Help-Refuting Chiropractic column

[rwguinn]

Lil' help dealing with this
http://www.star-telegram.com/2010/12/07/2687160/carter-chiropractic-care-benefits.html
Buncha idiots are under fire in Texas. Looks like attempted spin control...

A recent column ("Texas workers' compensation law should be changed") that advocated prohibiting doctors of chiropractic from serving as primary doctors in Texas omits several pertinent facts and would prove to be counterproductive.
Such a restriction would not provide meaningful reform of the workers' compensation insurance system, and it would put off-limits an affordable healthcare option that is safe and effective.
​

I especially have problems with the bolded part...
http://www.star-telegram.com/2010/12/07/2687160/carter-chiropractic-care-benefits.html#ixzz17XOyglYe​

 

[xjx388]

I can tell you that in my part of the state, Chiropractors are the dominant force in Workers Comp and Personal Injury cases. It seems to me that the medical community has almost given up fighting against them and decided to partner with them to some extent. The lawyers/employers send them over there because they are cheaper, then the Chiros actually refer to Physicians for medical management only. It's b***-ackward if you ask me.

 

[JJM]

Lil' help dealing with this
http://www.star-telegram.com/2010/12/07/2687160/carter-chiropractic-care-benefits.html
...

I especially have problems with the bolded part...

[The bolded part says chiro is safe and effective.] There is no evidence that chiro is effective for anything, except weak evidence for its value in treating low back pain. Chiro seems to be relatively safe, mostly because it is mostly, merely massage; but those folks do cause strokes (and death) with unnecessary neck snaps (of no proven effectiveness). About 50% of customers experience mild, transient discomfort. http://jrsm.rsmjournals.com/cgi/reprint/100/7/330

The only commonality to chiros is opposition to criticism of their business. Therefore, it is hard to say what any chiro does that may be risky. Some manipulate in potentially harmful ways, or delay receipt of needed medical care. They definitely cause harm in various ways; but they do not monitor their mistakes, as medical professionals do, so we don't know their error rates.

See http://www.ebm-first.com/ www.quackwatch.org and its subsidiary site chirobase, as well as www.skepdic.com for reliable info on chiro.

 

[rjh01]

<snip> but those folks do cause strokes (and death) with unnecessary neck snaps (of no proven effectiveness). About 50% of customers experience mild, transient discomfort. http://jrsm.rsmjournals.com/cgi/reprint/100/7/330
<snip>

Actually someone did raise this issue to me today and I decided to look it up in pub med. I found these articles

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2922298/?tool=pubmed
http://www.ncbi.nlm.nih.gov/pubmed/19251066

VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.

http://www.ncbi.nlm.nih.gov/pubmed/19251064

In Saskatchewan, we observed a dramatic increase in the incidence rate in 2000 and there was a corresponding relatively small increase in chiropractic utilization. In Ontario, there was a small increase in the incidence rate; however, chiropractic utilization decreased. At the ecological level, the increase in VBA stroke does not seem to be associated with an increase in the rate of chiropractic utilization.

This suggests that having your neck cracked by a chiropractic does not increase your chances of a stroke. To make matters worse I am not data mining. I could not find any papers that suggested that chiropractic does cause strokes. Or can someone tell me where I have gone wrong?

 

[Arthur Mann]

Chiropractors are all quacks.

 

[JJM]

... This suggests that having your neck cracked by a chiropractic does not increase your chances of a stroke. To make matters worse I am not data mining. I could not find any papers that suggested that chiropractic does cause strokes. Or can someone tell me where I have gone wrong?

