Chiropractic on SDN Forums

prechiros · Dec 17, 2004

Hi!

I'm curious why there is no discussion or forum for those interested in Chiropractic. I understand it can be controversial - but it is the top "alternative" provider of health care in the US.

DC's receive education comparable to MD's, and while our focus is different (ours primarily musculoskeletal) we are still active in the holistic healthcare of our patients.

I just think an honest look at chiropractic is in order somewhere on these forums...

That's my two cents. Thanks!

Michael Vollbrecht
Pre-Chiropractic Student, Chicago, IL

===

"If at first you don't succeed, try, try again. Then give up. No use being a damned fool about it." -- W.C. Fields

FoughtFyr · Dec 17, 2004

prechiros said:
DC's receive education comparable to MD's, and while our focus is different (ours primarily musculoskeletal) we are still active in the holistic healthcare of our patients.

I just think an honest look at chiropractic is in order somewhere on these forums.

Actually, the education is not comparable at all. This has been discussed ad nauseum in these forums. See:

http://forums.studentdoctor.net/showthread.php?t=151084

http://forums.studentdoctor.net/showthread.php?t=133855

http://forums.studentdoctor.net/showthread.php?t=144654

http://forums.studentdoctor.net/showthread.php?t=138478

and the end of this thread...

http://forums.studentdoctor.net/showthread.php?t=160510

In my opinion, chiropractic, as a profession worked to separate itself from medicine. Why should a medical student/resident site host a forum for them? There are not "alternative medicine" forums here, this is a "medical" site.

There exist several web boards for Palmer's minions, feel free to look there for support of your professional choice.

- H

FoughtFyr · Dec 17, 2004

prechiros said:
I just think an honest look at chiropractic is in order somewhere on these forums...

Try www.chirobase.org

- H

prechiros · Dec 17, 2004

FoughtFyr said:
Try www.chirobase.org

- H

No problem, I'll go someplace else.

PublicHealth · Dec 17, 2004

prechiros said:
No problem, I'll go someplace else.

Feel free to post questions about chiropractic in the "Allied Health" forum. Disregard FoughtFyr's posts -- he's our resident "chiro-basher." BackTalk, our "resident chiropractor," has provided some valuable insights into the chiropractic profession. You may want to PM him or start a new thread and ask him to address your questions. By the way, I'm a first-year medical student who is open-minded about chiropractic and alternative medicine.

Welcome aboard and happy posting!

Here are some chiro websites:

http://www.amerchiro.org/

http://www.chiropractic.org/

http://www.chiro.org/

http://www.chiroweb.com/

http://www.chiroweb.com/dynamic/

http://www.chiroeco.com/

...and a student forum:

http://www.chiroweb.com/cgi-bin/ubb/students/Ultimate.cgi

FoughtFyr · Dec 17, 2004

PublicHealth said:
Feel free to post questions about chiropractic in the "Allied Health" forum. Disregard FoughtFyr's posts -- he's our resident "chiro-basher."

Now stop, you'll make me blush! Gosh forbid someone suggest chiropractic be held to scientific standards. BTW - MacGyver is the resident "chiro-basher", not me. I just ask that the claims be validated.

And are you suggesting you agree with the OPs assertion that chiropractic education is equivalent to MD/DO??? Even BackTalk has given up that fight.

PublicHealth said:
BackTalk, our "resident chiropractor," has provided some valuable insights into the chiropractic profession. You may want to PM him or start a new thread and ask him to address your questions. By the way, I'm a first-year medical student who is open-minded about chiropractic and alternative medicine.

Welcome aboard and happy posting!

Here are some chiro websites:

http://www.amerchiro.org/

http://www.chiropractic.org/

http://www.chiro.org/

http://www.chiroweb.com/

http://www.chiroweb.com/dynamic/

http://www.chiroeco.com/

...and a student forum:

http://www.chiroweb.com/cgi-bin/ubb/students/Ultimate.cgi

Yep, I agree he can post here. I also think, as I said, he is more likely to find "career affirmation" on chiropractic sites, such as those you suggested. I do not think, however, that SDN should create a "chiropractic forum" as the OP asked for. And I think we will continue to disagree with the "open and honest assessment" of chiropractic as long as freeedom, MacGyver, myself, and many others insist on a scientific "proof" of chiropractic safety and efficacy.

Now if that qualifies as bashing, oh well!

- H

prechiros · Dec 17, 2004

FoughtFyr said:
And are you suggesting you agree with the OPs assertion that chiropractic education is equivalent to MD/DO??? Even BackTalk has given up that fight.
- H

I didn't mean to fight over anything, or bother anybody. I was just trying to have a decent conversation.

I apologize for asserting anything.

It's disappointing to me, because no matter where I go, I run into hostility. I appreciate people being open-minded about a topic I find very important. It's just hard to want to participate in online forums when people seem hell-bent on turning it into an argument.

Good luck in med school,

Mike

PublicHealth · Dec 17, 2004

prechiros said:
I didn't mean to fight over anything, or bother anybody. I was just trying to have a decent conversation.

I apologize for asserting anything.

It's disappointing to me, because no matter where I go, I run into hostility. I appreciate people being open-minded about a topic I find very important. It's just hard to want to participate in online forums when people seem hell-bent on turning it into an argument.

Good luck in med school,

Mike

Don't go away! Like many others in the medical community, FoughtFyr, MacGyver, and associates are skeptical of chiropractic. If anything, our discussions may help shape our thinking about this and other professions.

As mentioned above, DC education is not MD/DO education. Many chiro schools say this so that they may attract pre-meds into their ranks. Don't be fooled. Seek out DCs in your area, talk to them about their impressions of the field, and read as much as you can about it. Feel free to post your questions in this forum. We like to slug it out in here once in a while -- it's a healthy form of sublimation!

We'd be curious to know more about your thoughts and experiences regarding chiropractic. What are your reasons for pursuing a career in this field? Have you considered allopathic or osteopathic medicine?

FoughtFyr · Dec 17, 2004

prechiros said:
I didn't mean to fight over anything, or bother anybody. I was just trying to have a decent conversation.

I apologize for asserting anything.

It's disappointing to me, because no matter where I go, I run into hostility. I appreciate people being open-minded about a topic I find very important. It's just hard to want to participate in online forums when people seem hell-bent on turning it into an argument.

Good luck in med school,

Mike

I'm finished with medical school. But thanks. If you are looking for less hostile forums, see the ones Publichealth listed above. If you would like to read the discussions behind the "hostility" you sense, see the threads I listed above. In my opinion, you will very often run into questions from traditional medical providers. The reasons for this vary from negative interactions with straights and pseudo-mixers to those with more philosophic arguments, like myself. In any event, I'm not sure SDN is the forum you are seeking.

Best of luck yourself,

- H

50960 · Dec 17, 2004

Publichealth, thanks for saving this guy!! It is too bad people with legit questions get run off by overzealous members with their own agenda. I think there should be a chiro section, and I also don't think DPM's should be in the allied health section!!
I wish you could be be this nice to me at least once!!! LOL

niko327 · Dec 17, 2004

prechiros said:
I didn't mean to fight over anything, or bother anybody. I was just trying to have a decent conversation.

I apologize for asserting anything.

It's disappointing to me, because no matter where I go, I run into hostility. I appreciate people being open-minded about a topic I find very important. It's just hard to want to participate in online forums when people seem hell-bent on turning it into an argument.

Good luck in med school,

Mike

Dude, don't worry about it! You didn't assert anything, what you just experienced is an SDN love slap. Come on in, sit right back and enjoy the dysfunction.

PublicHealth · Dec 18, 2004

psisci said:
Publichealth, thanks for saving this guy!! It is too bad people with legit questions get run off by overzealous members with their own agenda. I think there should be a chiro section, and I also don't think DPM's should be in the allied health section!!
I wish you could be be this nice to me at least once!!! LOL

You know I love ya...

rooster · Dec 18, 2004

>>as long as freeedom, MacGyver, myself, and many others insist on a scientific "proof" of chiropractic safety and efficacy.<<<

Your statement above is just a blanket, non-specific, assertion.
Please be more specific as to what "scientific proof" you are looking for of "chriopractic safety and efficacy". Or, what are your sources to as to the absence of such. Meaningful dialogue must be more specific.

What is the basis for your beliefs?

FoughtFyr · Dec 18, 2004

rooster said:
>>as long as freeedom, MacGyver, myself, and many others insist on a scientific "proof" of chiropractic safety and efficacy.<<<

Your statement above is just a blanket, non-specific, assertion.
Please be more specific as to what "scientific proof" you are looking for of "chriopractic safety and efficacy". Or, what are your sources to as to the absence of such. Meaningful dialogue must be more specific.

What is the basis for your beliefs?

If you look at the threads I have posted above, you will see in depth discussions. Basically, to the best of my knowledge there is only limited data that, at best, suggest that chiropractic treatment is "as effective", but not more so, than conventional medicine in the treatment of low back pain. O.k. For the sake of argument, I'll accept those studies at face value (although there are serious methodological issues). But there are also several studies that suggest chiropractors can not recognize basic emergencies that require immediate medical care (such as neonatal fever), that many chiropractors advocate questionable practices (such as recommending against vaccination), and that many claim to be able to treat many other disease states (besides low back pain) where there is no data, or even plausible mechanism, for them to do so. Now, in the face of a treatment that offers no improvement over existing therapy, and carries sizable risk (from misinformation and mistreatment), I can not see my way clear to support Chiropractic.

