Chiropractic on SDN Forums

[PublicHealth]

Hmm...given the number of posts that each of us put up here each day, I wonder if SDN may affect the quality of the care we provide our patients! Who's regulating our behavior in these forums!?

Great discussion, by the way.

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[50960]

I am on vacation ph...as for the rest???

 

[BackTalk]

Good point PH. Since I’m a chiropractor I guess I don’t have to worry about it. This time of the year is always slow for us. Patients are preoccupied with the holidays and many are putting off treatment until next year. It leaves me plenty of time to play.

H, that’s interesting. I tend to agree. When the orthopedist who worked with me was new to town I remember he was on call at the ER many times to gather new patients. He was also on the list you speak of. What about a chiropractor being on the list for treating back or neck ailments? Would that be a possibility? Or would one have to be affiliated with the hospital? We have an Urgent care in town that is owned by a local hospital. When my daughter was suffering from ear infections I was a regular. I always thought about approaching them and asking if I could be put on the list. I never did but am curious of what their answer might be. At the time I was also new to town and they gave me a list of local family doctors.

Isn’t it rather easy to gain hospital privileges for a hospital if you are a MD? After all I’m sure they love the referrals to the PT department, lab and imaging center.

 

[50960]

It may be easy to gain privs if you are an MD who is in high demand, but peer review and recredentialing keep the loosers away. I serve on the credenitals committee of a large hospital, and nobody escapes the wrath of oversight. I think DC's should get on medical staffs...it would increase oversight and increase interaction with MDs.

 

[FoughtFyr]

Isn’t it rather easy to gain hospital privileges for a hospital if you are a MD? After all I’m sure they love the referrals to the PT department, lab and imaging center.

No, it is far from easy. You have to demonstrate proficiency in training (x number of sucessful procedures), accuracy in diagnosis (no or very few peer initiated peer reviews) and lengths of stay / treatment costs in line with other physicians. Your priviledges can be pulled if you fall "out of line" in any of these areas.

- H

 

[deleted6669]

the downside of staff listing at a hospital is that you have to agree to take city call pts x days/month who you evaluate and treat regardless of their ability to pay. great social program but a little tough on the pocketbook if it is an involved pt....
for instance you are an ortho doc on city call and someone comes in with a nasty surgical fx of some kind. you have to evaluate and treat them for the duration of that medical problem which means you operate and f/u without regard to their ability to pay.the hospital eats the cost of the o.r., staff rn's etc but you spend hours in the er, or, and clinic for which you are not compensated.
I have worked at places that keep a list of recommended local chiros but never seen one on call.....what would constitute a chiropractic emergency or require one to admit to an in hospital chiropractic service? nothing comes to mind......

 

[rooster]

>>>Really? Misinformation? Please, enlighten me.<<<

I attmepted to "enlighten" you by directing you(and even providing links) to respected and quality references/sources. Texts that are used and taught in DC school. I have told you where to go to get answers to your many questions. It is my impression that you choose to dismiss these sources.


>>>Be realistic, medical physicians are some of the most "watched" professionals on the planet. Between nurses at the bedside, pharmacists and therapists following patients, peer review committees for hospital privledges, case managers watching practice patterns for reimbursement, and morbidity and mortality meetings disecting bad outcomes, everything I do is looked at by a myriad of other professionals in settings both open and closed to the public. <<<

I am glad to hear this. There has been quite a bit regarding "medical error" in the news recently.



>>>Don't find a couple of textbooks that describe what "ought to be" and claim they describe what "is". There are no standards, a chiropractor can take their practice as far as they want. There are no peer review oversights to determine if the "right" things are being done. There are few "case managers" determining if one chiropractor treats as effectively as others treating the same condition with respect to time and costs.
These things are part and parcel of medicine -<<<

What is your proposal to address the above?


>>>what is chiropractic afraid of? Oh yeah, I forgot, the "fountainhead" was devinely inspired by the "innate", no oversight needed.<<<

This is a cheapshot. Shame on you.