[FONT=&quot]You have cited three articles by chiros desperately trying to rationalize-away the dangers of chiro.
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[FONT=&quot]See this [/FONT]http://www.quackwatch.org/01QuackeryRelatedTopics/chirostroke.html[FONT=&quot] for an explanation of how chiro neck manipulation causes stroke. Note the that known mechanism allows time to pass, so we often find people with strokes who made it out of the chiropractor’s office without symptoms. If one has a stroke a week later, and is never able to communicate again, the connection to chiro may go undiscovered. However, the bilateral artery dissection (leading to stroke) seems to be chiropractors’ “gift” to health care. If you go here http://www.ebm-first.com/ you can read about Sandra Nette. She collapsed outside the quack’s office and never spoke again; but when her husband got to the hospital the ER Dr. said “Chiropractor, right?” He recognized the chiro’s signature, bilateral artery dissection.
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[FONT=&quot]See C. Preul et al Clinical Neuroradiology 2010 “Bilateral Vertebral Artery Dissection After Chiropractic Maneuver” http://www.ncbi.nlm.nih.gov/pubmed/20959946 This doesn’t even provide an abstract; but I have the paper. Some poor woman had an MRI of her neck (which was normal) just before a chiro snapped it, and caused an immediate stroke. The “after” MRI showed the quack had damaged both arteries.
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[FONT=&quot]Go here http://www.sciencebasedmedicine.org/ and look at the posts on chiropractic. One of them explains what is wrong with another article by chiropractors claiming they are not causing strokes- despite the fact that one author (Cassidy) had to admit in court that he had a customer who had a stroke during his “treatment.”
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[FONT=&quot]See this survey [/FONT][FONT=&quot]http://www.ptjournal.org/cgi/content/full/79/1/50[/FONT] [FONT=&quot]which shows that chiros are largely responsible for strokes after neck manipulation. At the ebm-first URL that I provided (above) there is a link to a video in which Dr. Kinsinger explains that chiros are indiscriminate and incautious in there manipulations, so they cause more harm than others (e.g., PTs).
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[FONT=&quot]In addition to book chapters, I have 80 electronic articles about the dangers of chiropractic manipulation of the neck, it seems a bit odd that you could only find three articles by chiros frantically grasping at straws.
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[FONT=&quot]The problem is, as I noted above, complicated by the facts that the damage is infrequent, and the victim is often unable to make the connection. Thus, we do not know the magnitude of the problem. The rarity of an adverse event needs to be balanced by the value of the treatment. In this case, the benefit of chiro neck adjustment is zero compared to safer treatments. The risk of death is not a good trade-off for a minor ailment or, in the case of Ms. Nette, “routine maintenance” adjustments.

ETA: Sorry, I composed this post offline and copy-pasted it, and the formatting is messed-up.
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[rjh01]

Thanks JJM for your post. However it is not very useful. The problem is that I need to convince someone else who probably has seen the papers I linked. So I need to show that person something better. Unfortunately I do not think you have given me this.

The references in the quack watch article do not check out and are mostly old.


http://ptjournal.apta.org/content/79/1/50.full - is reasonable, but it is old.

The cases were published between 1925 and 1997.

http://www.sciencebasedmedicine.org/ - I think you are referring to this http://www.sciencebasedmedicine.org/?p=5897#more-5897 - I might be able to use it as it shows Chiropractic in a bad light, but that is not what I am after.

Some poor woman had an MRI of her neck (which was normal) just before a chiro snapped it, and caused an immediate stroke. The “after” MRI showed the quack had damaged both arteries.

In other words just a case study. I have read on this forum that this is not evidence.

When I have time I will do another search in pub med for something better.

 

[xjx388]

You aren't going to find much about safety and efficacy except for case studies and reviews of case studies. Everything else is very conflicted. Bottom line is that it might very well be effective for certain types of back pain, but there are real risks with spinal/cervical manipulation.

The problem in Texas is that, despite what the chiro who wrote the article says, they are usually not cost-effective. Patients go to them for 20-100 treatments and never seem to get better. They can see a pain management doc once a month and get better results. That's the real core of the problem, not "safety and efficacy."

 

[JJM]

... The references in the quack watch article do not check out and are mostly old.

Anatomy and physiology have not changed in the latest few years.

http://ptjournal.apta.org/content/79/1/50.full - is reasonable, but it is old.

Many chiros working in 1995 are still around. You need to show me an updated survey negating it- the one I cited is not outdated. Also, the the 2010 article I cited is not old, and it is quite specific.

http://www.sciencebasedmedicine.org/ - I think you are referring to this http://www.sciencebasedmedicine.org/?p=5897#more-5897 - I might be able to use it as it shows Chiropractic in a bad light, but that is not what I am after.

