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cost maybe?
Three recent scary chiro articles...
- Thread starter FoughtFyr
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skiiboy said:
Actually there is ONE ED that has started a pilot project with chiropractors in the ED. You know what - I'm for it! Anything to prevent direct access and insure the patient is seen by an MD/DO first and significant pathogy ruled out. At least this way the cauda equina syndromes are not adjusted, nor are the renal cell carcinomas (I've seen both), the patients get their immunizations as needed, and if there is really nothing else wrong with them besides idiopathic LBP, they are seen by the chiropractor. The part I do not like is that PTs are not concurrently available to patients who would prefer that modality over chiropractic. Plus it would be a great, easy to randomize trial, head to head, PT versus Chiropractic - let's get ready to rrrruuuummmble!
BTW - here is the link: (sorry PublicHealth, I didn't see your post before I responded).
http://www.chiroweb.com/archives/20/21/04.html
I have not seen an expansion of this program into any other EDs and I read the EM literature pretty closely. If you know of any please post proof skiiboy! But one program is not "many"...
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The reason why chiropractic, or any therapy including laying of hands, prayer and the use of crystals will work for idiopathic LBP, is the fact that most episodes of LBP will resolve spontaneously anyway.
Oh, plain radiographs are proven to be all but useless in the workup of patients with LBP (with exceptions).
In a sufficiently symptomatic patient, the plainfilm will have two possible findings but only one clinical consequence:
- positive --> further workup, typically MRI
- negative --> further workup, typically MRI
(There is nothing like a 'subluxation'. If you truly 'subluxed' something in your L-spine, you better be on a backboard on the way to the next level 1 or 2 trauma center)
Oh, plain radiographs are proven to be all but useless in the workup of patients with LBP (with exceptions).
In a sufficiently symptomatic patient, the plainfilm will have two possible findings but only one clinical consequence:
- positive --> further workup, typically MRI
- negative --> further workup, typically MRI
(There is nothing like a 'subluxation'. If you truly 'subluxed' something in your L-spine, you better be on a backboard on the way to the next level 1 or 2 trauma center)
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awdc said:That's what the physical therapists are there for.
awdc,
Why did you leave chiropractic?
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PublicHealth said:
Wow, I feel I get asked this so often I should have a sticky on it.
Well, this is what I said in another post:I guess to explain a little further. My interest dropped because I just couldn't see myself doing chiropractic/quasi-physical therapy for the rest of my life. I was really more interested using my applying my interests in pathology and physiology to patient care. During and shortly after chiropractic school, I had the opportunity to go on medical missions with physicians. From those experiences and friendships formed, I appreciated what real primary care is. My interest currently isn't in primary care but the great thing about medicine is that it offers a variety of areas to suit interests and personality.
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From www.amerchiro.org:
List of Facilities Eligible to Hire DCs under the NHSC Demo Program Now Available
The National Health Service Corps (NHSC) chiropractic student loan repayment demonstration pilot program will allow doctors of chiropractic to practice in medically underserved communities for loan repayment awards. This demonstration project will determine if adding doctors of chiropractic as permanent NHSC members would enhance the corps effectiveness. The ACA has obtained a listing of all facilities that are eligible to hire DCs under this program.
http://www.amerchiro.org/government/nhsc/NHSC_Facilities.pdf
More on this program: http://www.chiroweb.com/archives/23/09/09.html
List of Facilities Eligible to Hire DCs under the NHSC Demo Program Now Available
The National Health Service Corps (NHSC) chiropractic student loan repayment demonstration pilot program will allow doctors of chiropractic to practice in medically underserved communities for loan repayment awards. This demonstration project will determine if adding doctors of chiropractic as permanent NHSC members would enhance the corps effectiveness. The ACA has obtained a listing of all facilities that are eligible to hire DCs under this program.
http://www.amerchiro.org/government/nhsc/NHSC_Facilities.pdf
More on this program: http://www.chiroweb.com/archives/23/09/09.html
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PublicHealth said:
Great, now we are paying for "unproven" methods to be available to all. You know, given the amount of the population that screams "I can't afford health care" this program seems to me to be a step backward. Especially when you consider the following:
Trends in Alternative Medicine Use in the United States, 1990-1997
Eisenberg GM, Davis RB, Ettner SL, etal
From: Journal of the American Medical Association
Volume/Edition: 280 (18)
Pages/Time: 1569-1575
Source/Year: November 1998
Context: A prior national survey documented the high prevalence and costs of alternative medicine use in the United States in 1990.