 

[rooster]

Backtalk posted:
>>I think chiropractic will continue to grow in a positive manner.<<
He supported this assertion with a few examples. I added some additional examples to his list. If you find this "ad nauseum", don't participate. Not everyone agrees with you.

You then change the topic to vaccination issues. Well I find that those opposed to chiropractic pursue this topic "ad nauseum". As for myself, I have no concern with it personally or professionally. Others can deliberate this to death. My interests are elsewhere.

>>The often quoted NIH studies "in favor" of chiropractic, detailed in other threads, indicate that chiropractic is only "as effective" as traditional therapy. Given the risks demonstrated above, why is it that medicine should "accept" chiropractic? No real improvements and lots of risks...<<

Another indicator of your misinformation, or more likely, your bias. I look forward to addressing this issue in the future. My schedule today will not allow for it.


>>Or are you a straight who believes that Palmer was some sort of health deity devinely inspired to "discover" innate?<<

Another cheapshot

 

[rooster]

>>oh me... God bless the internet...
of course you realize i have no "source" for my general statement. it was just a generalization. but being a dc, you allready know that the MAJORITY of dc's do not send out films. heck, many dont even TAKE them! <<

What I was objecting to was posting it in such a fashion as though it were from some "source" , as opposed to your opinion. My experience is different than yours. In fact, in my area, the medical imaging centers solicit the DCs for their business and referrals. A dramatic difference when compared to the pre- Wilk vs AMA days, when dcs were boycotted from such referrals- wouldn't cha say?


>>i am not trying to start a war with chiro, i used to be one. it is just that since going to med school, i have seen a tremendous difference in the quality of education. 2 years of basic sciences followed by 2 years of "clinic" does not properly teach dc's to be primary health care providers. it simply isnt enough. it teaches you to treat musculoskeletal disorders, and as backtalk stated, if you guys stuck to that there would be all the business you could handle. but many dc's try to "play God" by telling pts chiro can handle everything, which is endangering the general public who often dont know that the term "dr" can mean many different things.<<

No one was debating medical vs chiropractic education. I find that akin to comparing apples and oranges. My concerns lay with dc education, and it's continued path of improvement. The only concern of mine regarding med school education is when erroneous information concerning chiropractic is being taught. Outside of that, I have no interest professionally.

 

[FoughtFyr]

I attmepted to "enlighten" you by directing you(and even providing links) to respected and quality references/sources. Texts that are used and taught in DC school. I have told you where to go to get answers to your many questions. It is my impression that you choose to dismiss these sources.

No, actually you did nothing to enlighten me. You posted links to textbooks, that does not describe any actual QI/QA system in place for chiropractic as a profession. There are, and have been for many years, huge, intricate sysytems in place, which I have described at length, to oversee physicians. I am asking "where are those systems for chiropractic?" Your answer - here is a textbook written about QI/QA. Look, I can read Ted Williams'es book on hitting home runs, it doesn't make me a pro baseball player. The answer, which unfortunately you don't like, is that there is no QI/QA oversight for chiropractors.

I am glad to hear this. There has been quite a bit regarding "medical error" in the news recently.

Yep, there has been. What is the #1 "medical error" contained in the IOM report? Failure to diagnose. By a wide margin. From anecdotal experience, chiropractors have this problem in a significant number of cases. Why can't I post a number of how many cases - oh yeah, NO OVERSIGHT! We do not have any idea how many cases chiropractors miss, or treat when they should refer, or treat for far too long, or...

What is your proposal to address the above?

I've said it before, no direct access. Mandate MD referral to chiropractors, same as PT. And yes, I know it will never happen.

>>>what is chiropractic afraid of? Oh yeah, I forgot, the "fountainhead" was devinely inspired by the "innate", no oversight needed.<<<

This is a cheapshot. Shame on you.