There is a LOT at that web site, not just one comment. Look at all the other stuff I cited, also, look at http://whatstheharm.net/ where victims of chiro are listed.

In other words just a case study. I have read on this forum that this is not evidence.

That is just your ignorance talking. The mechanism for harm is known, and there are numerous examples of it happening concurrent with chiropracty.

When I have time I will do another search in pub med for something better.

PubMed will bring you nonsense, it is in their charter. You have to be able to understand what you find there. Apparently you cannot.

 

[Blue Wode]

@ rjh01

It’s worth noting the following very pertinent points which were made by Professor Edzard Ernst in a recent critique of the UK NICE guidelines for acute low back pain which recommend spinal manipulation administered by physiotherapists, osteopaths, chiropractors and others as a first line treatment:

“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

And this is an even more recent paper by Professor Ernst which is well worth a read:

Vascular accidents after chiropractic spinal manipulation: Myth or reality?

"The association between chiropractic neck manipulation and vascular accidents is well established. A recent case control study, however, casts doubt on the notion that the association is caused by nature. A detailed critique of that study reveals several weaknesses. Therefore the balance of probabilities seems to indicate that the association, in fact, is causal."

More…
http://www.chirowatch.com/Stroke/2010 Vascular accidents after chiroSM - myth or reality.pdf

As safer, cheaper, and more convenient effective options are available for back and neck pain sufferers, the unfavourable risk/benefit profile for chiropractic (as outlined above) means that it cannot be a recommended as a treatment.

 

[Blue Wode]

BTW, Texan chiropractors appear to be an unhappy lot at the moment due to the Texas Medical Association's (TMA) lawsuit that could end up wiping out the whole US chiropractic profession:
http://www.ebm-first.com/chiropract...rs-rights-to-diagnose-medical-conditions.html

Apparently several US chiropractic organisations are getting together to hold a special seminar to support the chiropractic fight against the TMA lawsuit:
http://www.chiroeco.com/chiropractic/news/10570/52/ce-seminar-helps-fight-tma-lawsuit-/

 

[rjh01]

BTW, Texan chiropractors appear to be an unhappy lot at the moment due to the Texas Medical Association's (TMA) lawsuit that could end up wiping out the whole US chiropractic profession:
http://www.ebm-first.com/chiropract...rs-rights-to-diagnose-medical-conditions.html

<snip>

I cannot see how it could wipe out the whole US chiropractic profession. Is the decision of the Texas judge binding on all of the US? It might however restrain them from making diagnoses they should not be making.

A Texas district court judge has ruled that chiropractors must limit their diagnoses to biomechanical conditions of the spine and musculoskeletal system.

 

[rjh01]

@ rjh01

<snip>
And this is an even more recent paper by Professor Ernst which is well worth a read:
<snip>

That is what I was looking for. Thanks.

 

[FattyCatty]

Here is a study from Germany: Vertebral artery dissections after chiropractic neck manipulation in Germany over three years, from the Journal of Neurology,

In summary, we provide clinical data from 36 patients with vertebral artery dissections due to cervical chiropractic manipulations. Our data point to a yet to be precisely determined substantial risk including death for VAD after neck chirotherapy.

Some of the manipulations were performed by doctors (orthopedic surgeons, neurologists and GPs), some by chiropractors. Their data point to the procedure, not the practitioner, as the problem.

 

[AnnoyingPony]

In my state, naturopathy, homeopathy, acupuncture, chiropractic stuff, etc. is considered effective treatment for illness by the state.

 

[rjh01]

Here is a study from Germany: Vertebral artery dissections after chiropractic neck manipulation in Germany over three years, from the Journal of Neurology,

Some of the manipulations were performed by doctors (orthopedic surgeons, neurologists and GPs), some by chiropractors. Their data point to the procedure, not the practitioner, as the problem.

I think that would help as well. Thanks.

 

[JJM]

As per the OP, here is some discussion of the chiro acting as PCP http://www.sciencebasedmedicine.org/?p=8252

That blog entry is mostly concerned with the possibility that chiros will get prescribing power. However, there is another problem- chiropractors cannot diagnose serious illness http://www.chirobase.org/02Research/jwk.html