Objective: To document trends in alternative medicine use in the United States between 1990 and 1997.
Design: Nationally representative random household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997, respectively.
Participants: A total of 1539 adults in 1991 and 2055 in 1997.
Main Outcomes Measures: Prevalence, estimated costs, and disclosure of alternative therapies to physicians.
Results: Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8% in 1990 to 42.1% in 1997 (P < or= to.001). The therapies increasing the most included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. The probability of users visiting an alternative medicine practitioner increased from 36.3% to 46.3% (P=.002). In both surveys alternative therapies were used most frequently for chronic conditions, including back problems, anxiety, depression, and headaches. There was no significant change in disclosure rates between the 2 survey years; 39.8% of alternative therapies were disclosed to physicians in 1990 vs 38.5% in 1997. The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 (64.0%) and 1997 (58.3%) (P=.36). Extrapolations to the US population suggest a 47.3% increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all US primary care physicians. An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and/or high-dose vitamins (18.4% of all prescription users). Estimated expenditures for alternative medicine professional services increased 45.2% between 1990 and 1997 and were conservatively estimated at $21.2 billion in 1997, with at least $12.2 billion paid out-of-pocket. This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations. Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $27.0 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services.
Conclusions: Alternative medicine use and expenditures increased substantially between 1990 and 1997, attributable primarily to an increase in the proportion of the population seeking alternative therapies, rather than increased visits per patient.
Eisenberg GM, Davis RB, Ettner SL, etal
From: Journal of the American Medical Association
Volume/Edition: 280 (18)
Pages/Time: 1569-1575
Source/Year: November 1998
Context: A prior national survey documented the high prevalence and costs of alternative medicine use in the United States in 1990.
Objective: To document trends in alternative medicine use in the United States between 1990 and 1997.
Design: Nationally representative random household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997, respectively.
Participants: A total of 1539 adults in 1991 and 2055 in 1997.
Main Outcomes Measures: Prevalence, estimated costs, and disclosure of alternative therapies to physicians.
Results: Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8% in 1990 to 42.1% in 1997 (P < or= to.001). The therapies increasing the most included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. The probability of users visiting an alternative medicine practitioner increased from 36.3% to 46.3% (P=.002). In both surveys alternative therapies were used most frequently for chronic conditions, including back problems, anxiety, depression, and headaches. There was no significant change in disclosure rates between the 2 survey years; 39.8% of alternative therapies were disclosed to physicians in 1990 vs 38.5% in 1997. The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 (64.0%) and 1997 (58.3%) (P=.36). Extrapolations to the US population suggest a 47.3% increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all US primary care physicians. An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and/or high-dose vitamins (18.4% of all prescription users). Estimated expenditures for alternative medicine professional services increased 45.2% between 1990 and 1997 and were conservatively estimated at $21.2 billion in 1997, with at least $12.2 billion paid out-of-pocket. This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations. Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $27.0 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services.
Conclusions: Alternative medicine use and expenditures increased substantially between 1990 and 1997, attributable primarily to an increase in the proportion of the population seeking alternative therapies, rather than increased visits per patient.
Maybe if we somehow redistributed these funds towards making health care available to all who need it, we wouldn't have such a problem with the uninsured.
But that is o.k., I hear the VA will be hiring protienatics soon - so I'm set!
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FoughtFyr said:
O.k., I've got the entire article. It does not even come close to "proving" anything. The author, who is intimately involved in the creation of a database known as the Arthritis, Rheumatism, and Aging Medical Information System (or ARAMIS).