Really? Have you ever read The Chiropractor's Adjuster? Palmer was nuts! Look, your profession is not some ancient healing art. It was created by D.D. Palmer in the late 1800s, who was employed as a grocer at the time, who believed that he "discovered" the key to all of health, in fact, and I quote "the key to life itself". That is the basis for the profession. It is not the collected body of generations of healers, in fact, Palmer admonishes saying "I am the Fountainhead", the source of all chiropractic knowledge. Now you have spent a good deal of time training in his principles. I am not allowed to question the source of the knowledge?

- H

 

[FoughtFyr]

You then change the topic to vaccination issues. Well I find that those opposed to chiropractic pursue this topic "ad nauseum". As for myself, I have no concern with it personally or professionally. Others can deliberate this to death. My interests are elsewhere.

Can't win so I won't play, that's constructive. Well currently, in Western Wisconsin there is a significant pertussis outbreak. Many of the pediatric patients being brought to us have never been vaccinated, on advice of their chiropractors. From the same area we have had two cases of HiB meningitis in children, one of whom (10 years old) died, also not vaccinated on the advice of their chiropractors. I don't care if your interests lie elsewhere, this is a current and real topic today.

If you bothered to read the previous posts and threads, you will see that there are, likely many, responsible chiropractors, who on an individual basis, I agree with in terms of practice patterns. There is not however, any mechanism to distinguish these folks from the more fringe providers. There are no professional guidelines to discern a research proven "safe" scope of chiropractic care. And there is absolutely no means to protect against a chiropractor who preaches against immunization, believes they can cure cancer, etc. Just because you are not "interested" in it does not make it disappear as a professional issue.

BTW- the disturbing part of this study http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=10768681&dopt=Abstract is not the immunization issue. It is the fact that of chiropractors identifying themselves as "pediatric chiropractors" "presented with a hypothetical 2-week-old neonate with a fever, 17% would treat the patient themselves rather than immediately refer the patient to a doctor of medicine, doctor of osteopathy, or an emergency facility." Oops. Way scary! But hey, your interests lie elsewhere, mine involve protecting my patients.

>>The often quoted NIH studies "in favor" of chiropractic, detailed in other threads, indicate that chiropractic is only "as effective" as traditional therapy. Given the risks demonstrated above, why is it that medicine should "accept" chiropractic? No real improvements and lots of risks...<<

Another indicator of your misinformation, or more likely, your bias. I look forward to addressing this issue in the future. My schedule today will not allow for it.

Cool, I look forward to it. If you have some study that demonstrates that chiropractic care is significantly more effective than medical treatment for any condition with significant morbidity or mortality, I'm all ears. If you can provde some mechanism of QI/QA that even remotely assures chiropractors are diagnosing their patients accurately, I'll listen. But if you are going to show that chiropractic is "as effective" (but no more so) as medicine for treating low back pain, then I will continue to have concerns regarding the benefits as measured against some significant and demonstrable risks.

>>Or are you a straight who believes that Palmer was some sort of health deity devinely inspired to "discover" innate?<<

Another cheapshot

How so? Your background, practice pattern, and beliefs are unknown to me. I have close friends and family members who are straights, and believe, unfalterringly, in Palmer's "theology". Including one who will not immunize his newborn child, nor take them to a medical doctor for care. If that is you as well, then I'll not have this discussion. For them Chiropractic is as much religion as science and I don't suppose to be able to "prove" anything against faith. If you are more of a mixer, then I am curious to know from where you draw your theory of practice, as Chiropractic's are clearly laid out by Palmer.

I can't help it if you don't like the fact the Chiropractic theory is largely based in Palmer's biotheology of "innate".

- H

 

[BackTalk]

Interesting information on gaining hospital privileges, I truly didn't realize how complicated it is. -thanks.

the downside of staff listing at a hospital is that you have to agree to take city call pts x days/month who you evaluate and treat regardless of their ability to pay. great social program but a little tough on the pocketbook if it is an involved pt....for instance you are an ortho doc on city call and someone comes in with a nasty surgical fx of some kind. you have to evaluate and treat them for the duration of that medical problem which means you operate and f/u without regard to their ability to pay.the hospital eats the cost of the o.r., staff rn's etc but you spend hours in the er, or, and clinic for which you are not compensated. I have worked at places that keep a list of recommended local chiros but never seen one on call.....what would constitute a chiropractic emergency or require one to admit to an in hospital chiropractic service? nothing comes to mind......

