The Stephan trial and evidence-based healthcare

[Cali Panthers Fan]

Originally Posted by GGG

There is peer reviewed scientific evidence that chiro is effective in a limited scope. I'm not sure what breadth of scope each chiropractic college is advocating.

Officially, the colleges don't advocate for pseudoscience. Unofficially, it's deeply ingrained in the culture and mindset of practicing clinicians, especially those who are training the next generation of chiropractors. The higher ups in the chiropractic board of education are trying to get rid of this, but it's harder than you think because of the idolization of previous chiropractors who founded the profession had a philosophy that drove the profession for a long time when there was no scientific evidence.

The profession is also severely jaded towards the medical world because of a famous legal case. In 1979, the AMA was found guilty in an antitrust lawsuit. There was a stated goal of the AMA to "contain and eliminate the chiropractic profession". The case was won by the chiropractors and it was deemed illegal to restrict medical doctors from associating or referring to chiropractors.

So you have a double-edged sword of philosophy that deviates from scientific norms or any physical mechanisms. Then you also have a severe distrust of anything in the medical world, including to some extent, medical science. Chiropractors often point out the numerous problems with being under strictly medical care as it doesn't always result in the person being healthier if they use medication to solve an issue. Of course, that ignores the fact that the medical profession has plenty of self-criticism on these fronts and is making strides to improve outcomes for patients, but of course, it tends to be a logistical issue as time with patients is minimal, and coaching them on lifestyle (which is the biggest reason for most health problems) can be time intensive.

But it doesn't absolve chiropractors from delving into specious or pseudo-science to justify their treatment protocols. It should be noted that there is NO peer-reviewed literature establishing the safety of adjusting children or infants. There is a small amount of literature on juveniles (read as teenagers), but it's mostly on idiopathic scoliosis. I still occasionally go to chiropractic conventions to maintain a license, and I cringe every time I see someone giving a lecture on pediatric chiropractic.

There's still lots of work to do in the profession, and it pains me to see such bull#### come out of chiropractors mouths. However, there are established benefits in the literature for low back and neck pain. In fact, it's been established that chiropractic has equal or better outcomes for patients with mechanical low back pain compared to surgery, so it should be sought out as the first option, and most medical doctors are referring based on that information now. Continuing on this line of thinking, back pain is the most common chronic pain complaint globally, and if it's severe enough, opioids are commonly prescribed by medical doctors, making this a key factor in the current opioid crisis (the other factor being that people just want to get high). Chiropractic has a key role to play in managing pain and keeping people off addictive pain meds. It's a small, but important job to do, and if chiropractors simply kept to their scope of practice and did it well, there would be enough work for everyone for the rest of their days.

Unfortunately, most chiropractors want to be someone's primary care physician (which they are relatively trained to do), but also be someone's life coach, spiritual guide, and personal guru. It's a failure of ego and hubris, probably to do with feeling inferior to medical doctors.

__________________________________________________ __________

People that know I am a chiropractor have thrown snide comments my way all over these boards without fully knowing my position on the profession. I hope people understand now that I am far from a quack or any of these lunatics that you hear about in the news, and I will say that there are plenty of really good chiropractors that stick to an evidence-based practice, but you don't often hear from them.

I myself have turned my back on practice as I always had misgivings about what I was taught in school, but once I figured out it was a problem, I was too far along in the program to jump ship.

Now I teach at a university, and I teach science. I believe in science, I always have. I am hopeful that chiropractors learn how to integrate with medical practice based on evidence, but I know that's unlikely to happen under the current culture and education model.

[Fuzz]

I'm curious, since you mentioned back pain...is there evidence chiropracty(?) is better than physiotherapy for outcomes in back pain issues?

From my limited knowledge, it seems chiropractors are happy to have you keep coming back for adjustments, whereas physio is more about giving you the tools to fix it yourself, and only going for a few months. I could be way off on that, I've only been to physio a couple times but it helped greatly. So I'm curious on how the 2 compare in addressing back pain.

[MoneyGuy]

I’ve used both chiro and physio with great results.

[Cali Panthers Fan]

Originally Posted by Fuzz

I'm curious, since you mentioned back pain...is there evidence chiropracty(?) is better than physiotherapy for outcomes in back pain issues?