ARAMIS, "which has been funded by the National Institutes of Health for the past 25 years, is a prospective observational data bank system that systematically collects data on individuals with chronic rheumatic disease." O.k., so where is the problem? Here is the ARAMIS data:
Gastrointestinal (GI) Complications in Osteoarthritis
(OA) and Rheumatoid Arthritis (RA)
OA Hospitalizations
Number of patients 1,283
Person-years of observation 3,234
Person-years taking NSAIDs 2,199
Number of GI events 19
GI events in NSAID users 16
Annual incidence on NSAIDs (%) 2.51
Relative risk on NSAIDs 0.73 (SE 5 0.18)*
Annual incidence of upper GI events on NSAIDs (%) 0.50
Annual incidence of lower GI events on NSAIDs (%) 0.23
RA Hospitalizations
Number of patients 2,921
Person-years of observation 12,224
Person-years taking NSAIDs 8,471
Number of GI events 134
GI events in NSAID users 124
Annual incidence on NSAIDs (%) 5.49
Relative risk on NSAIDs 1.46 (SE 5 0.13)*
Annual incidence of upper GI events on NSAIDs (%) 1.27
Annual incidence of lower GI events on NSAIDs (%) 0.19
(* P , 0.001 for RA vs OA.) {emphasis added}
From this, the author concludes: "The Arthritis Foundation conservatively estimates that at least 13 million individuals in the United States with OA or RA regularly take NSAIDs. Applying the ARAMIS data to these figures, the number of potential hospitalizations for serious GI complications is about 107,000 per year." Which sounds great, right? Except for two facts. Elsewhere in the paper, the author describes additional risk factors that seem to suggest which specific persons taking NSAIDs are at increased risk. These data are not applied to the "conservative estimate" of 13 million individuals who regularly take NSAIDs. Second, as is contained in the data above, individuals with OA are far less likely than individuals with RA to develop GI complications (RR 0.73 v. 1.46). OA is far more prevalent than RA in the general population. Again, no measure of this is made in the creation of the author's estimate of those affected by GI complications from NSAIDs. Additionally, no mention is made at all of the pre-existing (or "base rate") of GI pathology except to note that there were events in both the OA and RA populations among individuals not taking NSAIDs. There are many individuals not on NSAIDs develop GI problems, yet the author only compares his data between the OA and RA groups, not against controls. It is impossible then to draw the conclusion that the entirety of the pathology present can be "blamed" on NSAID use - especially given that the data only contain 153 events out of more than 4,000 patients.
A better look at the issue is here;
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1834002
but their results are not as dramatic.
But, let's for a minute compare the results of the first article to the risk of vertebral artery dissection, one that the "chiro defenders" here seen to all say is minimal at best. From: http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=14589464
"The total number of chiropractic practice years assessed for this 10 year period was 32,885."
"A total of 43 cases were referred to CCPA during the study period. Twenty-three cases were confirmed to be a stroke that occurred at some point after cervical manipulation, and 21 of these cases resulted in claims of malpractice. The remaining 20 cases, on review of the charts, were determined by the treating physician or neurologist to be the result of factors unrelated to the treatment or the symptoms resolved without significant investigation."
"A total of 43 cases were referred to CCPA during the study period. Twenty-three cases were confirmed to be a stroke that occurred at some point after cervical manipulation, and 21 of these cases resulted in claims of malpractice. The remaining 20 cases, on review of the charts, were determined by the treating physician or neurologist to be the result of factors unrelated to the treatment or the symptoms resolved without significant investigation."
Before you cry foul, remember the NSAID paper only discussed association, it did not exclude any cases for "base rate", all associated cases were "blamed" on the NSAIDs. So, we have 43 cases in 32,885 chiropractic practice years for a rate of 1 event per 764.77 years. In the OA population taking NSAIDs we have 16 events in 2,199 person years of observation for a rate of 1 event per 137.43 years. So, if a chiropractor takes NSAIDs for OA pain, he is only 5.56 times more likely to have a GI complication than he is to cause a VAD in any given year. Since many on this board like to equate VAD from chiropractic therapy to "getting hit by lightning" then something 5x more likely than getting hit by lightning isn't such a risk after all, is it. And consider this, the data for the GI article contained no deaths in the OA group. The data above measure all GI complications, including those as mild as dyspepsia...
Yes, PublicHealth, I know the last paragraph is statistically pure junk. I am just making the point that there are three types of falsehoods: lies, damn lies, and statistics. The vision skiiboy posted of "hundreds of thousands of deaths a year" (attributable to NSAIDs) isn't quite true either...
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skiiboy said:
Please take a few minutes and read this analysis of a paper often quoted in this forum:
http://www.chirobase.org/14Misc/meeker.html
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Since you seem interested in videos related to "chiropractic" and chiropractors, please take a few moments and watch: "Adjusting the Joints" --one of the segments from the PBS Scientific American Frontiers production, A Different Way To Heal? You can view the whole show at:skiiboy said:
http://www.pbs.org/saf/1210/video/watchonline.htm
Click on: PLAY VIDEO in the section: Adjusting the Joints if you just want to see the stuff related to "chiropractic" and chiropractors.
For those without a broadband connection, you might be interested in reading some of my responses to viewer mail that was forwarded to me by the producers after the show aired nationally in June, 2002.
http://www.pbs.org/saf/1210/hotline/hbedanes.htm
Have fun.
~TEO.
John Badanes, DC, PharmD
LCCW '84, UCSF '97