That must really bite not to get paid and devote so much of your time. Could a resident be put on "city call"? I think it would be great for a chiropractor to get on the list you speak of. The good thing is the patient has already been checked out by the ER doctor and that is a good safeguard for any doctor on the list. In my opinion there isn't anything that truly is a "chiropractic emergency". I guess possibly a whiplash injury or back spasms would be something where a chiropractor would consult with the ER doctor. Usually when a patient presents to the ER they are in so much pain there isn't much a chiropractor can do. Medication is the best initial form of treatment. Once the medication has eased the muscle spasm and pain, then chiropractic care may be tolerable. Not all cases are like that, but the ones that end up in the ER probably are. You might want to check out this story about a chiropractor who works in a hospital and was called into the ER for a chiropractic consultation.

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

 

[BackTalk]

H, what study are you referencing when you say “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”. Haven’t there been numerous studies on the subject that conclude chiropractic care or rather spinal manipulation is more effective than conventional medicine for the treatment of chronic and acute back pain? Now you know me, I'm no wizard such as yourself when it comes to interpreting research data. I’m not saying you are wrong but am curious as to how you arrived at your opinion.

 

[PublicHealth]

H, what study are you referencing when you say “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”. Haven’t there been numerous studies on the subject that conclude chiropractic care or rather spinal manipulation is more effective than conventional medicine for the treatment of chronic and acute back pain? Now you know me, I'm no wizard such as yourself when it comes to interpreting research data. I’m not saying you are wrong but am curious as to how you arrived at your opinion.

Here is the "limited data:" http://nccam.nih.gov/health/chiropractic/index.htm

Note the following: "Research studies of chiropractic treatment for low-back pain have been of uneven quality and insufficient to allow firm conclusions. Nonetheless, the overall sense of the data is that for low-back pain, chiropractic treatment and conventional medical treatments are about equally helpful."

Unlike FoughtFyr's comments above, this article states: "Conditions commonly treated by chiropractors include back pain, neck pain, headaches, sports injuries, and repetitive strains. Patients also seek treatment of pain associated with other conditions, such as arthritis."

 

[PublicHealth]

BTW- the disturbing part of this study http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=10768681&dopt=Abstract is not the immunization issue. It is the fact that of chiropractors identifying themselves as "pediatric chiropractors" "presented with a hypothetical 2-week-old neonate with a fever, 17% would treat the patient themselves rather than immediately refer the patient to a doctor of medicine, doctor of osteopathy, or an emergency facility." Oops. Way scary!

First off, the study you referenced is almost five years old. Second, only 90 DCs participated in the survey. Third, results of the study may be generalized only to DCs practicing in the metro Boston area who belong to pediatric chiropractic societies and who own a practice with the name "family" but not "pain," "back," and "injury" in the practice name. Fourth, only 7% of the DCs surveyed in this study recommended against vaccination. Fifth and most importantly, the authors of this article clearly had an agenda--to shoot down pediatric chiropractic. Taken together, this article fails to support the assertion you so readily make regarding DCs' view toward immunization.

That said, the finding that 17% of the DCs surveyed would treat a neonate with a fever instead of referring to an MD, DO, or emergency facility is a bit scary. But then again, the type of care that a pediatric DC would provide a neonate with a fever was not reported in the article. As stated by the authors (p. 405): "These results may be limited because in a real situation the practitioner might have more information about the patient, would not choose between 3 exclusive options, and could reevaluate and question the patient during an office visit. The question may also have been interpreted in different ways, (ie, that the hypothetical patient had already seen a doctor of medicine or doctor of osteopathy or was concurrently seeing a pediatrician)."

But if you are going to show that chiropractic is "as effective" (but no more so) as medicine for treating low back pain, then I will continue to have concerns regarding the benefits as measured against some significant and demonstrable risks.