From my limited knowledge, it seems chiropractors are happy to have you keep coming back for adjustments, whereas physio is more about giving you the tools to fix it yourself, and only going for a few months. I could be way off on that, I've only been to physio a couple times but it helped greatly. So I'm curious on how the 2 compare in addressing back pain.

*Chiropractic

I wouldn't say better necessarily, but chiropractic seems to get some immediate pain relief faster. 6 month outcomes are virtually identical.

You are correct in that chiropractors want patients coming back compared to physios, which is problematic depending on the reason. Most of the time it's purely financially motivated. What you are talking about is called "maintenance care", and there's little evidence to suggest that it is beneficial. My personal recommendation for maintenance was always 6-8 weeks between visits in the absence of symptoms, or as needed should there be an exacerbation of symptoms. In my clinical experience, I found that those who didn't get some amount of maintenance care did have a relapse within the next calendar year. My thought is that those who get maintenance care are receiving a beneficial placebo effect mentally by taking regular care of their bodies and likely lowering the severity of pain should it arise, often to the point where they don't consider it anything more than a small twinge.

To me, that's good enough reason to get the care, even if it is a placebo effect. There's nothing wrong with placebo if it's known to provide patient benefits, and a lot of doctors are changing their bedside approach with patients to provide more placebo effect during a visit.

To answer your question, I have no problem if someone chose to see a physiotherapist if directed by their physician who gave them a diagnosis, but you need to see a doctor first as most physiotherapists are not trained extensively in diagnosis. Otherwise, they can go directly to a chiropractor who can diagnose and treat within the same visit, and if the symptoms are that severe, that short time window to treatment can be incredibly beneficial to the patient.

Why is it important to be diagnosed for simple back pain you ask? Simple. To rule out more severe conditions that may require emergency treatment. I would not trust a physiotherapist to diagnose because they are not liable should they miss something. Chiropractors ARE liable because it's in their scope of practice to diagnose or refer appropriately, so they have to be able to catch things that come through their office. If we're talking about which treatment is better? It's pretty much equal.

I hope that answers your question.

[PsYcNeT]

Unless someone is willing to nuke the Palmer School and it's two satellite campuses, you're always going to have quacks telling you to crack baby bones and manipulate spine viruses.

[photon]

Originally Posted by Cali Panthers Fan

To me, that's good enough reason to get the care, even if it is a placebo effect. There's nothing wrong with placebo if it's known to provide patient benefits, and a lot of doctors are changing their bedside approach with patients to provide more placebo effect during a visit.

My only problem with placebo is a) charging for it feels immoral, at least if the practitioner is aware of it and isn't up front about it and moreso b) if there's risk involved (especially if it's undisclosed).

My understanding is that there is some risk of stroke with neck manipulation, but I haven't read anything about that in a long time, do you have any info or comment on that?

Thanks for your super informative posts on this!

[DownhillGoat]

Originally Posted by photon

My understanding is that there is some risk of stroke with neck manipulation, but I haven't read anything about that in a long time, do you have any info or comment on that?

Short version - there's a risk of dissecting/tearing an artery, which then basically can cause a stroke. Blood will enter the tear and form a clot. My best friend went through that, fun times.

[#-3]

Originally Posted by Fuzz

I'm curious, since you mentioned back pain...is there evidence chiropracty(?) is better than physiotherapy for outcomes in back pain issues?

From my limited knowledge, it seems chiropractors are happy to have you keep coming back for adjustments, whereas physio is more about giving you the tools to fix it yourself, and only going for a few months. I could be way off on that, I've only been to physio a couple times but it helped greatly. So I'm curious on how the 2 compare in addressing back pain.

This is one random study I've pulled out, I think its indicative of consensus.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447299/

To summarize, heat packs appeared to be more effective chiropractic, although not in a statistically meaningful way, and over the length of the study regression to the mean is a more likely explanation than any intervention benefit.

