
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 Reply
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 Reply
@ 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. Reply
@ 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. Reply
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. Reply
@ 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. Reply
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? Reply
@ 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 Reply
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. Reply
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 Reply
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 Reply
@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). Reply
@ 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. Reply
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. Reply
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. Reply
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. Reply
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 Reply
@ 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. Reply
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. Reply
@ 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? Reply
@ 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”. Reply
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). Reply
@ 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. Reply
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. Reply
A N Other said: That scientific data is already in. You need to find it. Have they been published? Reply
@ 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. Reply
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. Reply
@ 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. Reply
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. Reply
@ Zeno Yes, robust peer reviewed scientific evidence, but i want you to learn something new, maybe see something from a different point of view. Reply
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. Reply
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? Reply
@ 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? Reply
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. Reply
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 Reply
“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. Reply
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? Reply
“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. Reply
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 Reply
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. Reply
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 Reply
“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. Reply
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.” Reply
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 Reply
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. Reply
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. Reply
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? Reply
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. Reply