Where's your data on "demonstrable risks" associated with chiropractic treatment for low back pain? I'm aware of the studies documenting risks associated with cervical manipulation, but none on LBP. In fact, the NIH article cited above states: "The rate of serious complications from chiropractic has been debated. There have been no organized prospective studies on the number of serious complications. From what is now known, the risk appears to be very low. It appears to be higher for cervical-spine, or neck, manipulation (e.g., cases of stroke have been reported). The rare complication of concern from low-back adjustment is cauda equina syndrome, estimated to occur once per millions of treatments (the number of millions varies; one study placed it at 100 million)."

With all the recent rumpus surrounding the use of NSAIDs and cardiovascular complications, chiropractic seems like a much better option for treating LBP!

 

[PublicHealth]

British Medical Journal 1995 Aug 5;311(7001):349-51.

Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up.

Meade TW, Dyer S, Browne W, Frank AO.

Epidemiology and Medical Care Unit, Wolfson Institute of Preventive Medicine, Medical College, St Bartholomew's Hospital, London.

OBJECTIVE--To compare the effectiveness over three years of chiropractic and hospital outpatient management for low back pain. DESIGN--Randomised allocation of patients to chiropractic or hospital outpatient management. SETTING--Chiropractic clinics and hospital outpatient departments within reasonable travelling distance of each other in 11 centres. SUBJECTS--741 men and women aged 18-64 years with low back pain in whom manipulation was not contraindicated. OUTCOME MEASURES--Change in total Oswestry questionnaire score and in score for pain and patient satisfaction with allocated treatment. RESULTS--According to total Oswestry scores improvement in all patients at three years was about 29% more in those treated by chiropractors than in those treated by the hospitals. The beneficial effect of chiropractic on pain was particularly clear. Those treated by chiropractors had more further treatments for back pain after the completion of trial treatment. Among both those initially referred from chiropractors and from hospitals more rated chiropractic helpful at three years than hospital management. CONCLUSIONS--At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals.

 

[PublicHealth]

Spine. 1995 Apr 15;20(8):948-55.

Manipulative therapy versus education programs in chronic low back pain.

Triano JJ, McGregor M, Hondras MA, Brennan PC.

Institute for Spine and Biomedical Research, Plano, Texas, USA.

STUDY DESIGN. A randomized trial was conducted on a representative sample of patients with untreated low back pain lasting 7 weeks or longer, or having more than 6 episodes in 12 months. OBJECTIVES. To contrast the effectiveness of manipulation, a manipulation mimic, and a back education program. Methodologic criticisms of earlier studies were addressed. SUMMARY OF BACKGROUND DATA. Published meta-analyses suggest clinical benefit from manipulation for acute patients. Data are inconclusive for patients having symptoms for longer than 1 month. METHODS. A total of 1267 consecutive patients were screened. Block randomization was used to assign 209 qualifying patients to treatment groups. Self-reported pain and activity tolerance served as primary outcome measures. Patients were assessed at enrollment, after 2 weeks of treatment, and again after 2 weeks without treatment. Multiple teams conducted recruitment, randomization, assessment, treatment, and data analysis independently without sharing information. Treatments were carefully described, monitored, and balanced for physician attention and physical contact effects. RESULTS. A total of 81.3% of subjects completed the study. Confounding factors and missing data were identified in approximately 20% of those completing the final follow-up. Analysis of the remaining data was carried out. A strong time effect under treatment was observed. Greater improvement was noted in pain and activity tolerance in the manipulation group. Immediate benefit from pain relief continued to accrue after manipulation, even for the last encounter at the end of the 2-week treatment interval. CONCLUSION. Time is a strong ally of the low back pain patient. In human terms, however, there appears to be clinical value to treatment according to a defined plan using manipulation even in low back pain exceeding 7 weeks' duration.

 

[BackTalk]

PH, that was one study I just came across a few minutes ago. I’m glad you noticed it and posted it.

 

[rooster]

Safety of spinal manipulation in the treatment of lumbar disc herniations: a systematic review and risk assessment.