Now, there are many Chiropractors (often referred to as "mixers") who run more responsible practices, but, given the DEEP division within the Chiropractic community, the lack of standardization in training or practice, and the questionable business practices of the training institutions (all well documented in the threads I listed - I am not going to repost here), it is impossible to tell which Chiropractor is which. So, I am not convinced. Additionally, there is no oversight (short of state boards, which are regulatory, not quality assurance driven), as there is for physicians (e.g., M&Ms, peer review, hospital boards) to hold an individual Chiropractor to any given standards. So how is a patient (or referring physician for that matter) to determine which is a skilled provider?

So show me an RCT (the same trial we require of any new medical practice) or even an observational study that meets Koch's postulates (suggesting a RCT would be beneficial) that shows Chiropractic care to be significantly better at preventing morbidity or mortality, and I'll listen. Get the profession to agree, amongst themselves, to standardize practices, so that recommending Chiropractic means roughly the same thing in different geographic areas, and I'll consider using their services. Hold them accountable for bad outcomes in both peer reviewed oversight as well as public health forums, and I'm in.

As for my "philospohical beliefs"... Well, I am a strong believer in education as a means to put theory into practice. I see this as key to advancing any science, but especially health related sciences. Chiropractic is a science without a theory. If you are to believe the posters here, most Chiropractic Colleges largely dismiss Palmer's subluxation theory. So what is their education based in? What is the scientific underpinning of their practice? If it is medicine (without surgery or drugs) as at least one poster here has suggested, then what is the need? There are already advanced providers based in medical theory - they are called MDs or DOs. Why create another type that excludes several components of the theory out of hand? And, can a group, trained outside a practice, invite themselves in? I for one don't believe it. Chiropractors I have spoken with IRL, and the statements made on the websites of many Chiropractic Colleges (themselves debunked in the Chiropractic Literature) suggest that most schools do adhere, in no small measure, to Palmer's theory. And that theory has been itself largely disproven.

So what is your basis to support Chiropractic? Are we just to believe that a grocer from the 1800's discovered an innate lifeforce that can not be demonstrated and it is the key to all of health? Are we supposed to cast aside centuries of continuously evolving science, that I'll grant you is imperfect, but is at least consistent, in favor of reducing subluxations because some marketing guru has convinced some people it is more "holistic"? Or is it just that there is simply too much cognitive dissonance created by the fact that some really intelligent people have spent far too much time and schooling chasing down a theory that simply doesn't hold true...

- H

PublicHealth · Dec 18, 2004

Some recent articles about chiropractic:

Arch Intern Med. 2004 Oct 11;164(18):1985-92.

Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs.

Legorreta AP, Metz RD, Nelson CF, Ray S, Chernicoff HO, Dinubile NA.

Department of Health Services, UCLA School of Public Health, Los Angeles, Calif, USA. [email protected]

BACKGROUND: Back pain accounts for more than $100 billion in annual US health care costs and is the second leading cause of physician visits and hospitalizations. This study ascertains the effect of systematic access to chiropractic care on the overall and neuromusculoskeletal-specific consumption of health care resources within a large managed-care system. METHODS: A 4-year retrospective claims data analysis comparing more than 700,000 health plan members with an additional chiropractic coverage benefit and 1 million members of the same health plan without the chiropractic benefit. RESULTS: Members with chiropractic insurance coverage, compared with those without coverage, had lower annual total health care expenditures ($1463 vs $1671 per member per year, P<.001). Having chiropractic coverage was associated with a 1.6% decrease (P = .001) in total annual health care costs at the health plan level. Back pain patients with chiropractic coverage, compared with those without coverage, had lower utilization (per 1000 episodes) of plain radiographs (17.5 vs 22.7, P<.001), low back surgery (3.3 vs 4.8, P<.001), hospitalizations (9.3 vs 15.6, P<.001), and magnetic resonance imaging (43.2 vs 68.9, P<.001). Patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode-related costs ($289 vs $399, P<.001). CONCLUSIONS: Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care. Systematic access to managed chiropractic care not only may prove to be clinically beneficial but also may reduce overall health care costs.

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Soc Sci Med. 2005 Feb;60(3):545-61.

Evidence-based medicine and its implications for the profession of chiropractic.

Villanueva-Russell Y.

Texas A&M University-Commerce, Department of Sociology and Criminal Justice, Social Sciences 232, P.O. Box 3011, Commerce, TX 75429, USA.

Evidence-based medicine (EBM) has grown in popularity and prominence in the world of orthodox medicine since the 1980s. The focus of this article is on the process of developing practice guidelines (one type of EBM) and its effects upon chiropractic, a profession with a "philosophy, science and art" that is constructed upon divergent epistemological and methodological tenets (namely, the idea of "vitalism"). The EBM movement is conceptualized as part of a larger political economy surrounding the health care environment that creates a new set of imperatives for orthodox medicine, and also branches of alternative medicine that are in the process of professionalization. The quantitative, positivist and empiricist assumptions of EBM dictate which approaches to treatment and which clinical procedures are legitimate and perhaps reimbursable under systems of managed care. The ramifications of practice guidelines and its effects upon the intraprofessional segments of the chiropractic profession are also discussed.

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Prev Med. 2005 Jan;40(1):46-53.

Use of complementary and alternative medicine among United States adults: the influences of personality, coping strategies, and social support.

Honda K, Jacobson JS.

Department of Epidemiology, Columbia University, New York, NY 10032, USA.

Background. Although patterns of utilization of complementary and alternative medicine (CAM) in the community have begun to be described, few studies have addressed the relationships between dispositional psychological factors and the use of CAM. The aim of this study was to examine the associations between CAM use and personality, coping strategies, and perceived social support in a representative sample of adults in the United States. Methods. Data were drawn from the Midlife Development in the United States Survey (MIDUS), a representative sample of 3,032 adults aged 25-74 in the US population. We analyzed use of acupuncture, biofeedback, chiropractic, energy healing, exercise/movement therapy, herbal medicine, high-dose megavitamins, homeopathy, hypnosis, imagery techniques, massage, prayer/spiritual practice, relaxation/mediation, and special diet within the last year. Multiple logistic regression analyses were used to evaluate the association of personality, dispositional coping strategies (primary and secondary control), and perceived social support and strain with CAM use, controlling for sociodemographic factors, medical care access, and physical and mental disorders. Results. Openness was positively associated with the use of all types of CAM except manipulative body-based methods. Extroversion was inversely correlated with the use of mind-body therapies. Primary control was inversely and secondary control directly correlated with the use of CAM. Perceived friend support was positively associated with the use of mind-body therapies, manipulative body-based methods, and alternative medical systems. Perceived partner strain was positively associated with the use of biologically based therapies, and family strain increased the odds of manipulative body-based methods. Conclusions. This study is the first to document a significant association between specific domains of personality, coping strategies, and social support, and the use of CAM among adults in the general population. Understanding the relationships between psychological factors and CAM use may help researchers and health care providers to address patients' needs more effectively and to achieve better adherence to treatment recommendations.

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Spine J. 2004 Sep-Oct;4(5):574-83.

Dose-response for chiropractic care of chronic low back pain.

Haas M, Groupp E, Kraemer DF.

Center for Outcome Studies, Western States Chiropractic College, 2900 NE 132nd Avenue, Portland, OR 97230, USA. [email protected]

BACKGROUND CONTEXT: There have been no trials of optimal chiropractic care in terms of number of office visits for spinal manipulation and other therapeutic modalities. PURPOSE: To conduct a pilot study to make preliminary identification of the effects of number of chiropractic treatment visits for manipulation with and without physical modalities (PM) on chronic low back pain and disability. STUDY DESIGN/SETTING: Randomized controlled trial with a balanced 4x2 factorial design. Conducted in the faculty practice of a chiropractic college outpatient clinic. PATIENT SAMPLE: Seventy-two patients with chronic, nonspecific low back pain of mechanical origin. MAIN OUTCOME MEASURES: Von Korff pain and disability (100-point) scales. METHODS: Patients were randomly allocated to visits (1, 2, 3 or 4 visits/week for 3 weeks) and to treatment regimen (spinal manipulation only or spinal manipulation with PM). All patients received high-velocity low-amplitude spinal manipulation. Half received one or two of the following PM at each visit: soft tissue therapy, hot packs, electrotherapy or ultrasound. RESULTS: Pain intensity: At 4 weeks, there was a substantial linear effect of visits favoring a larger number of visits: 5.7 points per 3 visits (SE=2.3, p=.014). There was no effect of treatment regimen. At 12 weeks, the data suggested the potential for a similar effect of visits on patients receiving both manipulation and PM. Functional disability: At 4 weeks, a visits effect was noted (p=.018); the slope for group means was approximately 5 points per 3 visits. There were no group differences at 12 weeks. CONCLUSIONS: There was a positive, clinically important effect of the number of chiropractic treatments for chronic low back pain on pain intensity and disability at 4 weeks. Relief was substantial for patients receiving care 3 to 4 times per week for 3 weeks.

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FoughtFyr...we're still waiting on that RCT! I'd be curious to hear your thoughts about the Arch Internal Medicine article.

FoughtFyr · Dec 18, 2004

PublicHealth said:
FoughtFyr...we're still waiting on that RCT! I'd be curious to hear your thoughts about the Arch Internal Medicine article.