I would say the founding premise of chiropractic is a lie, a misalignment in the spine is a debilitating illness that requires serious medical intervention. Not a 15 minute monthly visits. This founding lie makes it hard for them to completely turn their back on pseudoscience because to turn away from that would lead them down the path of becoming low impact physiotherapists.

physiotherapists are also largely relying on regression to the the mean for treatment. But they are making patients put in work and exercise to ensure there is limited loss of function towards the end of healing. Which is why pysio visits are 5 to 10 x longer than chyro visits, and often involve muscle training of some sort.

[Cali Panthers Fan]

Originally Posted by photon

My only problem with placebo is a) charging for it feels immoral, at least if the practitioner is aware of it and isn't up front about it and moreso b) if there's risk involved (especially if it's undisclosed).

My understanding is that there is some risk of stroke with neck manipulation, but I haven't read anything about that in a long time, do you have any info or comment on that?

Thanks for your super informative posts on this!

Well you’re talking about informed consent, and it’s a legal requirement for a physician to discuss it with patients and document it. Failure to do so may result in losing your license. The risk needs to be stated as about 1 in one million (although it may have changed since last I practiced) which is a ridiculously low risk overall. So while there is some risk, it’s so low as to be negligible and you’re a thousand times more likely to be hurt in a car accident on the way to the appointment.

I should mention that there are other observed benefits to maintenance care, but they would be deemed subclinical, meaning they aren’t immediately obvious in terms of symptoms of physiology. Maintenance care ensures that joints are moving through the full range of motion on a regular basis. We know that joints that don’t move completely also don’t activate mechanoreceptors in those joints properly or effectively. This creates aberrant neural input, and therefore, inappropriate activation of musculature, sometimes resulting in spasm. Over longer periods of time, it can result in the brain learning a new incorrect motor activation pattern, resulting in dysfunction of the musculoskeletal system. It doesn’t always lead to pain, but it can create small issues in balance, muscle over or under activation to stimulus, and degenerative joint disease if left untreated. I liken it to getting your teeth cleaned every 6 months. You don’t always have a problem that requires dental surgery or cavities being filled, but if left unchecked it could become a problem long term.

Now again, I would always present this as a recommendation for follow up after resolving the main issue, but never presented it as required. I also made sure they understood that the benefits would be minimal, but it would also possibly prevent future flare ups, and it would not guarantee the absence of a flare up.

I myself still get maintenance care, and I find that by 8 weeks I usually have a few things that need some attention. My wife on the other hand can go 3 or 4 months between adjustments and be just fine. It depends on the person, which is why some people believe in chiropractic so much, and others don’t seem to notice any benefit.

[NuclearFart]

The link between neck manipulation and dissection is challenging to accurately gauge because the majority of cited literature relies on case reports or retrospective case series which are heavily prone to under reporting and bias. Chiro organizations are also highly incentivized to downplay the incidence for business and malpractice reasons.

Regardless, I think the bigger concern about Chiro neck manipulation is the misdiagnosis -> mistreatment aspect. Anecdotally, we always see a couple cases per year of vertebral artery dissections that were initially treated by Chiros for "neck pain", where the patient did not present to the ER until after they progressed to a stroke. I don't think the Chiros caused the majority of these dissections to be honest, but they certainly delayed proper diagnosis and potential treatment which could have prevented a debilitating outcome.

[Cali Panthers Fan]

I think that’s rather unfair because most medical doctors wouldn’t be looking at VAS or stroke with a patient that presents with neck pain, so to say the chiropractor delayed care or misdiagnosed/mistreated the patient is to assume that anyone else would have caught it.

Besides, you don’t want to go into misdiagnosis problems because the medical world makes far more frequent and serious errors. There is a reason that malpractice insurance for chiropractors is a fraction of what it is for medical providers. Overall, the risk is extremely low and very few serious incidents seek chiropractic care, and those that need emergency care are properly referred the vast majority of the time. So you get a couple patients a year? Okay, so statistically speaking that’s insignificant and would be treated as outliers to the main data.

Not to diminish the importance of what you’re talking about, but I feel that putting it in proper context of relative risk is important.

[jayswin]

Originally Posted by DownhillGoat

Short version - there's a risk of dissecting/tearing an artery, which then basically can cause a stroke. Blood will enter the tear and form a clot. My best friend went through that, fun times.