Drew Oliphant, DC

J Manip Phys Ther Mar 2004

Objective: To provide a qualitative systematic review of the risk of spinal manipulation in the treatment of lumbar disc herniations (LDH), and to estimate of the risk of spinal manipulation causing a severe adverse reaction in a patient presenting with LDH.
Data sources: Relevant case reports, review articles, surveys and investigations regarding treatment of lumbar disc herniations with spinal manipulation, and adverse effects and associated risks were found with a search of the literature.

Data synthesis: Prospective/retrospective studies and review papers were graded according to quality, and results and conclusions were tabulated. From the data published, an estimate of the risk of spinal manipulation causing a clinically worsened disc herniation or CES in patients presenting with LDH is calculated. This is compared to estimates of the safety of NSAIDs and surgery in the treatment of LDH.

Results: An estimate of the risk of spinal manipulation causing a clinically worsened disc herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million.

Conclusion: The apparent safety of spinal manipulation, especially when compared to other 'medically-accepted' treatments for LDH, should stimulate its' use in the conservative treatment plan of LDH

 

[FoughtFyr]

Here is the "limited data:" http://nccam.nih.gov/health/chiropractic/index.htm

Note the following: "Research studies of chiropractic treatment for low-back pain have been of uneven quality and insufficient to allow firm conclusions. Nonetheless, the overall sense of the data is that for low-back pain, chiropractic treatment and conventional medical treatments are about equally helpful."

No, what I am referring to is summarized here: http://nccam.nih.gov/health/chiropractic/index.htm#app2

Three systematic reviews that concluded "Overall, the evidence was seen as weak and less than convincing for the effectiveness of chiropractic for back pain. Specifically, the 1996 systematic review reported that there were major quality problems in the studies analyzed; for example, statistics could not be effectively combined because of missing and poor-quality data. The review concludes that the data 'did not provide convincing evidence for the effectiveness of chiropractic.' The 2003 general review states that since the 1996 systematic review, emerging trial data 'have not tended to be encouraging&#8230;. The effectiveness of chiropractic spinal manipulation for back pain is thus at best uncertain.' The 2003 meta-analysis found spinal manipulation to be more effective than sham therapy but no more or no less effective than other treatments.

Several other points are helpful to keep in mind about the research findings. Many clinical trials of chiropractic analyze the effects of chiropractic manipulation alone, but chiropractic practice includes more than manipulation. Results of a trial performed in one setting (such as a managed care organization or a chiropractic college) may not completely apply in other settings. And, researchers have observed that the placebo effect may be at work in chiropractic care, as in other forms of health care." (See: http://nccam.nih.gov/health/chiropractic/index.htm#9a for specific citations)

Unlike FoughtFyr's comments above, this article states: "Conditions commonly treated by chiropractors include back pain, neck pain, headaches, sports injuries, and repetitive strains. Patients also seek treatment of pain associated with other conditions, such as arthritis."

Gimme a break. I never said people didn't go to chiropractors for a myriad of conditions. I said that there is little evidence (if any) for chiropractics' effectiveness in treating those conditions.

To quote the NCCAM again "So far, the scientific research on chiropractic and low-back pain has focused on if, and how well, chiropractic care helps in relieving pain and other symptoms that people have with low-back pain. This research often compares chiropractic to other treatments."

Patients "seek treatment" for lots of things from lots of sources (try "Enzyte" the all natural male enhancer! ), That doesn't mean the treatments work!

- H

 

[FoughtFyr]

First off, the study you referenced is almost five years old. Second, only 90 DCs participated in the survey. Third, results of the study may be generalized only to DCs practicing in the metro Boston area who belong to pediatric chiropractic societies and who own a practice with the name "family" but not "pain," "back," and "injury" in the practice name. Fourth, only 7% of the DCs surveyed in this study recommended against vaccination. Fifth and most importantly, the authors of this article clearly had an agenda--to shoot down pediatric chiropractic. Taken together, this article fails to support the assertion you so readily make regarding DCs' view toward immunization.