I'd have to read the entire thing. It may meet Koch's, i.e., chiropractic care is directly keeping costs down through therapuetic effect. However, it could also be that, directly or indirectly, those seeing the chiropractors are not utilizing other health care modalities, possibly when they should. There is no outcome data in the abstract that measures anything beside direct cost. Which I have never contested - yes, people do use chiropractors.

The other studies are less interesting to me. They seem to be reporting that yes, people do use chiropractors, yes, more is better when seeing a chiropractor, and a common defense that chiropractic is difficult to study (the EBM article). I'm in the middle of a research project on methamphetamine use, but if I get a moment I'll pull the articles and let you know what I think.

And I doubt you will ever get a better RCT than the NIH one, and that didn't make the case.

- H

PublicHealth · Dec 18, 2004

FoughtFyr said:
I'm in the middle of a research project on methamphetamine use, but if I get a moment I'll pull the articles and let you know what I think.

I'm a bit confused about your point that "chiropractic is a science without a theory." I think it's the other way around. Comments?

Regarding outcomes in the article by Legorreta et al. (which you should read before commenting on it), "access to chiropractic care correlated with a reduction in the cost of caring for neuromuscular complaints and back pain and was associated with lower utilization of radiography, magnetic resonance imaging, back surgery, and hospitalization" (Ness & Nisly, 2004, p. 1953).

There will ALWAYS be room for a better clinical trial. If you don't think so, then you should get more research experience. By the way, what is your research project on methamphetamine use examining? Does it meet Koch's postulates!?

For what it's worth, here's an editorial by two MDs that appeared in the issue of Archives cited above.

Cracking the Problem of Back Pain
Is Chiropractic the Answer?

Jose Ness, MD; Nicole Nisly, MD

Arch Intern Med. 2004;164:1953-1954.

Chiropractic is certainly one of the most popular therapeutic modalities encompassed by complementary and alternative medicine. In the well-known survey by Eisenberg et al,1 11% of respondents had used chiropractic in the preceding year. Visits to chiropractors account for most visits to practitioners who provide complementary and alternative medicine2 and represent the most common complementary and alternative medicine intervention employed by older adults.3 Chiropractors are now recognized as qualified practitioners by a growing number of health insurance companies4 and receive referrals from a considerable number of physicians practicing in other fields of expertise.5 Every state recognizes or requires examinations administered by the National Board of Chiropractic Examiners before licensing chiropractic professionals and defines continuing education criteria for license renewal.6-7 In the apt words used by Meeker and Haldeman,6 chiropractic is now "a profession at the crossroads of mainstream and alternative medicine."

Despite its growing popularity, the question remains as to whether chiropractic is a cost-effective intervention. Health care expenditures related to back pain, the most common complaint for which patients seek chiropractic aid, reached $26.3 billion in 1998 in the United States alone.8 Excessive and/or inappropriate use of diagnostic or therapeutic services has been cited as a significant contributing factor toward such expenditures.9 A recent systematic review10 concluded that chiropractic management did not lead to a reduction of costs related to back pain. However, this conclusion was preliminary and based solely on the results of 2 randomized trials, which included a total of 644 patients but used different interventions and different outcome measurements.11-12

PublicHealth · Dec 18, 2004

continued...

In this issue of ARCHIVES, Legorreta et al13 shed considerable light on the cost-effectiveness of chiropractic by performing a 4-year retrospective claims data analysis of more than 1 million members of a health care plan, comparing health care expenditures between those with and those without chiropractic coverage. Access to chiropractic care correlated with a reduction in the cost of caring for neuromuscular complaints and back pain and was associated with lower utilization of radiography, magnetic resonance imaging, back surgery, and hospitalization.10 The study raises the intriguing possibility that chiropractic may in fact be the more economic approach to the management of the complex, ill-defined, recurrent, and often refractory symptom of back pain.

One of the study's greatest strengths clearly lies in the sheer magnitude of the sample investigated, resulting, to my knowledge, in one of the largest analyses ever performed on the economic impact of chiropractic. However, important conceptual and methodological considerations ought to be addressed to paint a more accurate picture of the data's true significance.

The study design does not permit the definite determination of a cause-effect relationship between access to chiropractic and a more budget-effective approach to musculoskeletal care, pointing rather to the coexistence of the 2 phenomena in a managed-care population. Furthermore, the lack of a random element in defining the populations with and without access to chiropractic care may have partly compromised the validity of the results. The favorable health profile of the "chiropractically insured" is of particular concern. They comprise a younger and healthier population and, thus, are likely to have better outcomes and fewer health expenses. Even though the authors attempt to correct for this discrepancy, it is worrisome to assume the generalizability of the perceived cost-savings to a sicker, older cohort. In addition, the study portrays a population specific to a particular health care plan and within a particular state and, perhaps, not typically representative of other states or of patients who are insured by Medicaid or Medicare. Another generalizability issue arises from the lack of information regarding patient ethnicity, making the extrapolation of the authors' conclusions to minority populations problematic.

The cause of back pain or other musculoskeletal complaints may be of great significance in future cost analyses. Even though a staggering number of patients will have nonspecific back pain syndromes and may have equally satisfactory outcomes with a more cost-conservative diagnostic approach, the cases due to underlying serious illness (such as multiple myeloma, spinal cord compression, osteomyelitis) should be investigated separately. Most patients in the study used chiropractic care instead of usual medical care, resulting in lower expenses but also in the inability to ascertain the potential role and costs of integrated care in the treatment of complex cases. Issues such as the chronicity and localization of the musculoskeletal complaint also lend themselves to more detailed research not entirely addressed by Legorreta et al.13

PublicHealth · Dec 18, 2004

continued...

Safety concerns should be paramount in interpreting the results of future cost-effectiveness analyses. A systematic review of the available prospective data on the safety of chiropractic indicates that adverse events, albeit common, seem to be mild and transient.14 Local discomfort or pain, radiating pain, headaches, neck stiffness, fatigue, nausea, and dizziness have been reported.15 Serious complications such as cerebrovascular accidents, spinal cord compression, vertebral fracture, tracheal rupture, and carotid dissection have been described, especially with cervical manipulation, but are thought to be rare.14, 16-17 Careful scrutiny should be applied in future research toward defining the subset of patients who would be at higher risk for major complications from chiropractic and in whom the intervention would cease to be appropriate, let alone cost-effective. On the other hand, chiropractic manipulation may prove to be a safer alternative when compared with the use of nonsteroidal anti-inflammatory agents or opiates in frail patients who are highly susceptible to the development of devastating medication adverse effects.

Could the actual implementation of expanded or universal chiropractic coverage affect cost savings adversely? The inclusion of sicker patients in the chiropractically insured group could paradoxically lead to a higher degree of resource utilization by chiropractors, attenuating the expected cost reduction and decreasing the expense gap between chiropractors and other specialists caring for back pain.

The role of chiropractic in the delivery of health care has exhibited some fluidity in the recent past. Advocates from within the chiropractic profession argue for the right of chiropractors to be perceived and acknowledged as primary care providers, diagnosing and treating the myriad problems that characterize ambulatory care and not restricting their practice to the management of musculoskeletal conditions.18 Legorreta et al13 identify potential cost-savings related mostly to the management of back pain and related neuromuscular ailments but do not assess the economic feasibility of a more comprehensive model of chiropractic "primary" care. Extensive research in this area is warranted as chiropractic moves toward novel and/or broader roles in health care delivery.

The study published in this issue of ARCHIVES offers a tantalizing glimpse into possible large-scale economic benefits obtained through access to chiropractic coverage by large groups of insured patients. Nevertheless, critical questions remain regarding which subsets of patients could derive the most benefit from chiropractic care and yet incur fewer health expenditures. Once these questions are answered, we will have moved one step closer to success in the daunting task of managing back pain.

AUTHOR INFORMATION

Correspondence: Dr Ness, Department of Internal Medicine, Carver College of Medicine, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242 ([email protected]).

We thank Patsy McAtee for her efforts in the development of this editorial.

REFERENCES

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2. Wolsko PM, Eisenberg DM, Davis RB, Ettner SL, Phillips RS. Insurance coverage, medical conditions, and visits to alternative medicine providers: results of a national survey. Arch Intern Med. 2002;162:281-287. ABSTRACT/FULL TEXT
3. Foster DF, Phillips RS, Hamel MB, Eisenberg DM. Alternative medicine use in older Americans. J Am Geriatr Soc. 2000;48:1560-1565. ISI | MEDLINE
4. Pelletier KR, Astin JA. Integration and reimbursement of complementary and alternative medicine by managed care and insurance providers: 2000 update and cohort analysis. Altern Ther Health Med. 2002;8:38-39,42,44. MEDLINE
5. Astin JA, Marie A, Pelletier KR, Hansen E, Haskell WL. A review of the incorporation of complementary and alternative medicine by mainstream physicians. Arch Intern Med. 1998;158:2303-2310. ABSTRACT/FULL TEXT
6. Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med. 2002;136:216-227. ABSTRACT/FULL TEXT
7. Eisenberg DM, Cohen MH, Hrbek A, Grayzel J, Van Rompay MI, Cooper RA. Credentialing complementary and alternative medical providers. Ann Intern Med. 2002;137:965-973. ABSTRACT/FULL TEXT
8. Luo X, Pietrobon R, Sun SX, Liu GG, Hey L. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine. 2004;29:79-86. MEDLINE
9. Maetzel A, Li L. The economic burden of low back pain: a review of studies published between 1996 and 2001. Best Pract Res Clin Rheumatol. 2002;16:23-30. MEDLINE
10. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med. 2003;138:898-906. ABSTRACT/FULL TEXT
11. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998;339:1021-1029. ABSTRACT/FULL TEXT
12. Skargren EI, Carlsson PG, Oberg BE. One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain: subgroup analysis, recurrence, and additional health care utilization. Spine. 1998;23:1875-1883. CrossRef | ISI | MEDLINE
13. Legorreta AP, Metz RD, Nelson CF, Ray S, Chernicoff HO, DiNubile NA. Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs. Arch Intern Med. 2004;164:1985-1992. CrossRef | ISI | MEDLINE
14. Ernst E. Prospective investigations into the safety of spinal manipulation. J Pain Symptom Manage. 2001;21:238-242. CrossRef | ISI | MEDLINE
15. Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM. Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA neck pain study. J Manipulative Physiol Ther. 2004;27:16-25. CrossRef | ISI | MEDLINE
16. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. 2001;32:1054-1060. ABSTRACT/FULL TEXT
17. Haneline MT, Croft AC, Frishberg BM. Association of internal carotid artery dissection and chiropractic manipulation. Neurologist. 2003;9:35-44. MEDLINE
18. Duenas R, Carucci GM, Funk MF, Gurney MW. Chiropractic-primary care, neuromusculoskeletal care, or musculoskeletal care? results of a survey of chiropractic college presidents, chiropractic organization leaders, and Connecticut-licensed doctors of chiropractic. J Manipulative Physiol Ther. 2003;26:510-523. MEDLINE