Like just from a chiropract?

[NuclearFart]

Originally Posted by Cali Panthers Fan

I think that’s rather unfair because most medical doctors wouldn’t be looking at VAS or stroke with a patient that presents with neck pain, so to say the chiropractor delayed care or misdiagnosed/mistreated the patient is to assume that anyone else would have caught it.

Besides, you don’t want to go into misdiagnosis problems because the medical world makes far more frequent and serious errors.

There is a reason that malpractice insurance for chiropractors is a fraction of what it is for medical providers. Overall, the risk is extremely low and very few serious incidents seek chiropractic care, and those that need emergency care are properly referred the vast majority of the time. So you get a couple patients a year? Okay, so statistically speaking that’s insignificant and would be treated as outliers to the main data.

Not to diminish the importance of what you’re talking about, but I feel that putting it in proper context of relative risk is important.

You are making a Trump-like false equivalency argument with this "what about MD malpractice/misdiagnosis rate". The proper context here is that misdiagnosis etc. is going to be increased among medical providers because they deal with a significantly higher volume of physical pathology and complex medical problems inherently prone to sub optimal outcomes. MD are often the end of the line after paramedical providers have cherry picked the proverbial low lying fruit, ie. relatively easy problems with none/minimal complications. It's the definition of selection bias, of course there will be a discrepancy in outcomes. Furthermore, when the poop hits the fan, Chiros/naturopaths/etc frequently hide behind the fact they aren't MDs and warned the patient as such in their informed consent telling them to seek proper medical attention if they are concerned. This appears to be somewhat protective against malpractice, ergo the lower insurance rates.

I think its a very flawed assumption MDs aren't at least considering dissection in the back of their mind when assessing a patient for acute neck pain, if not for CYA reasons you already alluded to. There is certainly no shortage of patients sent to the ED from GP's for query dissection, yet I can say that I have never even seen one from a Chiro. I would also strongly argue MDs are much more attuned and competent in recognizing the signs of vertebrobasilar insufficiency compared to a Chiro. I'm not saying MDs do not ever miss them (they certainly do), but at least those patients are already within the healthcare net instead of dwelling in Chiro purgatory until a preventable adverse event occurred.

To label these cases as outliers for purposes of dismissing them is in line with Chiro organization stance, but ultimately a callous attitude to healthcare. You also speak of relative risk, but ignore that I'm just one acute care provider without any clue to the denominator. If I only see 250 patients a year, 2-3 is not a statistically insignificant.

[Cali Panthers Fan]

In your first paragraph, I made no assertion to the contrary, and I even said that the number of severe cases that seek chiropractic care is significantly less than MDs, so I don’t get what your objection is. I’m simply saying that when something serious does present itself to a chiropractor, they are trained to refer immediately. Should one or two decide to treat a patient in the absence of obvious clinical information, it’s simply part of the reality that mistakes happen in any kind of medical care. My point was that it’s not a common diagnosis to look at VAS first, so many clinicians of ANY discipline are likely to miss it in the absence of obvious clinical signs and symptoms, which is extremely common with VAS. Without tinnitus or vertigo there is nothing to distinguish it from normal neck pain and headaches.

It’s unfortunate that you label my thoughts as Trump-like false equivalency, and it tells me that you’re not interested in an honest exchange of ideas here. I’m on your side, but I also don’t feel like certain characterizations of an entire profession are appropriate. I highly object to phrases like “Chiro purgatory” as it seems like you have a significant bias against chiropractic. My question is, how much do you actually know about chiropractic training and education?

I don’t think your assertion that MDs are better at recognizing VAS than chiropractors is accurate. It’s the highest risk condition that could walk into a chiropractic office other than obvious stroke or heart attack, so chiropractors have been expertly trained at looking for those specific signs and symptoms should they even slightly suspect it to be the case. In any profession there are better doctors than others, so it’s always possible for someone to not remember their training and miss something.

You are an acute care provider that only sees 250 patients a year? So less than one a day? You must be the slowest care provider I have ever heard of. Yes, if that were the actual prevalence of the missed cases that see a chiropractor I could see your point, but considering it happens so infrequently that doesn’t really add up for me.