Hey, a thoughtful and concise analysis. I agree. The study is skewed as to the question of immunizations. It is hardly the best design, and the "agenda" is clear and taints the research. How come you don't turn this critical an eye toward the N=13 study of chiropractors analyzing lumbar spine x-rays? The important finding in this study, in my opinion, is discussed below.

That said, the finding that 17% of the DCs surveyed would treat a neonate with a fever instead of referring to an MD, DO, or emergency facility is a bit scary. But then again, the type of care that a pediatric DC would provide a neonate with a fever was not reported in the article. As stated by the authors (p. 405): "These results may be limited because in a real situation the practitioner might have more information about the patient, would not choose between 3 exclusive options, and could reevaluate and question the patient during an office visit. The question may also have been interpreted in different ways, (ie, that the hypothetical patient had already seen a doctor of medicine or doctor of osteopathy or was concurrently seeing a pediatrician)."

True. Except as a medical student (if you've done your Pediatric rotation yet), you know that there is no question as the serious nature of neonatal fever. The answer should be almost instinctive; fever + neonate = emergency.

Where's your data on "demonstrable risks" associated with chiropractic treatment for low back pain? I'm aware of the studies documenting risks associated with cervical manipulation, but none on LBP. In fact, the NIH article cited above states: "The rate of serious complications from chiropractic has been debated. There have been no organized prospective studies on the number of serious complications. From what is now known, the risk appears to be very low. It appears to be higher for cervical-spine, or neck, manipulation (e.g., cases of stroke have been reported). The rare complication of concern from low-back adjustment is cauda equina syndrome, estimated to occur once per millions of treatments (the number of millions varies; one study placed it at 100 million)."

Careful, don't mix my words. I am not saying that the risks come from the treatment itself. As I have said, I think there is some evidence, as you and others have posted here, that SMT works. I also agree that SMT is low risk. The risks come in from the other aspects of chiropractic. As I am sure you know, the IOM report on medical errors listed "failure to diagnose / missed diagnosis" as the #1 error in medicine. My concern regarding chiropractic is not the treatment of LBP, but rather the diagnois and treatment of everything else. There are a large number of chiropractors who believe they can diagnose and treat everything from gout to ADHD. You have posted some of the ADHD articles yourself. Now, when a patient is being treated by a chiropractor for these conditions, and eschewing medical therapies, they are at risk for untoward outcomes. The fact that the number of occurences of these events is unknown and immeasurable due to lack of QI/QA is another problem. This lack of QI/QA can also lead to abuses in length of treatment for any condition, including LBP. Lastly, the fact that chiropratic care is not standardized across the profession means that a patient seeking chiropractic care is never sure what they are getting!

With all the recent rumpus surrounding the use of NSAIDs and cardiovascular complications, chiropractic seems like a much better option for treating LBP!

I agree, assuming that more significant pathology has been ruled out.

- H

 

[FoughtFyr]

Guys,

With all due respect, I am bowing out of these arguments. None of us is going to convince the others of anything, and I question the utility of continued discussion. My point is that while SMT may work for LBP and other NMS conditions, it is not the panacea envisioned by Palmer. While many (most?) chiropractors realize this, some do not. The general public has no easy way to discern the beliefs or practices of a given chiropractor, because they are not generally well educated enough regarding chiropractic to ask. When they are educated, it is usually by the provider from whom they are seeking care (hardly an unbiased source). In most states, the chiropractic practice acts are written so broadly as to empower chiropractors who choose to do so to guide their patients to questionable decisions regarding their healthcare without repercussion.

I also have little question, based on significant personal experience, that chiropractors (in general) are poor at diagnosing non-NMS conditions. While this poses little problem for the patient of a competant "mixer" chiropractor, it can be (and has been) deadly to patients of straights or pseudo-mixers, whose patients may wait to seek medical therapy until their conditions are so advanced that reasonable hope is lost. Why? Because their chiropractor told them he/she was helping. I also realize that advising against immunizations is a fringe practice, but as an ED physician in an area currently hit by an epidemic of a pertussis, it is hard to ignore those "fringe" providers. And I do realize that the overwhelming majority of the pertussis cases we are seeing are from waned immunity after immunization, the very sick young unimmunized children are just a senseless reminder that the issue is very alive and real.