FoughtFyr · Dec 18, 2004

PublicHealth said:
I'm a bit confused about your point that "chiropractic is a science without a theory." I think it's the other way around. Comments?

Yeah, what theory? You and BackTalk in previous posts have often stated that most "reasonable" chiropractors disavow Palmer's theories. There are even organizations you have pointed to in previous posts that require their members to disavow them.

PublicHealth said:
There will ALWAYS be room for a better clinical trial. If you don't think so, then you should get more research experience. By the way, what is your research project on methamphetamine use examining? Does it meet Koch's postulates!?

No doubt there is always room for a better study, but can you find a study that demonstrates efficacy beyond LBP? And what about safety?

And yes, my study is well designed. Two of our faculty are Cochrane reviewers, it's solid. But thanks for asking. And gosh am I a jerk for suggesting we hold Chiropractic up to the light of science - GASP! There I am bashing again. Bad MD ***slapping wrist*** Bad! No drug rep gifts for you! :laugh:

BTW - How come you constantly ignore the basic arguement of risk versus benefit. I'm willing to grant you, for the purposes of discussion, that chiropractic is as effective as conventional medicine for LBP. How do you propose to control chiropractors who give "medical" advice that harms patients, what about chiropractors who "treat" any medical condition - including asthma, cancer, etc., and how do you propose to insure that chiropractors live up to similar standards as their peers in terms of length of treatment or outcomes measures? Physicians are all monitored in these areas.

Lastly what about chiropractors as PCPs. For example, I have a 1990s Pediatric Chiropractic text. It discusses how to perform a school athletic physical. Nowhere does it mention assessing for IHSS (a condition that kills several student athletes every year and can be assessed for with a BP cuff and stethoscope). How are we to insure that chiropractors can perform the exams they claim to be capable of?

But it is o.k., because they are cheaper than doctors.

- H

PublicHealth · Dec 18, 2004

FoughtFyr said:
No doubt there is always room for a better study, but can you find a study that demonstrates efficacy beyond LBP? And what about safety?

Anecdotal reports, and uncontrolled case studies and series, no clinical trials. Moreover, these studies have suffered from methodological flaws (e.g., Balon & Bior, 2004; Ernst, 2003).

FoughtFyr said:
And yes, my study is well designed. Two of our faculty are Cochrane reviewers, it's solid. But thanks for asking. And gosh am I a jerk for suggesting we hold Chiropractic up to the light of science - GASP! There I am bashing again. Bad MD ***slapping wrist*** Bad! No drug rep gifts for you!

Hey, give them SOME credit! With increased NIH support, more clinical trials will be conducted that will ultimately determine the efficacy of chiropractic manipulation in treating LBP and possibly other conditions. Chiropractic research has only recently begun to take form, as the medical powers-that-be have only recently begun to fund research for alternative treatment modalities after realizing that patients spent billions of dollars out-of-pocket for alternative healthcare. I understand your concerns about safety and am confident that chiropractic researchers will take this into consideration when conducting their studies and interpreting their results.

FoughtFyr said:
BTW - How come you constantly ignore the basic arguement of risk versus benefit. I'm willing to grant you, for the purposes of discussion, that chiropractic is as effective as conventional medicine for LBP. How do you propose to control chiropractors who give "medical" advice that harms patients, what about chiropractors who "treat" any medical condition - including asthma, cancer, etc., and how do you propose to insure that chiropractors live up to similar standards as their peers in terms of length of treatment or outcomes measures? Physicians are all monitored in these areas.

There is a need for regulation of the scope of practice among chiropractors. The vaccine issue nothwithstanding, I'd be curious to hear some examples of the type of "medical" advice that chiropractors readily give to patients that harms them in a substantive way. Better yet, show me a study that has systematically examined this issue (it doesn't have to be authored by Cochrane reviewers

). I'd be willing to bet that chiropractic treatment is associated with fewer risks and complications than medical treatment.

FoughtFyr · Dec 18, 2004

PublicHealth said:
There is a need for regulation of the scope of practice among chiropractors. The vaccine issue nothwithstanding, I'd be curious to hear some examples of the type of "medical" advice that chiropractors readily give to patients that harms them in a substantive way. Better yet, show me a study that has systematically examined this issue (it doesn't have to be authored by Cochrane reviewers ). I'd be willing to bet that chiropractic treatment is associated with fewer risks and complications than medical treatment.

O.k., here:
http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=10768681&dopt=Abstract

and I have to throw in the immunizations!

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7884327&dopt=Abstract

Shady claims by Chiropractic Colleges - written by chiropractors:

Grod JP, Sikorski D, Keating J. Unsubstantiated claims in patient brochures from the largest state, provincial, and national chiropractic associations and research agencies. JMPT 24:514-519, 2001. (Sorry no link).

Come on, be reasonable, it is currently a largely unproven "science", loosely regulated, and extremely variable by provider.

And, no, it will never be fewer risks than medical treatment. This is simply because the training is far less for a chiropractor than an MD/DO. So, if we take a condition that an MD is trained in and a chiropractor is not - and there are many of them, often with associated high morbidity and mortality - and 100 patients with that condition present to both a chiropractor and an MD/DO, what happens? The MD/DO misses some percentage of them. And missed diagnosis is the most common medical error. The chiropractor misses all of them. Why? The eyes can not see what the mind doesn't know. It is that simple.

Again, I am not saying that there is no way or no time that chiropractic is effective. I am saying that on a population basis the risks far outweigh the benefits. Or is that "bashing"?

- H

PublicHealth · Dec 18, 2004

Damn "life energy" researchers are at it again...http://www.osher.hms.harvard.edu/r_trials.asp

FoughtFyr · Dec 18, 2004

PublicHealth said:
Damn "life energy" researchers are at it again...http://www.osher.hms.harvard.edu/r_trials.asp

If you fund it, they will come...

- H

50960 · Dec 19, 2004

I do have a problem with chiros who claim they can treat ADD/ADHD. As a psych if I claimed I could treat seizures or contractures etc... I would be in hot water quickly. How do DC's get away with such advertising??

PublicHealth · Dec 19, 2004

psisci said:
I do have a problem with chiros who claim they can treat ADD/ADHD. As a psych if I claimed I could treat seizures or contractures etc... I would be in hot water quickly. How do DC's get away with such advertising??

http://www.amerchiro.org/media/tips/adhd.shtml

****************************

J Manipulative Physiol Ther. 2004 Oct;27(8):e14.

Cervical kyphosis is a possible link to attention-deficit/hyperactivity disorder.

Bastecki AV, Harrison DE, Haas JW.

OBJECTIVE: To discuss the case of a patient who was diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a general practitioner and was treated with chiropractic care. CLINICAL FEATURES: A 5-year-old patient was diagnosed with ADHD and treated by a pediatrician unsuccessfully with methylphenidate (Ritalin), Adderall, and Haldol for 3 years. The patient received 35 chiropractic treatments during the course of 8 weeks. A change from a 12 degrees C2-7 kyphosis to a 32 degrees C2-7 lordosis was observed after treatment. During chiropractic care, the child's facial tics resolved and his behavior vastly improved. After 27 chiropractic visits, the child's pediatrician stated that the child no longer exhibited symptoms of ADHD. The changes in structure and function may be related to the correction of cervical kyphosis. CONCLUSION: The patient experienced significant reduction in symptoms. Additionally, the medical doctor concluded that the reduction in symptoms was significant enough to discontinue the medication. There may be a possible connection that correction of cervical kyphosis in patients with ADHD may produce a desirable clinical outcome.

****************************

J Manipulative Physiol Ther. 1989 Oct;12(5):353-63.

An evaluation of chiropractic manipulation as a treatment of hyperactivity in children.

Giesen JM, Center DB, Leach RA.

Mississippi State University.