It sounds like you have an axe to grind with chiropractors. Again, I’m highly critical of the profession, but with anything it should be an accurate critique and not exaggerated to try to demonize an entire profession. I would argue that recognizing stroke and VAS is the one area where chiropractors are highly trained to recognize early signs and symptoms. I say this from personal experience receiving that training and speaking with many practicing chiropractors who have cases walk in their doors and immediately refer them for imaging.

So I guess we both have our anecdotal cases and no larger data set to suggest that chiropractors are uniquely problematic in this regard. I haven’t seen anything at any rate, but if you have some peer-reviewed data to share I’d be happy to look at it.

[peter12]

I want links to actual studies.

[afc wimbledon]

The problem with Chiro's is the same as the problem with any borderline quackery, they are so defensive of their 'specialty' it blinds them to their own boundries in a way you wouldn't normally see in a, for example, ear nose and throat doctor who finds evidence of something they cant treat.

Regular doctors happily pass off patients to other specialists, they don't seem to feel the need to claim their speciality will cure everything the way homeopaths and chiro's seem to.
There might be some limited efficacy to chiropractic treatment, but it is so limited and so lacking in scientific grounding that those that practice it are in reality little different from any other cult, and cults, without the usual grounding and boundries always end up thinking they are the only answer for everything, whether they are religious or 'medical'.

When I can ring up a chiro with a bit of neck pain and he or she tells me there is nothing they can do for me as statistical evidence shows they are only useful for a limited area of lower back pain, at that point they can call themselves 'medicine' and also that is the point they will stop hurting people.

[troutman]

Summary of Key Research about Chiropractic

https://sciencebasedmedicine.org/ref.../chiropractic/

[towards the end of the blog]

[peter12]

After struggling through a year and a half of herniated discs and doing anything ANYTHING to alleviate the almost unbearable pain, I will say that the only treatment that worked was 6 months of physio followed by strength training 3 times a week. That's it.

[PsYcNeT]

Local clinic that treats NEWBORNS

THEY DON'T EVEN HAVE FULLY FORMED BONES OR MUSCLES



Just ####ing monstrous.

[Cali Panthers Fan]

Originally Posted by afc wimbledon

The problem with Chiro's is the same as the problem with any borderline quackery, they are so defensive of their 'specialty' it blinds them to their own boundries in a way you wouldn't normally see in a, for example, ear nose and throat doctor who finds evidence of something they cant treat.

Regular doctors happily pass off patients to other specialists, they don't seem to feel the need to claim their speciality will cure everything the way homeopaths and chiro's seem to.
There might be some limited efficacy to chiropractic treatment, but it is so limited and so lacking in scientific grounding that those that practice it are in reality little different from any other cult, and cults, without the usual grounding and boundries always end up thinking they are the only answer for everything, whether they are religious or 'medical'.

When I can ring up a chiro with a bit of neck pain and he or she tells me there is nothing they can do for me as statistical evidence shows they are only useful for a limited area of lower back pain, at that point they can call themselves 'medicine' and also that is the point they will stop hurting people.

I don’t take any issue with this characterization. That’s pretty fair, and once I looked into all the evidence I found that chiropractic was very limited in it’s ability to treat. But that being said, it isn’t useless either.

My problem has always been that chiropractors want to be the messiah to their patients, to “change their lives” and get them out of the medical model. To me that’s unethical.

I should mention that my father is a chiropractor as well and is one of these “messiah” types. I have challenged him repeatedly but he is so indoctrinated that he cannot listen to reason. And yes, before you ask my father is an anti-vaxxer and I have repeatedly begged him to change his mind, but to no avail. I have found this with many others who are “dyed in the wool” so to speak. It has been so contentious that my father and I rarely speak anymore, which has been personally very difficult.

I’ve been through the ringer on these subjects. It’s been personally and professionally very difficult for me to reconcile the reality with what I was raised to believe. Had I known what the profession was really about I would never have signed up, but it’s too late for that now.

I guess what I would say is that if the culture or climate around chiropractic did change I wouldn’t have any objection to young people going down that road. As it stands right now, I would beg any young person to reconsider becoming a chiropractor.