But I am not going to change your minds, nor you mine. So, thanks for the discussion, it has been enlightening.

- H

 

[PublicHealth]

No, what I am referring to is summarized here: http://nccam.nih.gov/health/chiropractic/index.htm#app2

Several other points are helpful to keep in mind about the research findings. Many clinical trials of chiropractic analyze the effects of chiropractic manipulation alone, but chiropractic practice includes more than manipulation. Results of a trial performed in one setting (such as a managed care organization or a chiropractic college) may not completely apply in other settings. And, researchers have observed that the placebo effect may be at work in chiropractic care, as in other forms of health care." (See: http://nccam.nih.gov/health/chiropractic/index.htm#9a for specific citations)

The Appendix you referenced is from the same article I referenced above. Just scroll down.

Regarding the research findings on chiropractic, your comments underscore the points I made above about the generalizability of clinical trial data. Idealized conditions, inclusion/exclusion criteria, and standardized treatment regimens are not representative of real-life, everyday chiropractic practice. Moreover, how these results reflect the entire spectrum of chiropractic practice, whether it's rural Indiana, metro New York, managed and non-managed care, chiropractic or non-chiropractic college setting, etc, awaits further research. As I stated above countless times, chiropractic research is just beginning to take form. People are beginning to ask questions about chiropractic that case studies cannot answer. The UCLA group, led by Hurwitz (a DC, PhD: http://www.mbcrc.med.ucla.edu/MemberBios/MmbrHurwitz.htm), is leading the charge. With increased support from NCCAM, you will see more research on chiropractic and other alternative treatments in the years ahead. Give it time, look at the data, and then form your opinions about it.

Your points about regulation of chiropractic and practicing outside the scope of one's practice are well-taken. I completely agree with you that these issues must be addressed in a systematic manner. But who's to say that the medical folks are correct? Asian doctors have been sticking needles into people and providing them with homeopathic remedies for years -- compare the health of those folks to the health of Americans with all of our technologically sophisticated drugs and surgical interventions. There MUST be something that Americans are getting out of going to alternative healthcare practitioners that their medical practitioners are not providing them if they are spending tens of billions of dollars out-of-pocket each year on such services.

 

[PublicHealth]

Guys,

With all due respect, I am bowing out of these arguments. None of us is going to convince the others of anything, and I question the utility of continued discussion. My point is that while SMT may work for LBP and other NMS conditions, it is not the panacea envisioned by Palmer. While many (most?) chiropractors realize this, some do not. The general public has no easy way to discern the beliefs or practices of a given chiropractor, because they are not generally well educated enough regarding chiropractic to ask. When they are educated, it is usually by the provider from whom they are seeking care (hardly an unbiased source). In most states, the chiropractic practice acts are written so broadly as to empower chiropractors who choose to do so to guide their patients to questionable decisions regarding their healthcare without repercussion.

I also have little question, based on significant personal experience, that chiropractors (in general) are poor at diagnosing non-NMS conditions. While this poses little problem for the patient of a competant "mixer" chiropractor, it can be (and has been) deadly to patients of straights or pseudo-mixers, whose patients may wait to seek medical therapy until their conditions are so advanced that reasonable hope is lost. Why? Because their chiropractor told them he/she was helping. I also realize that advising against immunizations is a fringe practice, but as an ED physician in an area currently hit by an epidemic of a pertussis, it is hard to ignore those "fringe" providers. And I do realize that the overwhelming majority of the pertussis cases we are seeing are from waned immunity after immunization, the very sick young unimmunized children are just a senseless reminder that the issue is very alive and real.

But I am not going to change your minds, nor you mine. So, thanks for the discussion, it has been enlightening.

- H

We're going to miss you!

It's been fun.