The principle aim of this study was to determine the effectiveness of chiropractic manipulative therapy in the treatment of children with hyperactivity. Using blinds between investigators and a single subject research design, the investigators evaluated the effectiveness of the treatment for reducing activity levels of hyperactive children. Data collection included independent evaluations of behavior using a unique wrist-watch type device to mechanically measure activity while the children completed tasks simulating school-work. Further evaluations included electrodermal tests to measure autonomic nervous system activity. Chiropractic clinical evaluations to measure improvement in spinal biomechanics were also completed. Placebo care was given prior to chiropractic intervention. Data were analyzed visually and using nonparametric statistical methods. Five of seven children showed improvement in mean behavioral scores from placebo care to treatment. Four of seven showed improvement in arousal levels, and the improvement in the group as a whole was highly significant (p = 0.009). Agreement between tests was also high in this study. For all seven children, three of the four principal tests used to detect improvement were in agreement either positively or negatively (parent ratings of activity, motion recorder scores, electrodermal measures, and X-rays of spinal distortions). While the behavioral improvement taken alone can only be considered suggestive, the strong interest agreement can be taken as more impressive evidence that the majority of the children in this study did, in fact, improve under specific chiropractic care. The results of this study, then, are not conclusive, however, they do suggest that chiropractic manipulation has the potential to become an important nondrug intervention for children with hyperactivity. Further investigation in this area is certainly warranted.

russellb · Dec 19, 2004

PublicHealth said:
http://www.amerchiro.org/media/tips/adhd.shtml

****************************

J Manipulative Physiol Ther. 2004 Oct;27(8):e14.

Cervical kyphosis is a possible link to attention-deficit/hyperactivity disorder.

Bastecki AV, Harrison DE, Haas JW.

OBJECTIVE: To discuss the case of a patient who was diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a general practitioner and was treated with chiropractic care. CLINICAL FEATURES: A 5-year-old patient was diagnosed with ADHD and treated by a pediatrician unsuccessfully with methylphenidate (Ritalin), Adderall, and Haldol for 3 years. The patient received 35 chiropractic treatments during the course of 8 weeks. A change from a 12 degrees C2-7 kyphosis to a 32 degrees C2-7 lordosis was observed after treatment. During chiropractic care, the child's facial tics resolved and his behavior vastly improved. After 27 chiropractic visits, the child's pediatrician stated that the child no longer exhibited symptoms of ADHD. The changes in structure and function may be related to the correction of cervical kyphosis. CONCLUSION: The patient experienced significant reduction in symptoms. Additionally, the medical doctor concluded that the reduction in symptoms was significant enough to discontinue the medication. There may be a possible connection that correction of cervical kyphosis in patients with ADHD may produce a desirable clinical outcome.

****************************

J Manipulative Physiol Ther. 1989 Oct;12(5):353-63.

An evaluation of chiropractic manipulation as a treatment of hyperactivity in children.

Giesen JM, Center DB, Leach RA.

Mississippi State University.

The principle aim of this study was to determine the effectiveness of chiropractic manipulative therapy in the treatment of children with hyperactivity. Using blinds between investigators and a single subject research design, the investigators evaluated the effectiveness of the treatment for reducing activity levels of hyperactive children. Data collection included independent evaluations of behavior using a unique wrist-watch type device to mechanically measure activity while the children completed tasks simulating school-work. Further evaluations included electrodermal tests to measure autonomic nervous system activity. Chiropractic clinical evaluations to measure improvement in spinal biomechanics were also completed. Placebo care was given prior to chiropractic intervention. Data were analyzed visually and using nonparametric statistical methods. Five of seven children showed improvement in mean behavioral scores from placebo care to treatment. Four of seven showed improvement in arousal levels, and the improvement in the group as a whole was highly significant (p = 0.009). Agreement between tests was also high in this study. For all seven children, three of the four principal tests used to detect improvement were in agreement either positively or negatively (parent ratings of activity, motion recorder scores, electrodermal measures, and X-rays of spinal distortions). While the behavioral improvement taken alone can only be considered suggestive, the strong interest agreement can be taken as more impressive evidence that the majority of the children in this study did, in fact, improve under specific chiropractic care. The results of this study, then, are not conclusive, however, they do suggest that chiropractic manipulation has the potential to become an important nondrug intervention for children with hyperactivity. Further investigation in this area is certainly warranted.

Ummm, Public Health, are you implying that the results of these 2 articles are sufficient to make any conclusions at all? If you were giving a talk about ADHD during your peds rotation, would you reference these studies and conclude that spinal manipulation has a role in the treatment of ADHD, or would you fear being torn a new arsehole by your colleagues for relying on that sort of data? Do you think that it's appropriate for a health care provider to advertise in the yellow pages, etc. that spinal manipulation can cure ADHD?

rooster · Dec 19, 2004

russellb said:
Ummm, Public Health, are you implying that the results of these 2 articles are sufficient to make any conclusions at all? <<

Perhaps not "conclusions", but certainly a qualified, honest, need to investigate. Does any provider have the absoute, unquestionable, answer?
Seems there is a lot of unswered questions/dilemas/best practice uncertainties/lack of unequivical authority, in this area.
Do you want to eliminate any possible options? If So, Why?

rooster · Dec 19, 2004

russellb said:
Ummm, Public Health, are you implying that the results of these 2 articles are sufficient to make any conclusions at all? <<

Perhaps not "conclusions", but certainly a qualified, honest, need to investigate. Does any provider have the absoute, unquestionable, answer?
Seems there is a lot of unswered questions/dilemas/best practice uncertainties/lack of unequivical authority, in this area.
Do you want to eliminate any possible options? If So, Why?

russellb · Dec 19, 2004

rooster said:
Perhaps not "conclusions", but certainly a qualified, honest, need to investigate. Does any provider have the absoute, unquestionable, answer?
Seems there is a lot of unswered questions/dilemas/best practice uncertainties/lack of unequivical authority, in this area.
Do you want to eliminate any possible options? If So, Why?

I disagree. I don't think that either of those studies is strong enough on its own to warrant further investigation, although I'd like to hear FoughtFyr's opinion, given his MPH degree. If there is a desire within the Chiropractic community to undertake further investigation, then so be it. Do you not find it interesting that the posted study from 1989 has not been followed up with any serious further investigation in terms of larger scale controlled trials? One would expect that one or several of the Chiropractic colleges could fund a larger controlled trial with a view towards an eventual larger federal grant.

I agree that there are plenty of unanswered questions regarding this condition and ADHD is well outside my area of expertise. And no, one shouldn't eliminate possible options. But one has to consider what the 'possible options' really are. The money to study possible interventions is limited, and one should choose to study that which is most plausible. I suppose that SMT isn't completely implausible as a form of treatment for ADHD, but it does seem rather unlikely to hold significant promise. However, the point made initially is that there are Chiropractors who advertise SMT as an effective treatment for ADHD, and I've even read a statement by a former president of the Ontario Chiropractic Association in which he claimed to have 'cured' numerous cases of ADHD. Based on the available evidence, these claims are unsubstantiated and the advertising is potentially deceitful.

PublicHealth · Dec 19, 2004

russellb said:
I disagree. I don't think that either of those studies is strong enough on its own to warrant further investigation, although I'd like to hear FoughtFyr's opinion, given his MPH degree. If there is a desire within the Chiropractic community to undertake further investigation, then so be it. Do you not find it interesting that the posted study from 1989 has not been followed up with any serious further investigation in terms of larger scale controlled trials? One would expect that one or several of the Chiropractic colleges could fund a larger controlled trial with a view towards an eventual larger federal grant.

I agree that there are plenty of unanswered questions regarding this condition and ADHD is well outside my area of expertise. And no, one shouldn't eliminate possible options. But one has to consider what the 'possible options' really are. The money to study possible interventions is limited, and one should choose to study that which is most plausible. I suppose that SMT isn't completely implausible as a form of treatment for ADHD, but it does seem rather unlikely to hold significant promise. However, the point made initially is that there are Chiropractors who advertise SMT as an effective treatment for ADHD, and I've even read a statement by a former president of the Ontario Chiropractic Association in which he claimed to have 'cured' numerous cases of ADHD. Based on the available evidence, these claims are unsubstantiated and the advertising is potentially deceitful.

These are case reports. Anyone who has taken an entry-level experimental design course could tell you that such data does not support the widespread use of a particular intervention. But when you consider the child with ADHD in the 2004 report, I'm sure his pediatrician and parents had all but given up on traditional medicine, and were willing to try anything to help their child. By golly, the "back jockey" in town fixed him up! Does this mean that chiropractic should be a front-line intervention for ADHD? Of course not. Does it mean that chiropractic may, IN SOME SITUATIONS, help treat ADHD? Probably. Perhaps the results of the therapy may be better explained by a placebo effect? Perhaps the DC was friendlier to the child than the pediatrician, which through some unknown interpersonal mechanism, rid the child of his ADHD. Who the hell knows what happened. Until we have more data, we may never know.

Based on these two reports, however, I agree that chiropractors should not advertise that they could treat ADHD. As far as further investigation, I'm sure the chiro folks will eventually take this on, once they can demonstrate in large-scale clinical trials the efficacy of chiro manipulation in treating their "bread-and-butter" NMS conditions. Chiro schools are not swimming in research dollars, either, so it'll likely be a while before you see any RCTs in this area. Oh, I have an MPH, too.

Please also keep in mind that there are many other licensed alternative practitioners out there who making unsubstantiated claims about their services. It's not just the chiros.

russellb · Dec 19, 2004

Does it mean that chiropractic may, IN SOME SITUATIONS, help treat ADHD? Probably.

Come on now, you know as well as I do that the best you can say is that it's not impossible the SMT played a role in the child's improvement. I suppose I'm arguing sematics, but I think that the above statement takes things further than they can really go based upon the available evidence, though I suppose you may be arguing that the improvement may be related to non-specific effects of the patient's interaction with the Chiropractor as opposed to SMT itself.

Perhaps the results of the therapy may be better explained by a placebo effect? Perhaps the DC was friendlier to the child than the pediatrician, which through some unknown interpersonal mechanism, rid the child of his ADHD. Who the hell knows what happened. Until we have more data, we may never know.

True.

Based on these two reports, however, I agree that chiropractors should not advertise that they could treat ADHD

This is the point that I'm attempting to make and I'm not sure why you didn't make this same comment in response to psisci's post.

As far as further investigation, I'm sure the chiro folks will eventually take this on, once they can demonstrate in large-scale clinical trials the efficacy of chiro manipulation in treating their "bread-and-butter" NMS conditions.

One would hope so, though it's a bit surprising that there is still some controversy surrounding the 'bread and butter' conditions, given that quite a bit of research has been done in this area.

Chiro schools are not swimming in research dollars, either, so it'll likely be a while before you see any RCTs in this area.

That's true, but I would bet that Chiropractic studies are less expensive per patient than many medical clinical trials as medications, in hospital care, etc. are not part of the equation. I'm not even asking for RCTs for starters. A decent cohort study might be a nice stepping stone. I think that making the excuse that there isn't enough money for decent pilot studies is a bit of a cop out, particularly if practitioners, including the president of a provincial association, are going to make such claims.

Oh, I have an MPH, too.

I thought so. That's why I'm puzzled that you often post studies without commentary. You know how to analyse them, so why not add your comments and let everyone know what you think the results imply? Posting without commentary leaves the reader uncertain with regard to your opinion and has a deceitful quality to it, as though you're trying to hide the fact that you know how to interpret the data. FoughFyr usually comments on the studies that he posts or reads, so we know where he stands and how he arrived at his opinion.

Please also keep in mind that there are many other licensed alternative practitioners out there who making unsubstantiated claims about their services. It's not just the chiros.

You're obviously correct on this point. Chiropractors are probably the most visible alternatie providers, hence many of us are familiar with some of the unsubstantiated claims they make. But I'm also familiar with at least some of the data supporting SMT for low back pain and some other NMS conditions. I'm also aware of the potential for other treatments offered by some Chiropractors, such as Active Release Therapy, to have a positive impact on NMS conditions. I've said in the past that if I were a clinician, I would happily refer patients with NMS complaints to certain Chiropractors I know personally.

50960 · Dec 19, 2004

giddey-up!!!

for once PH is arguing with someone besides me!

FoughtFyr · Dec 20, 2004

Well, you know I'm not going to leave this one alone. First of all, there is ABSOLUTELY no plausible mechanism for a subluxation to "cause" ADHD. Research has the cause pretty well determined to be (an) abnormality(es) of dopamine neurotransmission. Now most research is angling to map the gene involved.

See:
http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15389764
http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15389753
http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15578612
http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15294348
http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=14995087
and so on.

FYI – As my research is in methamphetamine, and methylphenidate is a close analogue, many of the papers I reviewed dealt with receptor alterations in ADHD. I'm pretty well versed on the subject. Now, how you could possibly demonstrate that subtle alterations in the spine cause cell structure deficits in the temporal lobe is beyond me. Even more far-fetched is the supposition that these cells will suddenly repair alterations in their protein synthesis as a result of chiropractic manipulation given that the DNA is itself altered.

Now for these so called studies. First, I do not consider JMPT a credible academic journal. That said, neither of these does anything to augment your case. The first is a case report – which you've acknowledged. What you failed to note is that the case was diagnosed by a general practitioner. A GP diagnosis of ADHD is hardly the standard of care, yet alone study. Now I agree, the patient was being treated for the disorder, a state of affairs I disagree with given the lack of a more sophisticated diagnosis including use of one of the proven behavioral scales. One could more easily attribute the "cure" to the cessation of the medications used to "treat" the condition than to the chiropractic care.

The second "study" was not a case report PublicHealth, it is a very poorly designed experiment. The researchers attempted to demonstrate the efficacy of chiropractic care versus placebo. Unfortunately, they used "hyperactive children", as opposed to those actually diagnosed with ADHD. They also used "independent evaluations of behavior using a unique wrist-watch type device to mechanically measure activity while the children completed tasks simulating school-work" as opposed to a proven instrument for measuring therapeutic effect. But the worst part of all is that "placebo care was given prior to chiropractic intervention". So kids were given placebo care, then measured at some tasks designed to simulate school work. Then they were given chiropractic care and their performance was measured on the same tasks. Guess what? It improved. What have we learned? Children can be taught! Give them the same task to repeat a second time, they get better at it. Yippeee!

PublicHealth, you know better than this…

PublicHealth said:
Please also keep in mind that there are many other licensed alternative practitioners out there who making unsubstantiated claims about their services. It's not just the chiros.

So now rape is o.k. because there are murderers out there too?

- H

FoughtFyr · Dec 20, 2004

Here is what I dont understand PublicHealth why do you support chiropractic? I just dont get it. Look at the history, chiropractic is not some ancient art that western medicine is ignoring, it was created in September, 1895 by D.D. Palmer.

I am the originator, the Fountain Head of the essential principle that disease is the result of too much or not enough functionating. I created the art of adjusting vertebrae, using the spinous and transverse processes as levers, and named the mental act of accumulating knowledge, the cumulative function, corresponding to the physical vegetative function -- growth of intellectual and physical -- together, with the science, art and philosophy -- Chiropractic. It is now being followed, more or less, by 2,000 Chiropractors, and its use is being attempted by several other methods. It was I who combined the science and art and developed the principles thereof. I have answered the time-worn question -- what is life?
From: The Chiropractor's Adjuster (also called The Text-Book of the Science, Art and Philosophy of Chiropractic). Published in 1910 by the Portland Printing House Company of Portland, Oregon, and reprinted in 1966 by his grandson, David D. Palmer, 1966.

This is not some ancient art, ignored by modern medicine. It is the invention of a man who was employed as a grocer at the time, who believed he cured a janitors deafness through spinal manipulation. Now, spinal manipulation therapy (SMT) had been used for centuries, going back to at least to Hippocrates roughly 400 B.C. and it continues to be used today by osteopathic physicians, physical therapists, and athletic trainers. But chiropractic is NOT just spinal manipulation. It is a system of belief, based on the teachings of Palmer.

Chiropractic's uniqueness lies not in its use of SMT, but in its theoretical reason for doing so. Just as prescientific osteopathy found its justification in the rule of the artery (the belief that manipulation improved circulation by reducing muscle spasms), chiropractic is based upon the rule of the nerve (the belief that SMT has important effects upon nerve flow).
The word chiropractic literally means done by hand. The term was adopted by chiropractic's founder, Daniel David Palmer. Palmer was a layman with an intense interest in metaphysical health philosophies such as magnetic healing (Mesmer's animal magnetism), phrenology, and spiritualism. In 1895, he claimed to have restored the hearing of a nearly deaf janitor by manipulating the man's spine.
Obsessed with uncovering the primary cause of disease, Palmer theorized that 95 percent of all disease was caused by spinal subluxations (partial dislocations) and the rest by luxated bones elsewhere in the body. Palmer speculated that subluxations impinged upon spinal nerves, impeding their function, and that this led to disease. He taught that medical diagnosis was unnecessary, that one need only correct the subluxations to liberate the body's own natural healing forces. He disdained physicians for treating only symptoms, alleging that, in contrast, his system corrected the cause of disease.
Palmer did not employ the term subluxation in its medical sense, but with a metaphysical, pantheistic meaning. He believed that the subluxations interfered with the body's expression, of the "Universal Intelligence" (God), which Palmer dubbed the Innate Intelligence. (soul, spirit, or spark of life). Palmer's notion of having discovered a way to manipulate metaphysical life force is sometimes referred to as his biotheology.
From: http://www.chirobase.org/01General/controversy.html

Why do you as a medical student and MPH so feverishly believe that what this man discovered is true? Why him? Why not Dr. Lorrie Day, or L. Ron Hubbard, or Hulda Clark? What makes his theory so appealing to you that you constantly defend it? I can see acupuncture, which has been developed over thousands of years, or Ayruveda, which has also been around forever. But to place your faith in chiropractic means that you believe that in 1895, a grocer not only found the key to all of health, but also that the key he found can not be proven in any scientific way. You also have to believe that this key eluded all healers before him, as his work began with him I am the originator, the Fountain Head, as opposed to all validated health care methods, which have evolved over time.

I just don't get it...

- H

PsyDRxPnow · Dec 20, 2004

"By the way, I'm a first-year medical student who is open-minded about chiropractic and alternative medicine".

http://www.chiroweb.com/cgi-bin/ubb/students/Ultimate.cgi[/QUOTE]

Is that what you consider yourself, "open-minded?" :laugh:

BackTalk · Dec 20, 2004

As always, thanks Public Health for you kind words. Mike I will do the best to answer your questions.

FoughtFyr poses many valid questions. Dont let that scare you away from this board.

I'm curious why there is no discussion or forum for those interested in Chiropractic. I understand it can be controversial - but it is the top "alternative" provider of health care in the US.

I really do not know why there isnt a chiropractic category on this board. I have emailed the moderators on more than one occasion and they have never responded. Maybe their reasoning is similar to FoughtFyr. Its their site and they are free to choose whatever they want to do with it. At least we can log on and post. Since chiropractic is the second largest healthcare profession, I think its safe to say we are no longer alternative.

DC's receive education comparable to MD's, and while our focus is different (ours primarily musculoskeletal) we are still active in the holistic healthcare of our patients.

I agree that are education is comparable to that of a MD (first two years) but I wouldnt go as far as saying it was equivalent. I agree that are primary focus is or rather should be primarily musculoskeletal.

I just think an honest look at chiropractic is in order somewhere on these forums...

I agree. Dont hold your breath.

I didn't mean to fight over anything, or bother anybody. I was just trying to have a decent conversation.

I think everyone knows that. Its just the way it is when chiropractic and medicine collide. You can have decent conversations here and Ive made a few good friends on the way. Sometimes debates can get heated. One thing I have leaned here is that MDs are very critical, not only with other professions but also with other MDs. If you say something someone doesnt agree with just be able to back it up or simply admit your wrong.

It's disappointing to me, because no matter where I go, I run into hostility.

Welcome to chiropractic. Honestly, if you find it disappointing then you may want to consider another career. Dont take that as an insult. As a chiropractor you will find yourself always defending what it is you do.

I appreciate people being open-minded about a topic I find very important. It's just hard to want to participate in online forums when people seem hell-bent on turning it into an argument.

Sometimes the only way to communicate is through argument. Dont let that scare you away.

PublicHealth · Dec 20, 2004

FoughtFyr said:
Here is what I dont understand PublicHealth why do you support chiropractic? I just dont get it.

For the same reason why I support osteopathic manipulation. The jury is out on whether OMM is efficacious in treating NMS conditions, yet it is taught at every osteopathic medical school in the US, as well as at osteopathy schools abroad. Come to think of it, there is more research supporting chiropractic than there is on OMM. Slowly, this is beginning to change, but both osteopathic medicine and chiropractic are far from conducting the large-scale RCTs that you claim are needed to validate these interventions.

Bottom line: there is more to healthcare than drugs and surgery. While not (yet) supported by large-scale RCTs, manipulative therapies such as chiropractic and OMM have helped and continue to help many people who suffer from NMS conditions. That said, I wholeheartedly concur that something needs to be done to regulate DCs from practicing outside of their area of expertise.

FoughtFyr · Dec 21, 2004

PublicHealth said:
For the same reason why I support osteopathic manipulation. The jury is out on whether OMM is efficacious in treating NMS conditions, yet it is taught at every osteopathic medical school in the US, as well as at osteopathy schools abroad. Come to think of it, there is more research supporting chiropractic than there is on OMM. Slowly, this is beginning to change, but both osteopathic medicine and chiropractic are far from conducting the large-scale RCTs that you claim are needed to validate these interventions.

Bottom line: there is more to healthcare than drugs and surgery. While not (yet) supported by large-scale RCTs, manipulative therapies such as chiropractic and OMM have helped and continue to help many people who suffer from NMS conditions. That said, I wholeheartedly concur that something needs to be done to regulate DCs from practicing outside of their area of expertise.

Right, I agree, SMT (either OMM or as practiced by PTs, athletic trainers, etc.) is a very valid tool in health management. But, chiropractic is, by it's own definitions, so much more than SMT. Why defend it? Why not let the practitioners (of OMM and medical SMT) do their thing? Why introduce the risks of misinformation, poor regulation, and questionable practices that accompany chiropractic?

- H

PublicHealth · Dec 21, 2004

FoughtFyr said:
Right, I agree, SMT (either OMM or as practiced by PTs, athletic trainers, etc.) is a very valid tool in health management. But, chiropractic is, by it's own definitions, so much more than SMT. Why defend it? Why not let the practitioners (of OMM and medical SMT) do their thing? Why introduce the risks of misinformation, poor regulation, and questionable practices that accompany chiropractic?

- H

Because the existing literature on chiropractic has not convinced me one way or another whether chiropractic manipulation is efficacious in treating NMS conditions. I doubt that chiropractic could treat ADHD and other non-NMS conditions, and agree that misinformation, questionable practices, and poor regulation plague the field. Nevertheless, I sincerely believe that chiropractic serves an important role in healthcare, especially for patients who do not respond to drugs and who don't want surgery.

Every field will have its quacks, and perhaps there are more in chiropractic. That being said, chiropractors are increasingly beginning to work collaboratively with physicians in rehabilitation settings. This integrative approach to rehabilitation is, in my opinion, the future of PM&R.

By the way, you mentioned that "SMT (either OMM or as practiced by PTs, athletic trainers, etc.) is a very valid tool in health management." Where is the evidence in support of this statement? Where are the RCTs supervised by Cochrane reviewers?

BackTalk · Dec 21, 2004

SMT (either OMM or as practiced by PTs, athletic trainers, etc.) is a very valid tool in health management.

Yeah, it's only valid when done by practitioners who have less training in it, and only if done by anyone other than a chiropractor.

FoughtFyr, what do we need a MD for when a DO is equally trained? Actually, a DO has more training which includes OMM. What do we need DC's or MD's for when osteopaths can do both?

FoughtFyr · Dec 21, 2004

BackTalk said:
Yeah, it's only valid when done by practitioners who have less training in it, and only if done by anyone other than a chiropractor.

No, only when it is done by practitioners either themselves fully trained in diagnosis (DOs) or overseen by those who are (PTs, athletic trainers, etc.). I'm all for chiropractic if we remove direct access.

Actually BT, as I have said before, it is not SMT that I have a problem with, it is "the rest" of chiropractic. SMT has been performed for centuries. Chiropractic was invented by D.D. Palmer in 1895 - a grocer, with no formal training, who, if we are to believe in chiropractic, had a sudden epiphany and created a brand new system of health maintainence from the ground up. And who, BTW, steals credit for "creating" SMT, when history proves otherwise - more likely an homage to his lack of education as opposed to willful deceit.

BackTalk said:
FoughtFyr, what do we need a MD for when a DO is equally trained? Actually, a DO has more training which includes OMM. What do we need DC's or MD's for when osteopaths can do both?

As for MD vs. DO, in the modern sense there is far to little difference to separate the two. At MSU MD and DO students have exactly the same program and sit in all of the same classes with the exception of an OMM class taken by the DOs while the MD students attend a health policy course. I'm not sure you can separate them out. As for SMT by MDs, as an MD there are many therapies I order that I am not trained to perform myself. The same is true of DOs.

Now, "pre-modern", also called "pre-scientific", osteopathy was a different kettle of fish. Much like chiropractic now, it was very loosely regulated, and often made fantastic claims. Also similar to chiropractic, it was "invented" by one man, in this case Dr. Andrew Still. The key difference? As a physician himself, Still did not fully disavow whole sections of therapy (pharmacology and surgery) but instead regarded them as "last resorts". He was essentially putting forth a differing theory within medicine, one which has been largely disproven. But, given the fact that the school created under his practices were fully inclusive of all medical training (that is, training in surgery and pharmacology), their integation "back" into western medicine has been seamless. I guess the question isn't "Why have MDs and DCs?" but rather "Why have DCs when there are DOs?"

- H

FoughtFyr · Dec 21, 2004

PublicHealth said:
By the way, you mentioned that "SMT (either OMM or as practiced by PTs, athletic trainers, etc.) is a very valid tool in health management." Where is the evidence in support of this statement? Where are the RCTs supervised by Cochrane reviewers?

Who cares! What is the downside? If there is someone who is suffering from an NMS condition, who has been evaluated by a physician to rule out significant pathology, and who has not gotten relief from other therapies, I'm all for trying it. Idiopathic LBP is a real problem and I haven't seen any good studies to prove that SMT, in adults, is harmful. So in the face of the failure of other treatments, give it a shot.

My problem with chiropractic, for what seems like the hundredth time, is NOT with SMT (when used for NMS conditions). It is with the assesstion by almost all chiropractors that they are adequately trained to rule out non-NMS conditions and adequately diagnose all patients who present to them. And even worse, the assertion by a limited number who believe they can treat nearly all patients who present to them - even those without NMS conditions. These assertions, in my opinion, represent a real and serious risk to patients. So, given that there are no studies to demonstrate a real and serious benefit from chiropractic care (versus non-chiropractic care), the risks far outweigh the benefits.

I think I mentioned in a different post (and yes BT, I agree with you - this will never happen) that I do see a role for chiropractors in today's healthcare - as PTs with a different philosophy. Remove direct access and have chiropractors treat NMS conditions on mandatory physician referrals and I will be happy. Heck, in that set-up RCTs as head-to-head studies would be a snap!

- H

BackTalk · Dec 21, 2004

H, if direct access were removed the chiropractic profession as it stands today would never last. Chiropractors would have a hard time getting referrals form physicians. It would take a long time for chiropractors to develop relationships with MDs to get referrals. The only way it would work is to have a chiropractic department within the hospital. The chiropractors could perform any necessary manual therapy and the physical therapists would be in charge of any rehabilitation. There are a few hospitals that have it setup this way and from what I understand the programs have been a success.

Interesting articles...

http://www.chiroweb.com/archives/20/21/04.html
http://www.chiroweb.com/archives/21/11/06.html

50960 · Dec 21, 2004

Kaiser, N Ca. has a chiro dept...

jturpin4 · Dec 21, 2004

Yes, I would like to have a DC forum as well.

FoughtFyr · Dec 22, 2004

BackTalk said:
H, if direct access were removed the chiropractic profession as it stands today would never last. Chiropractors would have a hard time getting referrals form physicians. It would take a long time for chiropractors to develop relationships with MD's to get referrals. The only way it would work is to have a chiropractic department within the hospital. The chiropractors could perform any necessary manual therapy and the physical therapists would be in charge of any rehabilitation. There are a few hospitals that have it setup this way and from what I understand the programs have been a success.

Interesting articles...

http://www.chiroweb.com/archives/20/21/04.html
http://www.chiroweb.com/archives/21/11/06.html

I'm not sure that it wouldn't last. Osteopathy had a long period of change but has emerged a valued, scientific modality. If chiropractic colleges drove the changes (as did DO schools), and quick RCTs were published in peer reviewed journals (other than JMPT), I think it could work. I have yet to see a plausible argument against chiropractic care in a limited practice setting - all of the arguments I have, or have seen, deal with the abuse, or potential abuse, of reasonable limits to chiropractic practice. And I think chiropractic feeds these arguments with the practices of "straights" and "pseudo-mixers" as well as with its aggressive marketing - a concept which is upsetting to most physicians (outside of plastic surgery).

BTW - I have finally "found" what I think is the source for the often repeated claim from chiropractic colleges that chiropractors have "more training" than MDs. You do!

Allow me to explain. According to the CCE USA's website, as well as those of several state chiropractic associations, chiropractors are required to have 4200 "instructional hours" of training. This includes classroom time as well as clinical time. It is a sizable load for three calendar years. MDs do not have a specific requirement, but according to an article (see: http://jama.ama-assn.org/cgi/content/full/292/9/1025 ) we spend, on average 1600 so so classroom hours in the first two years. Since that is the only published number - chiropractic students are "better trained".

Except for the pesky problem of the 3rd and 4th year. While there are no nationally published numbers, there are growing complaints that 3rd year medical students should not be exempt from the 80 hour work week rules that govern residents. The implication being that 3rd year clerks work more than 80 hours weekly. But without data, I can't address that, except through personal experience. So let's look at my third year:

48 week program
Family practice - longitudinal across the year, one day per week, 8 hours a day, four weeks off, no call - total time: 352 hours
Surgery - 12 week clerkship, 5 days a week (plus FP), average work day 12 hours, 6 overnight calls, 1 weekend call - total time: 720 hours (plus 96 hours of call)
Internal Medicine - 12 week clerkship, 5 days per week (plus FP), average work day 11 hours, 14 call nights until midnight, 2 weekend call - total time: 660 hours (plus ~ 136 hours of call)
Psychiatry - 8 week clerkship, 4.5 days per week (plus FP), average work day 8 hours, call from home so I won't even count it - total time: 288 hours
Pediatrics - 8 week clerkship, 4 days per week (plus FP), average work day 10 hours, 5 call nights until midnight, 2 17 hour weekend calls - total time: 320 hours (plus 74 hours of call)
OB/GYN - 8 week clerkship, 4.5 days per week (plus FP), average work day 10 hours, 5 overnight calls, 2 weekend calls - total time: 360 hours (plus 118 hours of call)

All told, my third year was roughly 2700 hours plus ~425 hours of call in 48 weeks (or ~65 hrs/wk) and I spent most of that year being in the hospital or clinic 6 (sometimes 7) days per week, between my FP day and the wards. The schedule for fourth years vary by individual student, because of electives. Call volume is far reduced as is ward time. My best guesstimate is roughly 1800 hours plus 200 of call. So, the third and fourth years together (~5125 hours) are more than the hours needed for a DC (at least in my alma mater's cirriculum). This is to say nothing of the ~1600 classroom hours in years one and two. And, of course, leaving out residency entirely.

I will now agree with you however, that chiropractic college may be roughly equal to years one and two of medical school (but I would still like to see the breakdown of the 4200 hours)

Just thought this was interesting.

- H

BTW - thank you for keeping this thread civil.

FoughtFyr · Dec 22, 2004

jturpin4 said:
Yes, I would like to have a DC forum as well.

Here:
http://www.chiroweb.com/cgi-bin/ubb/students/Ultimate.cgi

- H

FoughtFyr · Dec 22, 2004

BackTalk said:
Interesting articles...

http://www.chiroweb.com/archives/20/21/04.html
http://www.chiroweb.com/archives/21/11/06.html

Very interesting. To quote "Patients who present to the ED with neck or back pain are screened by the attending ED physician, who is responsible for ruling out serious pathology, fracture, neurological deficit, and other findings that might contraindicate spinal manipulation. The ED physician may order x-rays, blood work or other diagnostic tests. When a severe condition presents, orthopedists, neurologists or neurosurgeons are enlisted to take over the case. Historically, all patients without serious pathology were given prescriptions and discharged from the hospital, with or without adequate relief. With our chiropractor-on-call program, the ED physician now has the option of calling for a chiropractic consultation, which gives the patient the opportunity to receive additional relief."

Sounds an awful lot like what I suggested. MDs referring to DCs after all serious pathology is ruled out! Now, if all patients of DCs were generated in this fashion - I might be a convert.

Now, if you really want to make things interesting, have that ED run an odd/even day RCT study were PTs are used (in the manner described in the article) on even days, and DCs on odd. Measure pain relief, patient satisfaction, etc. It may make a compelling case for this type of program. Again, protect the public from chiropractors who overestimate their diagnostic and/or therapuetic abilities (i.e., no direct access - physician referral mandatory), and I'm all for it! I even acknowledge chiropractic (in that setting) is likely as efficacious as PT. My objection is solely risk vs. benefit.

- H

BackTalk · Dec 22, 2004

FoughtFyr said:
I'm not sure that it wouldn't last. Osteopathy had a long period of change but has emerged a valued, scientific modality. If chiropractic colleges drove the changes (as did DO schools), and quick RCTs were published in peer reviewed journals (other than JMPT), I think it could work. I have yet to see a plausible argument against chiropractic care in a limited practice setting - all of the arguments I have, or have seen, deal with the abuse, or potential abuse, of reasonable limits to chiropractic practice. And I think chiropractic feeds these arguments with the practices of "straights" and "pseudo-mixers" as well as with its aggressive marketing - a concept which is upsetting to most physicians (outside of plastic surgery).

BTW - I have finally "found" what I think is the source for the often repeated claim from chiropractic colleges that chiropractors have "more training" than MDs. You do!

Allow me to explain. According to the CCE USA's website, as well as those of several state chiropractic associations, chiropractors are required to have 4200 "instructional hours" of training. This includes classroom time as well as clinical time. It is a sizable load for three calendar years. MDs do not have a specific requirement, but according to an article (see: http://jama.ama-assn.org/cgi/content/full/292/9/1025 ) we spend, on average 1600 so so classroom hours in the first two years. Since that is the only published number - chiropractic students are "better trained".

Except for the pesky problem of the 3rd and 4th year. While there are no nationally published numbers, there are growing complaints that 3rd year medical students should not be exempt from the 80 hour work week rules that govern residents. The implication being that 3rd year clerks work more than 80 hours weekly. But without data, I can't address that, except through personal experience. So let's look at my third year:

48 week program
Family practice - longitudinal across the year, one day per week, 8 hours a day, four weeks off, no call - total time: 352 hours
Surgery - 12 week clerkship, 5 days a week (plus FP), average work day 12 hours, 6 overnight calls, 1 weekend call - total time: 720 hours (plus 96 hours of call)
Internal Medicine - 12 week clerkship, 5 days per week (plus FP), average work day 11 hours, 14 call nights until midnight, 2 weekend call - total time: 660 hours (plus ~ 136 hours of call)
Psychiatry - 8 week clerkship, 4.5 days per week (plus FP), average work day 8 hours, call from home so I won't even count it - total time: 288 hours
Pediatrics - 8 week clerkship, 4 days per week (plus FP), average work day 10 hours, 5 call nights until midnight, 2 17 hour weekend calls - total time: 320 hours (plus 74 hours of call)
OB/GYN - 8 week clerkship, 4.5 days per week (plus FP), average work day 10 hours, 5 overnight calls, 2 weekend calls - total time: 360 hours (plus 118 hours of call)

All told, my third year was roughly 2700 hours plus ~425 hours of call in 48 weeks (or ~65 hrs/wk) and I spent most of that year being in the hospital or clinic 6 (sometimes 7) days per week, between my FP day and the wards. The schedule for fourth years vary by individual student, because of electives. Call volume is far reduced as is ward time. My best guesstimate is roughly 1800 hours plus 200 of call. So, the third and fourth years together (~5725 hours) are more than the hours needed for a DC (at least in my alma mater's cirriculum). This is to say nothing of the ~1600 classroom hours in years one and two. And, of course, leaving out residency entirely.

I will now agree with you however, that chiropractic college may be roughly equal to years one and two of medical school (but I would still like to see the breakdown of the 4200 hours)

Just thought this was interesting.

- H

BTW - thank you for keeping this thread civil.

What do you think of this study?

Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M.
A Comparative Study of Chiropractic and Medical Education.
Altern Ther Health Med. 1998; 4 (5): 6475

"The results suggest that, while medical students spend more time gaining clinical experience (1405 hours for chiropractic vs. 5227 hours for medicine, which includes a 3year residency), chiropractic students spend more time in lectures and laboratories learning basic and clinical sciences (3790 hours for chiropractic vs. 2648 hours for medicine). Other comparisons showed that some subjects such as microbiology were equally represented in both curricula, while others, such as anatomy, physiology and pathology, were emphasized more in the chiropractic colleges."

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